Impact of improving severity of secondary mitral regurgitation on survival

Abstract

Aims Secondary mitral regurgitation (SMR) is frequent in patients with heart failure with reduced ejection fraction (HFrEF) and portends detrimental prognosis. Despite interventions addressing the mitral valve (MV) have been proven effective to improve survival, an important knowledge gap exists regarding the role of medical therapy (MT) in this context. Thus, we aimed at investigating the role of MT optimization in patients with SMR and HFrEF. Methods and results A total of 435 patients with SMR and HFrEF were retrospectively evaluated. Of those, 158 with severe SMR were finally included, with 63 (40%) managed with MT alone and 96 (60%) with MV intervention plus MT. Echocardiography was performed after 30 days of MT optimization or MV intervention. Responders were patients with a final mitral regurgitation (MR) grade of ≤2+. Survival data were gathered through the National Database Index and patient chart review. MR severity improved in 131 patients (100% MV intervention; 57% MT) but stayed the same or worsened in 27 patients. Responders and non‐responders were similar for baseline characteristics. Overall, long‐term survival of responders was significantly higher than non‐responders [hazard ratio (HR) 0.55, 95% confidence interval (CI) (0.32–0.96), P = 0.032]. No difference in survival was observed when evaluated by intervention type in the overall population (MT alone, n = 63; MV intervention plus MT, n = 95) [HR 0.77, 95% CI (0.48–1.26), P = 0.3], nor within responder group (MT alone, n = 36; MV intervention plus MT, n = 95) [HR 1.03, 95% CI (0.56–1.89), P = 0.94]. Conclusions MT reduces SMR severity in 57% of the patients with severe SMR. A final SMR grade of ≤2+ is linked to improved survival, independently of the type of treatment they receive.

Cardiac Surgery 2022 Reviewed

“…46 While this meta-analysis evaluated neither the degree of mitral regurgitation (MR) reduction with treatment nor the durability of the repairs, the results and other data give rise to assuming a correlation between the degree of MR and mortality and/or adverse events. This assumption was supported in 2022 by Sannino et al 47 assessing 158 patients with severe FMR who either received MitraClip (60%) or medical therapy alone (40%) as treatment. They measured the change in MR degree in response to the treatment.…”

“…5 Survival probability of a cohort of patients with functional mitral regurgitation who received either medical therapy or medical plus MitraClip therapy according to treatment success (i.e., MR reduction) (A) or according to treatment performed (B) (reproduced with permission from Sannino et al). 47 • In the field of mitral valve surgery, evidence culminated in 2022 supporting the concept that the best long-term treatment effects, including life prolongation, are associated with the quality (degree of MR reduction) and the durability of the repair. • The treatment of TR, if performed concomitantly, may lead to more pacemaker implantations.…”

A year in heart failure: updates of clinical and preclinical findings

“…The novel PASCAL system for transcatheter mitral valve repair showed comparable outcomes in terms of clinical improvement after 1 year compared with MitraClip in a 1:2 propensity‐matched cohort of 123 MR cases 30 . Importantly, also medical therapy of HFrEF can improve functional MR, as demonstrated in a retrospective analysis of 159 patients, which showed a reduced MR severity in 57% of the proportion receiving only medical therapy 31 . An echocardiographic MR grading ≤2 after either medical therapy optimization or mitral valve intervention was associated improved survival, independently of medical or interventional treatment, 31 suggesting MR reduction as a treatment goal in HFrEF.…”

“…30 Importantly, also medical therapy of HFrEF can improve functional MR, as demonstrated in a retrospective analysis of 159 patients, which showed a reduced MR severity in 57% of the proportion receiving only medical therapy. 31 An echocardiographic MR grading ≤2 after either medical therapy optimization or mitral valve intervention was associated improved survival, independently of medical or interventional treatment, 31 suggesting MR reduction as a treatment goal in HFrEF. The latter notion opens an avenue for the discovery of targeted therapies for MR as part of the HFrEF therapeutic strategies.…”

Editors' highlight picks from 2023 in ESC heart failure

“…In addition to TAVI, ESC Heart Failure provided important updates on also transcatheter mitral valve repair (TMVr) in 2023. Reduction of secondary MR in patients with HF with reduced ejection fraction (HFrEF) was associated with improved prognosis and that final MR grade, rather than the MR cause, determined the prognosis 25 . Reports in ESC Heart Failure have also specifically looked at interventional treatment in special MR subpopulations.…”