https://doi.org/10.1007/s00392-025-02625-4
1Universitätsmedizin der Johannes Gutenberg-Universität Mainz Zentrum für Kardiologie Mainz, Deutschland; 2Cardiovascular Research Foundation New York, USA; 3IRCCS San Raffaele Milano, Italien; 4LMU Klinikum der Universität München Medizinische Klinik und Poliklinik I München, Deutschland; 5Herzzentrum der Universität zu Köln Klinik III für Innere Medizin Köln, Deutschland; 6Universitätsklinikum Ulm Klinik für Innere Medizin II Ulm, Deutschland; 7Herz- und Diabeteszentrum NRW Bad Oeynhausen, Deutschland; 8Herzzentrum der Universität zu Köln Klinik für Kardiologie, Angiologie, Pneumologie und Internistische Intensivmedizin Köln, Deutschland; 9Universitätsmedizin der Johannes Gutenberg-Universität Mainz Kardiologie 1, Zentrum für Kardiologie Mainz, Deutschland; 10Herz- und Diabeteszentrum NRW Klinik für Kardiologie Bad Oeynhausen, Deutschland; 11Universitätsmedizin der Johannes Gutenberg-Universität Mainz Zentrum für Kardiologie im Herz- und Gefäßzentrum Mainz, Deutschland
Background
Recurrence of significant mitral regurgitation (MR) after surgery in primary MR is challenging, with the optimal treatment yet to be determined. Few reports exist on the efficacy of transcatheter edge-to-edge repair (TEER) in this setting, and a proper comparison with redo surgery is lacking. This study compares the short- and mid-term outcomes of TEER versus redo surgery in this context.
Methods
REDO-MR is a new, multicenter, international registry including patients with history of surgical mitral valve repair who underwent a re-intervention (redo-surgery, valve-in-ring or TEER) for recurrent significant MR. Within this registry, 279 pts from 6 European and one North-American centers with history of surgery for primary MR were identified and included in the analysis. Among them, 182 underwent Redo surgery, and 97 TEER (timeframe 2004-2024). Propensity score (PS) matching was performed for 8 pre-operative parameters (age, history of atrial fibrillation, history of coronary artery disease, history of COPD, eGFR, STS score, EF, pre-operative NYHA class) and procedural outcomes as well as mortality up to 2 years were compared.
Results
After PS matching, 184 pts (TEER n=92, surgery n=92) were analyzed. The median age was 70 years [60; 77], the subjects were predominantly male (60%) and the median STS score was 2.6 [1.4; 3.7].
Patients in the TEER group experienced fewer in-hospital complications (post-operative inotropic support [13% vs. 60%], atrial fibrillation [5.6% vs. 37%], blood transfusions [2.2% vs. 46%], acute kidney injury [3.4% vs. 23%], p<0.01 for all) and had shorter hospital stays (6 days [5-8] vs. 7 [6-10], p=0.03).
At discharge, residual MR was mild or less in 53% of TEER patients and 98% of surgical patients (p<0.001). Two-year freedom from moderate MR or more was significantly higher in the surgical group (89 ± 4.4% in TEER vs. 96 ± 2.1% in surgery, p<0.01).
Logistic regression showed that, in the TEER cohort, commissural prolapse (p<0.01), restricted posterior leaflet motion (p=0.02), and MR severity at discharge (p<0.01) were associated with moderate MR or more during follow-up, while a pre-operative central main jet (A2-P2) was linked to a lower occurrence of this outcome.
Mortality at 30 days did not differ between groups (no TEER deaths vs. one surgical death, p=ns), and 2-year freedom from cardiac death was similar (93 ± 3% after TEER vs. 95 ± 4% after surgery, p=0.52). The only factor independently associated with the 2-year clinical endpoint on Cox regression was pre-operative LVEF (p<0.01). Neither the treatment option (TEER vs Redo surgery, p=0.17), nor residual MR of moderate or more during follow-up (p=0.9) were associated with cardiac death at 2-years.
Conclusions
In patients with failed surgical mitral valve repair, TEER is a safe and effective option to reduce MR, particularly in those with favorable anatomy. Although redo-surgery achieves better MR reduction initially and over time, it is not associated with better short- and mid-term survival. Therefore, TEER is a reasonable first-line treatment, with redo-surgery as a backup if significant MR recurs.