Management of patients with mitral regurgitation ineligible for standard therapy undergoing TMVI screening

DOI: 10.4244/EIJ-D-21-00708

Sebastian Ludwig
Sebastian Ludwig1,2, MD; Roya Sedighian1, MD; Jessica Weimann1, MSc; Benedikt Koell1,2, MD; Lara Waldschmidt1, MD; Andreas Schäfer3, MD, MBHA; Moritz Seiffert1,2, MD; Dirk Westermann1,2, MD; Hermann Reichenspurner2,3, MD, PhD; Stefan Blankenberg1,2, MD; Niklas Schofer1, MD; Edith Lubos1,2, MD; Lenard Conradi3, MD; Daniel Kalbacher1,2, MD
1. Department of Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany; 2. German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany; 3. Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Hamburg, Germany

Background: Transcatheter mitral valve implantation (TMVI) represents a novel treatment alternative for patients with severe mitral regurgitation (MR) considered ineligible for standard therapies. Data on the management of patients after TMVI screening is scarce.

Aims: We aimed to investigate outcomes of patients with severe MR undergoing TMVI evaluation treated with either TMVI, bailout-transcatheter edge-to-edge repair (bailout-TEER) or medical therapy (MT).

Methods: Between May 2016 and February 2021, 121 patients with MR considered ineligible for standard therapy were screened for TMVI. Outcomes were assessed for the subgroups of patients treated with TMVI, bailout-TEER and MT. The primary composite endpoint was all-cause death or heart failure hospitalisation after one year.

Results: The subgroups of TMVI (N=38), bailout-TEER (N=28) and MT (N=44) differed significantly with regard to MR aetiology (secondary MR: TMVI 68.4%, bailout-TEER 39.3%, MT 38.6%, p=0.014) and left ventricular ejection fraction (TMVI 37.0% [31.4-51.2], bailout-TEER 48.0% [35.3-58.3], MT 54.5% [40.8-60.0], p<0.001). At discharge and after one year, MR was reduced to ≤mild residual MR in all patients undergoing TMVI, while ≥moderate residual MR was present in 25.9% and 20.0% of patients, respectively, after bailout-TEER, and in 100.0% of patients on MT at one year. The primary endpoint occurred in 72.2% of patients remaining on MT, in 51.6% of patients undergoing TMVI and in 40.2% of those receiving bailout-TEER.

Conclusions: In MR patients considered ineligible for standard therapy, TMVI provided acceptable clinical outcomes and MR elimination in the majority of patients. In screen-failed patients, bailout-TEER represented a reasonable alternative while MT was associated with poor outcomes.

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