Association of Pulmonary Hypertension With Clinical Outcomes of Transcatheter Mitral Valve Repair

Abstract

pHTN) is associated with increased risk of mortality after mitral valve surgery for mitral regurgitation. However, its association with clinical outcomes in patients undergoing transcatheter mitral valve repair (TMVr) with a commercially available system (MitraClip) is unknown.OBJECTIVE To assess the association of pHTN with readmissions for heart failure and 1-year all-cause mortality after TMVr. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study analyzed 4071 patients who underwent TMVr with the MitraClip system from November 4, 2013, through March 31, 2017, across 232 US sites in the Society of Thoracic Surgery/American College of Cardiology Transcatheter Valve Therapy registry. Patients were stratified into the following 4 groups based on invasive mean pulmonary arterial pressure (mPAP): 1103 with no pHTN (mPAP, <25 mm Hg [group 1]); 1399 with mild pHTN (mPAP, 25-34 mm Hg [group 2]); 1011 with moderate pHTN (mPAP, 35-44 mm Hg [group 3]); and 558 with severe pHTN (mPAP, Ն45 mm Hg [group 4]). Data were analyzed from November 4, 2013, through March 31, 2017.INTERVENTIONS Patients were stratified into groups before TMVr, and clinical outcomes were assessed at 1 year after intervention. MAIN OUTCOMES AND MEASURESPrimary end point was a composite of 1-year mortality and readmissions for heart failure. Secondary end points were 30-day and 1-year mortality and readmissions for heart failure. Linkage to Centers for Medicare & Medicaid Services administrative claims was performed to assess 1-year outcomes in 2381 patients. RESULTSAmong the 4071 patients included in the analysis, the median age was 81 years (interquartile range, 73-86 years); 1885 (46.3%) were women and 2186 (53.7%) were men. The composite rate of 1-year mortality and readmissions for heart failure was 33.6% (95% CI, 31.6%-35.7%), which was higher in those with pHTN (27.8% [95% CI, 24.2%-31.5%] in group 1, 32.4% [95% CI, 29.0%-35.8%] in group 2, 36.0% [95% CI, 31.8%-40.2%] in group 3, and 45.2% [95% CI, 39.1%-51.0%] in group 4; P < .001). Similarly, 1-year mortality (16.3% [95% CI, 13.4%-19.5%] in group 1, 19.8% [95% CI, 17.0%-22.8%] in group 2, 22.4% [95% CI, 18.8%-26.1%] in group 3, and 27.8% [95% CI, 22.6%-33.3%] in group 4; P < .001) increased across pHTN groups. The association of pHTN with mortality persisted despite multivariable adjustment (hazard ratio per 5-mm Hg mPAP increase, 1.05; 95% CI, 1.01-1.09; P = .02). CONCLUSIONS AND RELEVANCEThese findings suggest that pHTN is associated with increased mortality and readmission for heart failure in patients undergoing TMVr using the MitraClip system for severe mitral regurgitation. Further efforts are needed to determine whether earlier intervention before pHTN develops will improve clinical outcomes.

Pulmonary artery pressures and outcomes after MitraClip

“…While other studies have shown lower survival in patients with pre‐procedural severe PHT, 8,19 their survival was similar in our study. To further evaluate this issue, we performed a log‐rank analysis for patients who had improved their pulmonary pressure compared with patients whose sPAP had worsened or remained unchanged and showed that survival was similar.…”

MitraClip or Ventricular Assist Device?

“…8) For example, the absence of pulmonary hypertension is associated with better clinical outcomes following the MitraClip procedure. 12) Further investigations of key parameters to optimize patient selection for the MitraClip therapy are warranted.…”

Selection of the Optimal Candidate to MitraClip for Secondary Mitral Regurgitation: Beyond Mitral Valve Morphology

“…While EROA and RVol are the gold standards in MR severity assessment, the hemodynamic load (supported by RF assessment) and the extent and presence of advanced LV disease have recently been emphasized in recent randomized trials as key factors in determining the benefits of targeting the LV alone (OMT + CRT) or additionally the mitral valve (PMVR). However, clinical experience and published data also highlight the need to consider several additional factors, including the presence of severe RV dysfunction, advanced LV impairment (typically associated with very high BNP values), and an irreversible precapillary component of pulmonary hypertension ( 92 ), that can attenuate the benefit of PMVR and predict potential futility. Where doubt remains, functional testing to assess ventricular reserve ( 75 , 83 ) and dynamic RV-to-pulmonary circulation uncoupling ( 82 , 93 ) can be useful for further risk stratification.…”