Transcatheter edge-to-edge-repair of functional mitral regurgitation induces significant remodeling of mitral annular geometry

Michael Paukovitsch; Dominik Felbel; Madeleine Jandek; Mirjam Keßler; Wolfgang Rottbauer; Sinisa Markovic; Matthias Groeger; Marijana Tadic; Leonhard Moritz Schneider

doi:10.3389/fcvm.2023.1143702

Transcatheter edge-to-edge-repair of functional mitral regurgitation induces significant remodeling of mitral annular geometry

Front Cardiovasc Med. 2023 Jun 23:10:1143702. doi: 10.3389/fcvm.2023.1143702. eCollection 2023.

Authors

Michael Paukovitsch¹, Dominik Felbel¹, Madeleine Jandek¹, Mirjam Keßler¹, Wolfgang Rottbauer¹, Sinisa Markovic¹, Matthias Groeger¹, Marijana Tadic¹, Leonhard Moritz Schneider¹

Affiliation

¹ Department of Cardiology, University Heart Center Ulm, Ulm, Germany.

Abstract

Background: Mitral annular alterations in the context of heart failure often lead to severe functional mitral regurgitation (FMR), which should be treated with transcatheter edge-to-edge repair (M-TEER) according to current guidelines. M-TEER's effects on mitral valve (MV) annular remodeling have not been well elucidated.

Methods: 141 consecutive patients undergoing M-TEER for treatment of FMR were included in this investigation. Comprehensive intraprocedural transesophageal echocardiography was used to assess the acute effects of M-TEER on annular geometry.

Results: Average patient age was 76.2 ± 9.6 years and 46.1% were female patients. LV ejection fraction was reduced (37.0% ± 13.7%) and all patients had mitral regurgitation (MR) grade ≥III. M-TEER achieved optimal MR reduction (MR ≤ I) in 78.6% of patients. Mitral annular anterior-posterior diameters (A-Pd) were reduced by -6.2% ± 9.5% on average, whereas anterolateral-posteromedial diameters increased (3.7% ± 8.9%). Overall, a reduction in MV annular areas was observed (2D: -1.8% ± 13.1%; 3D: -2.7% ± 13.7%), which strongly correlated with A-Pd reduction (2D: r = 0.6, p < 0.01; 3D: r = 0.65, p < 0.01). Patients that achieved A-Pd reduction above the median (≥6.3%) showed significantly lower rates of the composite endpoint rehospitalization for heart failure or all-cause mortality than those with less A-Pd reduction (9.9% vs. 28.6%, p = 0.037, log-rank p = 0.039). Furthermore, patients reaching the composite endpoint had an increase in annular area (2D: 3.0% ± 15.4%; 3D: 1.9% ± 15.3%), whereas those not reaching the endpoint showed a decrease (2D: -2.7% ± 12.4%; 3D: -3.6% ± 13.3%), although residual MR after M-TEER was similar between these groups (p = 0.57). In multivariate Cox regression adjusted for baseline MR, A-Pd reduction ≥6.3% remained a significant predictor of the combined endpoint (OR: 0.35, 95% CI: 0.14-0.85, p = 0.02).

Conclusion: Our findings indicate that effects of M-TEER in FMR are not limited to MR reduction, but also have significant impact on annular geometry. Moreover, A-Pd reduction, which mediates annular remodeling, has a significant impact on clinical outcome independent of residual MR.

Keywords: annuloplasty; anterior-posterior mitral annulus diameter; functional mitral regurgitation (FMR); transcatheter edge-to-edge repair; transesophageal echocardiography.