Heart team approach in treatment of mitral regurgitation: patient selection and outcome

Abstract

ObjectiveA multidisciplinary heart valve team is recommended for the evaluation of treatment in patients with valvular heart disease, but evidence supporting this concept is lacking. In patients with severe mitral regurgitation, we thought to analyse the patient selection process by the heart team for different treatment options and the outcome after treatment.MethodsIn this single-centre cohort study, all patients treated for mitral regurgitation between July 2013 and September 2018 were included. Primary end points during follow-up were all-cause mortality and a combined end point, consisting of all-cause mortality, cardiovascular rehospitalisation and mitral valve reintervention.Results179 patients (44.8%) were treated using Mitraclip, 185 (46.2%) by surgical repair and 36 (9.0%) by surgical replacement. The mortality risk according to EuroScore II differed significantly between treatment groups (6.6%±5.6%, 1.7%±1.5% and 3.6%±2.7% for Mitraclip, surgical repair and replacement, respectively, p<0.001). In-hospital mortality for the 3 groups were 3.4%, 1.6% and 8.3%, respectively (p=0.091). Overall, surgical repair patients had higher 4-year survival (HR 0.40 (95% CI 0.26 to 0.63), p<0.001) and fewer combined end points (HR 0.51 (95% CI 0.32 to 0.80), p<0.001) compared with surgical replacement and Mitraclip patients. However, patients undergoing Mitraclip for isolated, primary mitral regurgitation achieved very good long-term survival.ConclusionThe multidisciplinary heart team assigned only low-risk patients with favourable anatomy to surgical repair, while high-risk patients underwent Mitraclip or surgical replacement. This strategy was associated with lower than expected in-hospital mortality for Mitraclip patients and high 4-year survival rates for patients undergoing surgical or percutaneous repair of isolated primary mitral regurgitation.

Severity of Functional Mitral Regurgitation on Admission for Acute Decompensated Heart Failure Predicts Long‐Term Risk of Rehospitalization and Death

“…Therefore, as our understanding of FMR continues to evolve, a heart team approach—including a heart failure specialist—is increasingly important. 36 , 37 …”

Transcatheter Versus Surgical Valve Repair in Patients with Severe Mitral Regurgitation

“…In contrast to the aforementioned reports, Külling and coauthors [30] reported better survival after SMV than TMVR at 4 years (n = 185, p < 0.001). It has to be noted that although the EuroSCORE-II was significantly higher among TMVR patients (TMVR: 6.6% vs. MV repair: 1.7% vs. MV replacement: 3.6%), matching was not attempted, and the study design was retrospective.…”

“…However, prospective studies providing a head-to-head comparison of TMVR and SMV in degenerative as well as functional MR are still sparse, and results are contradictory. While several authors showed no difference in overall survival up to 5 years [16,28,29], others reported superior outcome after SMV [13,30]. The only prospective randomized controlled trial in this respect was the EVEREST II trial, published in 2011 [5].…”

Percutaneous Tricuspid Valve Repair

“…Several factors must be met to achieve a favorable technical outcome using transcatheter TV repair. Heart teams assessing and treating such patients must be specialized in many aspects, including clinical management of OHT patients, advanced imaging for complex valvular disease, competency in percutaneous valve treatment options, and expert knowledge in valvular heart surgery (mitral and tricuspid valve surgeons) ( 8 , 9 ). Furthermore, anatomic assessment of the TV is critical for the choice of the procedure.…”