Transcatheter or surgical repair for degenerative mitral regurgitation in elderly patients: A propensity-weighted analysis

Abstract

Objective: To compare the outcomes of MitraClip and surgical mitral repair in low-intermediate risk elderly patients affected by degenerative mitral regurgitation (DMR).Methods: We retrospectively selected patients aged !75 years, with Society of Thoracic Surgeons Predicted Risk Of Mortality (STS-PROM) <8%, submitted to MitraClip (n ¼ 100) or isolated surgical repair (n ¼ 206) for DMR at 2 centers between January 2005 and May 2017. To adjust for baseline imbalances, we used a propensity score model for average treatment effect on survival.Results: After weighting, MitraClip showed fewer postoperative complications (P <.05) but increased residual mitral regurgitation (MR) !2 (27.0% vs 2.8%, P <.001) compared with surgery. One-year survival was greater after MitraClip compared with surgery (97.6% vs 95.3%, hazard ratio [HR], 0.09; confidence interval [CI], 0.02-0.37, P ¼ .001), whereas 5-year survival was lower (34.5% vs 82.

Risk of Prolonged Mechanical Ventilation After Cardiac Surgery: Predicting the Unpredictable?

“…4,5 In parallel, new interventional (transcatheter) procedures represent nowadays an emerging alternative to cardiac surgery, also leading to a change in the previously established cardiac surgery patient selection. 6,7 This in turn may have an impact on the variables that were identified as predictors in this recent score. Hence, datasets from previous years using older techniques in the management of cardiac surgery may be used only with caution.…”

Commentary: Looking for support for the MitraClip

“…In this study, the 5-year estimate for MR of at least 3þ was 36.9% for MitraClip, compared with 3.9% in the surgical arm. 9 This compares with the rates of 12.3% and 1.8% seen in EVEREST II, 10 with the caveat that the EVEREST II patients were younger. Nevertheless, for the elderly patient at low or moderate risk, the 1-year results may be sufficient to advocate for the transcatheter approach.…”

“…7 Expanding the clinical indications for MitraClip includes considering functional MR 8 and lowering the risk profile of patients considered. 9 The former is being addressed by the Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation (COAPT) trial.…”

Commentary: Moving the guidelines for mitral repair

“…Weighted Cox regression found a hazard ratio of 2.19 (P ¼ .033). Despite the many limitations of the study, which are well delineated and admirably modeled by Buzzatti and colleagues, 3 the message is clear: In the elderly population, whatever approach is chosen, the result of the intervention must provide durable relief from severe mitral regurgitation to warrant interventional risk.…”