Intraprocedural reduction of left atrial v wave predicts clinical outcome of transcatheter edge-to-edge mitral valve repair

Michael Georg Paulus (Regensburg)1, J. Rösch (Regensburg)1, F. Fochler (Regensburg)1, M. Haus (Regensburg)1, P. Felfeli (Regensburg)1, C. Schach (Regensburg)1, L. S. Maier (Regensburg)1, A. Luchner (Regensburg)2, C. Birner (Amberg)3, B. Unsöld (Gießen)4, C. Meindl (Regensburg)1, K. Debl (Regensburg)1

1Universitätsklinikum Regensburg Klinik und Poliklinik für Innere Med. II, Kardiologie Regensburg, Deutschland; 2Krankenhaus Barmherzige Brüder Regensburg Klinik für Kardiologie Regensburg, Deutschland; 3Klinikum St. Marien Klinik für Innere Medizin I Amberg, Deutschland; 4Universitätsklinikum Gießen und Marburg GmbH Medizinische Klinik I - Kardiologie und Angiologie Gießen, Deutschland


Intraprocedural assessment of residual mitral regurgitation (MR) is crucial for success of transcatheter edge-to-edge mitral valve repair (M-TEER) yet challenging in the case of ambiguous echocardiographic findings. While monitoring changes in left atrial (LA) pressure during the procedure may complement evaluation of residual MR after device placement, their value in determining postprocedural clinical outcome is unknown.
Methods and results
We enrolled 265 patients undergoing M-TEER for symptomatic moderate-to-severe or severe MR in a prospective single-center study. LA pressure was recorded before and after device implantation via the side port of the steering catheter of the device. Participants were followed up for a median of twelve months after the intervention. Mean age was 77±8 years, 42.9% of patients presented with reduced left ventricular ejection fraction (LVEF). MR was of secondary etiology in 62.3% of the study population. Four weeks after the procedure, reduction to MR grade II or less was achieved in 94.4% of patients. During M-TEER, mean LA v wave decreased from 31±15 to 22±10 mmHg (p<0.001) after device implantation, accompanied by a modest reduction of LA mean pressure from 17±6 to 15±6 mmHg (p<0.001). When adjusted for age, LVEF, NTproBNP, baseline LA v wave, and MR grade, reduction of LA v wave after device implantation independently predicted a combined endpoint of death, hospitalization for heart failure, or repeat intervention during follow-up (odds ratio per mmHg 1.026, 95% CI 1.003-1.049, p=0.024). Importantly, adding residual MR grade four weeks post intervention as a covariate did not diminish the predictive value of LA v wave reduction (odds ratio 1.033, 95% CI 1.007-1.060, p=0.014), implicating its prognostic importance in addition to echocardiographic outcomes.
Reduction of LA v wave during M-TEER predicts clinical outcome. Consideration of changes in LA hemodynamics after device placement may improve intraprocedural decision making.
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