Cardio‐hepatic syndrome in patients undergoing mitral valve transcatheter edge‐to‐edge repair

Abstract

Aims The impact of the cardio‐hepatic syndrome (CHS) on outcomes in patients undergoing mitral valve transcatheter edge‐to‐edge repair (M‐TEER) for relevant mitral regurgitation (MR) is unknown. The objectives of this study were three‐fold: (i) to characterize the pattern of hepatic impairment, (ii) to investigate the prognostic value of CHS, and (iii) to evaluate the changes in hepatic function after M‐TEER. Methods and results Hepatic impairment was quantified by laboratory parameters of liver function. In accordance with existing literature, two types of CHS were distinguished: ischaemic type I CHS (elevation of both transaminases) and cholestatic type II CHS (elevation of two out of three parameters of hepatic cholestasis). The impact of CHS on 2‐year mortality was evaluated using a Cox model. The change in hepatic function after M‐TEER was assessed by laboratory testing at follow‐up. We analysed 1083 patients who underwent M‐TEER for relevant primary or secondary MR at four European centres between 2008 and 2019. Ischaemic type I and cholestatic type II CHS were observed in 11.1% and 23.0% of patients, respectively. Predictors for 2‐year all‐cause mortality differed by MR aetiology. While in primary MR cholestatic type II CHS was independently associated with 2‐year mortality, ischaemic CHS type I was an independent mortality predictor in secondary MR patients. At follow‐up, patients with MR reduction ≤2+ (obtained in 90.7% of patients) presented with improved parameters of hepatic function (median reduction of 0.2 mg/dl, 0.2 U/L and 21 U/L for bilirubin, alanine aminotransferase and gamma‐glutamyl transferase, respectively, p < 0.01). Conclusions The CHS is frequently observed in patients undergoing M‐TEER and significantly impairs 2‐year survival. Successful M‐TEER may have beneficial effects on CHS.

Cardio-hepatic syndrome in patients undergoing transcatheter aortic valve replacement

“…Recently, we identified the presence of the cardiohepatic syndrome (CHS) to be associated with impaired survival prognosis after transcatheter tricuspid and mitral valve edge-to-edge repair [ 12 ]. In concordance with preexisting literature, the latter was as defined by an elevation of two out of three laboratory parameters of hepatic cholestasis [ 13 , 14 ].…”

Ten Future Challenges in the Field of Transcatheter Mitral Valve Edge-to-Edge Repair

“…These recommendations were based on the results of randomized trials, namely the Endovascular Valve Edge-to-Edge Repair Study (EVEREST II, which included primary MR patients), the Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation (COAPT, which included secondary MR patients), and several large-scale registries [ 2 , 4 , 5 , 6 , 7 , 8 , 9 ]. Real-world data have shown similar feasibility, effectiveness, and safety of M-TEER in a non-randomized setting despite differences in study populations [ 5 , 9 , 10 , 11 ].…”

Transcatheter edge‐to‐edge repair: fix the heart, heal the liver

“…In this issue of the Journal, Stolz et al 4 aimed to investigate the prevalence, prognostic value, and evolution of CHS in patients with MR undergoing TEER. The authors characterized the pattern of hepatic impairment using laboratory parameters and distinguished two types of CHS: cholestatic CHS when two out of three parameters of hepatic cholestasis were elevated (bilirubin, gamma-glutamyl transferase, and alkaline phosphatase), ischaemic CHS with the elevation of both transaminases (aspartate and alanine transaminases).…”