S. Ludwig (Hamburg)¹, A. Coisne (Lille)², K. Hamzi (Paris)³, W. Ben Ali (Montreal)⁴, B. Köll (Hamburg)¹, D. Kalbacher (Hamburg)⁵, A. Scotti (New York)⁶, A. Duncan (London)⁷, R. Makkar (Californien)⁸, M. Akodad (Vancouver)⁹, S. Bleiziffer (Bad Oeynhausen)¹⁰, G. Nickenig (Bonn)¹¹, T. Kaneko (Boston)¹², H. Ruge (München)¹³, M. Adam (Köln)¹⁴, L. Sondergaard (Kopenhagen)¹⁵, G. Dahle (Oslo)¹⁶, M. Taramasso (Zürich)¹⁷, T. Walther (Frankfurt am Main)¹⁸, J. Kempfert (Berlin)¹⁹, J.-F. Obadia (Lyon)²⁰, O. Chehab (London)²¹, G. Tang (New York)²², S. Goel (Houston)²³, N. Fam (Toronto)²⁴, P. Denti (Milan)²⁵, F. Praz (Bern)²⁶, R. S. von Bardeleben (Mainz)²⁷, J. Hausleiter (München)²⁸, A. Latib (Ney York)²⁹, T. Modine (Bordeaux)³⁰, T. Pezel (Paris)³, J. Granada (New York)³¹, L. Conradi (Köln)^32
1Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Kardiologie Hamburg, Deutschland; ²Heart Valve Clinic, CHU Lille Department of Clinical Physiology and Echocardiography Lille, Frankreich; ³Lariboisière Hospital Paris, Frankreich; ⁴Montreal Heart Institute Montreal, Kanada; ⁵Universitäres Herz- und Gefäßzentrum Hamburg Allgemeine und Interventionelle Kardiologie Hamburg, Deutschland; ⁶Montefiore Medical Center, Albert Einstein College of Medicine Montefiore-Einstein Center for Heart and Vascular Care New York, USA; ⁷Royal Brompton and Harefield Hospital Consultant Cardiologist London, Großbritannien; ⁸Cedars-Sinai Medical Center Californien, USA; ⁹St. Paul's Hospital Vancouver, Kanada; ¹⁰Herz- und Diabeteszentrum NRW Klinik für Thorax- und Kardiovaskularchirurgie Bad Oeynhausen, Deutschland; ¹¹Universitätsklinikum Bonn Medizinische Klinik und Poliklinik II Bonn, Deutschland; ¹²Brigham and Women's Hospital Boston, USA; ¹³Deutsches Herzzentrum München Klinik für Herz- und Gefäßchirurgie München, Deutschland; ¹⁴Herzzentrum der Universität zu Köln Klinik III für Innere Medizin Köln, Deutschland; ¹⁵Rigshospitalet Kopenhagen, Dänemark; ¹⁶Rikshospitalet Oslo, Norwegen; ¹⁷HerzZentrum Hirslanden Cardiology Zürich, Schweiz; ¹⁸Universitätsklinikum Frankfurt Klinik für Thorax-, Herz- und Thorakale Gefäßchirurgie Frankfurt am Main, Deutschland; ¹⁹Deutsches Herzzentrum der Charite (DHZC) Klinik für Herz-, Thorax- und Gefäßchirurgie Berlin, Deutschland; ²⁰Civils Hospices of Lyon Lyon, Frankreich; ²¹St. Thomas' Hospital Department of Cardiology London, Großbritannien; ²²Mount Sinai Hospital New York, USA; ²³Houston Methodist Hospital Houston, USA; ²⁴St. Michael's Hospital Toronto, Kanada; ²⁵San Raffaele Hospital IRCCS Ospedale San Raffaele Milan, Italien; ²⁶Inselspital - Universitätsspital Bern Universitätsklinik für Kardiologie Bern, Schweiz; ²⁷Universitätsmedizin der Johannes Gutenberg-Universität Mainz Zentrum für Kardiologie im Herz- und Gefäßzentrum Mainz, Deutschland; ²⁸LMU Klinikum der Universität München Medizinische Klinik und Poliklinik I München, Deutschland; ²⁹Montefiore Medical Center, Albert Einstein College of Medicine Montefiore-Einstein Center for Heart and Vascular Care Ney York, USA; ³⁰Centre Hospitalier Universitaire Bordeaux Service Médico-Chirurgical: Valvulopathies-Chirurgie Cardiaque-Cardiologie Interventionelle Structurelle Bordeaux, Frankreich; ³¹Cardiovascular Research Foundation New York, Deutschland; ³²Universitätsklinikum Köln Klinik und Poliklinik für Herzchirurgie Köln, Deutschland

Background:

Although several transcatheter therapies are available for the treatment of patients with mitral regurgitation (MR), a significant proportion of patients remain ineligible for any mitral valve (MV) intervention. Medical therapy in these patients is associated with poor outcomes.

Aims:

To characterize patients ineligible for MV interventions from a large international registry using an unsupervised phenotypic clustering approach.

 
Methods: Between 2014 and 2022, the CHOICE-MI registry included 984 patients undergoing screening for transcatheter mitral valve replacement at 33 international sites. For this study, only patients with screening failure resulting in medical therapy alone were included. Patients receiving transcatheter or surgical treatment were excluded (Figure 1). A cluster analysis was performed on baseline clinical and imaging variables, and predictors of all-cause mortality within these clusters were assessed.

 

Results:

Among 284 patients (77.4±8.82 years, 56.0% female, EuroSCORE II 6.6±5.8%) considered ineligible for any MV intervention, two clinically distinct phenogroups (PG) were identified using unsupervised hierarchical clustering of principal components (Figure 2): (PG1) Elderly women with primary MR, high left ventricular (LV) ejection fraction, and annular calcification; (PG2) Patients with secondary or mixed MR, LV and annular dilation, and high prevalence of comorbidities. There were no differences regarding Kaplan-Meier estimated 1-year all-cause mortality (PG1 vs. PG2, 21.4% vs. 23.4%, p=0.89) and 1-year cardiovascular mortality (10.4% vs. 13.5%, p=0.53). Predictors of mortality were albumin, renal function, extracardiac arteriopathy for PG1, and albumin, coronary artery disease, and prior myocardial infarction for PG2.

 

Conclusions:

This study identified two major subgroups among patients ineligible for mitral interventions showing profound differences in clinical and anatomical profiles, and predictors of outcome. Identifying these factors may drive technological evolution to address the unmet clinical need for therapeutic options in patients with MR.