Guideline-directed medical therapy after transcatheter edge-to-edge mitral valve repair

Abstract

ObjectiveA sizeable proportion of patients with secondary mitral regurgitation (SMR) do not receive guideline-directed medical therapy (GDMT) for heart failure (HF). We investigated the association between the use of GDMT and mortality in patients with SMR who underwent transcatheter edge-to-edge repair (TEER).MethodsWe retrospectively analysed patients with SMR and a left ventricular ejection fraction of <50% who underwent TEER at three centres. According to current HF guidelines, GDMT was defined as triple therapy consisting of beta-blockers, renin–angiotensin system (RAS) inhibitors and mineralocorticoid receptor antagonists (MRAs). Patients were divided into two groups: GDMT and non-GDMT groups. We calculated the propensity scores and carried out inverse probability of treatment weighting (IPTW) analyses to compare 2-year mortality between the two groups.ResultsOf 463 patients, 228 (49.2%) were treated with GDMT upon discharge. IPTW-adjusted Kaplan-Meier curve showed patients with GDMT had a lower incidence of mortality than those without GDMT (19.8% vs 31.1%, p=0.011). In IPTW-adjusted Cox proportional hazards analysis, GDMT was associated with a reduced risk of 2-year mortality (HR: 0.58; 95% CI: 0.35 to 0.95; p=0.030), which was consistent among clinical subgroups. Moreover, patients with GDMT had a higher rate of left ventricular reverse remodelling at 1 year after TEER than those without GDMT.ConclusionGDMT, defined as triple therapy consisting of beta-blockers, RAS inhibitors and MRAs, was associated with a reduced risk of 2-year mortality after TEER for SMR. Optimisation of medical therapy is crucial to improve clinical outcomes in patients undergoing TEER for SMR.

Evaluation of the Efficacy of Transcatheter Intervention, Surgery, and Pharmacological Treatment of Functional Mitral Regurgitation — A Bayesian Network Meta-Analysis with ≥12-Month Follow-up

“…For the 16 observational studies, the risk of bias was assessed using the NOS (Table 4, Ref. [10][11][12][13][15][16][17]19,21,[23][24][25]28,29,32,33]). The 16 observational studies had risk scores of 6 or higher, and the 12 cohort studies had scores of 8 or higher, indicating that most of the studies were of good quality.…”

“…Six articles [10,14,25,26,29,32] reported 30-day allcause mortality, twelve articles [11][12][13][14]20,22,24,26,27,29,33,34] reported 1-year all-cause mortality, and eight articles [10,11,13,22,[24][25][26][27] reported 2-year all-cause mortality. The network relationship is shown in Fig.…”

“…Six articles [12,13,16,22,33,34] reported improvement in MR in one year (from ≥3+ to ≤2+). The network diagram is shown in Fig.…”

Heartbeat: medical therapy, not just mechanical intervention, for optimal outcomes in patients with secondary mitral regurgitation

“…In patients with heart failure (HF) and secondary mitral regurgitation (SMR) undergoing transcatheter edge-to-edge repair (TEER) the role of guideline directed medical therapy (GDMT) after the procedure has been unclear. In a retrospective analysis of 463 patients undergoing TEER for SMR, Tanaka and colleagues1 observed a lower 2 year mortality in the 228 (49%) treated with GDMT, defined as triple therapy consisting of beta-blockers, renin–angiotensin system inhibitors and mineralocorticoid receptor antagonists, compared with those who did not receive GDMT (HR: 0.58; 95% CI: 0.35 to 0.95; p=0.030) (figure 1). Reverse left ventricular remodelling (a reduction in the LV end-systolic volume of ≥10% from baseline to 1 year follow-up) also was more common in patients on GDMT (40.2% vs 26.8%; p=0.038).…”

The synergy of myopathic valvular disease

“…With recent advancements in the treatment of heart failure with reduced ejection fraction (HFrEF) including the addition of angiotensin receptor–neprilysin inhibitor, sodium–glucose cotransporter 2 inhibitors (SGLT2i) and transcatheter edge-to-edge mitral valve repair (TEER), the treatment of patients with cardiomyopathy and secondary mitral regurgitation (SMR) has become increasingly complex and can lead to suboptimal utilisation of indicated therapies. Tanaka and colleagues1 have provided a real-world analysis of guideline-directed medical therapy (GDMT) among HFREF patients with SMR and managed with TEER. Their findings reinforce the importance of engaging focused heart failure (HF) cardiologists and allied teams to optimise medical therapy before and after TEER.…”