Haemodynamic effects of percutaneous mitral valve edge‐to‐edge repair in patients with end‐stage heart failure awaiting heart transplantation

Abstract

AimsFunctional mitral regurgitation is complicating end‐stage heart failure and potential heart transplantation by increasing pulmonary artery pressures. The aim of the present study was to investigate feasibility and haemodynamic effects of percutaneous mitral valve edge‐to‐edge repair using the MitraClip™ device in patients with end‐stage heart failure awaiting heart transplantation.Methods and resultsIn this retrospective study, we identified nine patients suffering from end‐stage heart failure listed for heart transplantation in whom moderate–severe or severe functional mitral regurgitation was recognized and treated with percutaneous mitral valve edge‐to‐edge repair. Twenty‐two patients listed for heart transplantation and presenting with moderate–severe or severe functional mitral regurgitation treated in the pre‐MitraClip™ era served as controls. Patients were analysed at two separate time points: MitraClip™ group: pre‐procedure and post‐procedure (follow‐up: 215 ± 53 days) and control group: study entry with recognition of moderate–severe or severe functional mitral regurgitation (follow‐up: 197 ± 47 days). Percutaneous mitral valve edge‐to‐edge repair with the MitraClip™ was feasible and safe in our high‐risk end‐stage heart failure population. The intervention resulted in significant reduction of mitral regurgitation (grade 3.0 [0.5] to 1.5 [0.5]; P = 0.009), left atrial diameter (51 mm [16] to 49 mm [4]; follow‐up MitraClip™ vs. control group P = 0.0497), pulmonary artery pressures (sPA 50 mmHg [15] to 45 mmHg [10]; P = 0.02; mPA 34 mmHg [8] to 30 mmHg [10]; P = 0.02), and New York Heart Association class (3.5 [1.0] to 3.0 [0.5]; P = 0.01) and improved mixed‐venous oxygen saturation (57% [11] to 55% [7]; follow‐up MitraClip™ vs. control group P = 0.02). No changes in the control group were observed.ConclusionsMitraClip™ implantation as ‘bridge‐to‐transplant’ strategy in patients with end‐stage heart failure and severe functional mitral regurgitation awaiting heart transplantation is feasible and appears to result in favourable haemodynamic effects.

Initial experience with percutaneous mitral valve repair in patients with cardiac amyloidosis

“…We and others have demonstrated that PMVR is an option as 'bridge to transplant' in nonamyloid cardiomyopathy patients awaiting heart transplantation. 67 Although the majority of patients in the present study were too aged for a 'bridge to transplant' approach, our data may add to the idea that interventional treatment of MR may significantly extend the therapeutic possibilities for those critical ill patients.…”

MitraClip improves cardiopulmonary exercise test in patients with systolic heart failure and functional mitral regurgitation

“…9 Third, from a physiopathological perspective, PMVR reduces MR, thus decreasing left-side volume overload and pulmonary pressures and increasing cardiac output. 10 And fourth, this haemodynamic enhancement has translated into positive left ventricular remodelling and improvement in clinical symptoms, quality of life, and 6 min walk test in different series. [11][12][13] Although only modest increments in LVEF have been reported in this scenario, these changes, alongside the reduction in regurgitant volume, imply an improvement in antegrade ejection flow that might be one of the underlying mechanisms for a better cardiopulmonary performance.…”

MitraClip implantation followed by insertion of a left ventricular assist device in patients with advanced heart failure

“…In this regard, mean LVEDD was 71 mm before MC in our patients, pointing to a very sick cohort of patients with exceptionally poor outcomes and probably in many centres those patients would have been rejected for PMVR in contemporary practice. However, at our centre, we have conduced MC procedures in advanced HF patients over the last decade with respectable success, 7,16,33 documenting that PMVR is even feasible in patients with heavily dilated LV, when patients are carefully selected and the operator is experienced.…”

“…In these patients with advanced HF, it remains unclear whether a prior MC implantation has any benefit as a bridge to LVAD. We have recently published that PMVR can be successfully used as a ‘bridge to transplant’ strategy in patients awaiting heart transplantation 33 . However, this is a situation where the aspired treatment strategy is not immediately available, making a ‘bridge to’ strategy necessary.…”

“…We have recently published that PMVR can be successfully used as a 'bridge to transplant' strategy in patients awaiting heart transplantation. 33 However, this is a situation where the aspired treatment strategy is not immediately available, making a 'bridge to' strategy necessary. Our present data are the first to compare the strategy of PMVR and subsequent LVAD insertion in an advanced HF population with immediate LVAD implantation.…”