Baseline Left Atrial Pressure Predicts Mortality Following Transcatheter Edge-to-Edge Mitral Valve Repair

Shaer, Ahmed El; Mahayni, Abdulah; Simard, Trevor; Eleid, Mackram F.; Guerrero, Mayra; Rihal, Charanjit S.; Alkhouli, Mohamad

doi:10.1016/j.jcin.2021.07.057

Cited by 10 publications

(8 citation statements)

References 4 publications

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“…Invasive hemodynamic assessment has historically provided important incremental data to guide operators intraprocedurally, with LA pressure, in particular, aiding in predicting clinical outcomes. [24][25][26][27] In this study, however, lower baseline LA pressures were observed with blunted acute hemodynamic results in the A-FMR cohort, likely reflecting the more marked atrial myopathy, altered LA compliance, and potentially more loading-sensitive pressure changes in this cohort. 5 Consequently, the optimal metric for defining intra-procedural MTEER success in A-FMR remains unclear and will require further…”

Section: Discussioncontrasting

confidence: 53%

“…This is reflected in the tendency of A‐FMR to be quantified as less severe at baseline and have diminished absolute reduction post MTEER, while also contributing to the blunted hemodynamic response demonstrated. Invasive hemodynamic assessment has historically provided important incremental data to guide operators intraprocedurally, with LA pressure, in particular, aiding in predicting clinical outcomes 24–27 . In this study, however, lower baseline LA pressures were observed with blunted acute hemodynamic results in the A‐FMR cohort, likely reflecting the more marked atrial myopathy, altered LA compliance, and potentially more loading‐sensitive pressure changes in this cohort 5 .…”

Section: Discussionmentioning

confidence: 62%

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Atrial mitral regurgitation: Characteristics and outcomes of transcatheter mitral valve edge‐to‐edge repair

Simard

Reddy

Thaden

et al. 2022

Cathet Cardio Intervent

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Background Mitral transcatheter edge‐to‐edge repair (MTEER) is an established therapeutic approach for mitral regurgitation (MR). Functional mitral regurgitation originating from atrial myopathy (A‐FMR) has been described. Objectives We sought to assess the clinical, echocardiographic and hemodynamic considerations in A‐FMR patients undergoing MTEER. Methods From 2014 to 2020, patients undergoing MTEER for degenerative MR (DMR), functional MR (FMR), and mixed MR were assessed. A‐FMR was defined by the presence of MR > moderate in severity; left ventricular (LV) ejection fraction (LVEF) ≥ 50%; and severe left atrial (LA) enlargement in the absence of LV dysfunction, leaflet pathology, or LV tethering. The diagnosis of A‐FMR (vs. ventricular‐FMR [V‐FMR]) was confirmed by three independent echocardiographers. Baseline characteristics, procedural outcomes as well as clinical and echocardiographic follow‐up are reported. Device success was defined as final MR grade ≤ moderate; MR reduction ≥1 grade; and final transmitral gradient <5 mmHg. Results 306 patients underwent MTEER, including DMR (62%), FMR (19%), and mixed MR (19%). FMR cases included 37 (63.8%) V‐FMR and 21 (36.2%) A‐FMR. Tricuspid regurgitation (≥ moderate) was higher in A‐FMR (80.1%) compared to V‐FMR (54%) and DMR (42%). Device success did not significantly differ between A‐FMR and V‐FMR (57% vs. 73%, p = 0.34) or DMR (57% vs. 64%, p = 1.0). The A‐FMR cohort was less likely to achieve ≥3 grades of MR reduction compared to V‐FMR (19% vs. 54%, p = 0.01) and DMR (19% vs. 49.7%, p = 0.01). Patients with V‐FMR and DMR demonstrated significant reductions in mean left atrial pressure (LAP) and peak LA V‐wave, though A‐FMR did not (LAP −0.24 ± 4.9, p = 0.83; peak V‐wave −1.76 ± 9.1, p = 0.39). In follow‐up, echocardiographic and clinical outcomes were similar. Conclusions In patients undergoing MTEER, A‐FMR represents one‐third of FMR cases. A‐FMR demonstrates similar procedural success but blunted acute hemodynamic responses compared with DMR and V‐FMR following MTEER. Dedicated studies specifically considering A‐FMR are needed to discern the optimal therapeutic approaches.

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Section: Discussioncontrasting

confidence: 53%

Section: Discussionmentioning

confidence: 62%

Atrial mitral regurgitation: Characteristics and outcomes of transcatheter mitral valve edge‐to‐edge repair

Simard

Reddy

Thaden

et al. 2022

Cathet Cardio Intervent

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“…Hemodynamic success of the TEER procedure is an area of growing interest. Previous studies have documented an association between baseline LAP and long‐term mortality after TEER, and between final LAP after the procedure with long‐term mortality 6,7 . However, the definition of hemodynamic success varied and the determinants of attaining hemodynamic success have not been previously explored.…”

Section: Discussionmentioning

confidence: 99%

“…Recently, several studies proposed the incorporation of invasive hemodynamics in the assessment of TEER success. [5][6][7][8][9][10][11] These studies documented an independent association between a reduction in left atrial pressure (LAP) after TEER and improved outcomes suggesting that improving LAP should be considered as a target of the procedure. Nonetheless, predictors of LAP reduction with TEER have not been previously explored.…”

Section: Introductionmentioning

confidence: 99%

“…However, echocardiographic criteria of residual MR after TEER have neither been standardized or validated. Recently, several studies proposed the incorporation of invasive hemodynamics in the assessment of TEER success 5–11 . These studies documented an independent association between a reduction in left atrial pressure (LAP) after TEER and improved outcomes suggesting that improving LAP should be considered as a target of the procedure.…”

Section: Introductionmentioning

confidence: 99%

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Predictors of hemodynamic response to mitral transcatheter edge‐to‐edge repair

Samimi

Ponce

Alarouri

et al. 2023

Cathet Cardio Intervent

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Background: Improvement in left atrial pressure (LAP) during transcatheter edge-toedge repair (TEER) is associated with improved outcomes. We sought to investigate the predictors of optimal hemodynamic response to TEER. Methods:We identified patients who underwent TEER at Mayo Clinic between May 2014 and February 2022. Patients with missing LAP data, an aborted procedure, and those undergoing a concomitant tricuspid TEER were excluded. We performed a logistic regression analysis to identify predictors of optimal hemodynamic response to TEER (defined as LAP ≤ 15 mmHg).Results: A total of 473 patients were included (Mean age 78.5 ± 9.4 years, 67.2% males). Overall, 195 (41.2%) achieved an optimal hemodynamic response after TEER.Patients who did not achieve an optimal response had higher baseline LAP (20.0 [17][18][19][20][21][22][23][24][25] vs. 15.0 [12-18] mmHg, p < 0.001), higher prevalence of AF (68.3% vs. 55.9%, p = 0.006), functional MR (47.5% vs. 35.9%, p = 0.009), annular calcification (41% vs. 29.2%, p = 0.02), lower left ventricular EF (55% vs. 58%, p = 0.02), and more frequent postprocedural severe MR (11.9% vs. 5.1%, p = 0.02) and elevated mitral gradient >5 mmHg (30.6% vs. 14.4%, p < 0.001). In the multivariate logistic regression analysis, AF (OR = 0.58; 95% CI = 0.35-0.96; p = 0.03), baseline LAP (OR = 0.80; 95% CI = 0.75-0.84; p < 0.001) and postprocedural mitral gradient <5 mmHg (OR = 0.35; 95% CI = 0.19-0.65; p < 0.001), were independent predictors of achieving an optimal hemodynamic response. In the multivariate model, residual MR was not independently associated with optimal hemodynamic response.Conclusions: Optimal hemodynamic response is achieved in 4 in 10 patients undergoing TEER. AF, higher baseline LAP, and higher postprocedural mitral gradient were negative predictors of optimal hemodynamic response after TEER.

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Mitral regurgitation in heart failure with preserved ejection fraction: The interplay of valve, ventricle, and atrium

Dhont,

van den Acker,

van Loon

et al. 2024

European J of Heart Fail

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Mitral regurgitation (MR) is highly prevalent among patients with heart failure and preserved ejection fraction (HFpEF). Despite this combination being closely associated with unfavourable outcomes, it remains relatively understudied. This is partly due to the inherent heterogeneity of patients with HFpEF. To address this gap, dissecting HFpEF into mechanism‐based phenotypes may offer a promising avenue for advancing our comprehension of these complex intertwined conditions. This review employs the validated CircAdapt model to explore the haemodynamic implications of moderate to severe MR across a well‐defined spectrum of myocardial disease, characterized by impaired relaxation and reduced myocardial compliance. Both heart failure and mitral valve disease share overlapping symptomatology, primarily attributed to elevated pulmonary pressures. The intricate mechanisms contributing to these elevated pressures are multifaceted, potentially influenced by diastolic dysfunction, left atrial myopathy, and MR. Accurate evaluation of the haemodynamic and clinical impact of MR necessitates a comprehensive approach, taking into account the characteristics of both the left atrium and left ventricle, as well as their intricate interactions, which may currently be underemphasized in diagnostic practice. This holistic assessment is imperative for enhancing our understanding and refining therapeutic strategies within this patient cohort.

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Baseline Left Atrial Pressure Predicts Mortality Following Transcatheter Edge-to-Edge Mitral Valve Repair

Cited by 10 publications

References 4 publications

Atrial mitral regurgitation: Characteristics and outcomes of transcatheter mitral valve edge‐to‐edge repair

Atrial mitral regurgitation: Characteristics and outcomes of transcatheter mitral valve edge‐to‐edge repair

Predictors of hemodynamic response to mitral transcatheter edge‐to‐edge repair

Mitral regurgitation in heart failure with preserved ejection fraction: The interplay of valve, ventricle, and atrium

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