Characterizing Patients Ineligible for Mitral Valve Intervention: Phenotypic Clustering Sub-Analysis from the CHOICE-MI Registry

Sebastian Ludwig (Hamburg)1, A. Coisne (Lille)2, K. Hamzi (Paris)3, W. Ben Ali (Montréal)4, B. Köll (Hamburg)1, D. Kalbacher (Hamburg)5, A. Scotti (New York)6, A. Duncan (London)7, R. Makkar (Los Angeles)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 (Mailand)25, F. Praz (Bern)26, R. S. von Bardeleben (Mainz)27, J. Hausleiter (München)28, A. Latib (New York)6, T. Modine (Bordeaux)29, T. Pezel (Paris)3, J. Granada (New York)30, L. Conradi (Hamburg)31

1Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Kardiologie Hamburg, Deutschland; 2CHU Lille Lille, Frankreich; 3Lariboisière Hospital Paris, Frankreich; 4Montreal Heart Institute Montréal, Kanada; 5Universitäres Herz- und Gefäßzentrum Hamburg Allgemeine und Interventionelle Kardiologie Hamburg, Deutschland; 6Montefiore Medical Center New York, USA; 7Royal Brompton Hospital London, Großbritannien; 8Cedars Sinai Medical Center Los Angeles, 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 München, Deutschland; 14Herzzentrum der Universität zu Köln Klinik III für Innere Medizin Köln, Deutschland; 15Rigshospitalet Kopenhagen, Dänemark; 16Rikshospitalet Oslo, Norwegen; 17HerzZentrum Hirslanden Zürich 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 London, Großbritannien; 22Mount Sinai Hospital New York, USA; 23Houston Methodist Hospital Houston, USA; 24St. Michael's Hospital Toronto, Kanada; 25San Rafaele Hospital Mailand, Italien; 26Inselspital Bern 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; 29CHU Bordeaux Bordeaux, Frankreich; 30Cardiovascular Research Foundation New York, USA; 31Universitäres Herz- und Gefäßzentrum Hamburg Klinik und Poliklinik für Herz- und Gefäßchirurgie Hamburg, Deutschland



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.


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.



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.



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.

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