We are already familiar with the strong impact of secondary mitral valve regurgitation (SMR) in survival and quality of life.
Most of these patients present heart failure (HF) with reduced ejection fraction (HFrEF). Stages of heart failure based on extra-mitral cardiac involvement has been shown relevant. There is also extensive research on aortic valve disease and data on medically treated HFrEF-SMR patients divided into stages.
Patients with left ventricular dilation or left atrial enlargement have shown around 85% survival rate at 3 years, while this reduces to 75% with tricuspid regurgitation or pulmonary hypertension. Finally, patients with right ventricular dysfunction present the worse prognosis, with 60% survival rate at 3 years, approximately.
The aim of this retrospective study was to apply the HR stages above mentioned to patients undergoing transcatheter Edge-to-edge (M-TEER), and assess the prognostic implications of these classification in terms of survival and symptoms.
Primary end point was all cause mortality, and symptoms expressed as functional class according to NYHA at 2 years. Patients were classified into 4 stages: stage 1 (LV end diastolic volume ≥ 159 ml or EF < 50%), stage 2 (history of atrial fibrillation or indexed left atrial volume > 34 ml/m2), stage 3 (tricuspid regurgitation ≥ 3 and/or PSAP >65 mmHg), stage 4 (biventricular dysfunction.
Of 1354 patients set to be analyzed, only 849 met inclusion criteria. Mean age was 72 and there were more men, mostly in stage 2 (46% of patients), followed by stage IV (29%), stage III (15%) and stage I (10%).
Survival rate at 2 years was significantly different between stages (stage I: 78.1%, stage II: 71.9%, stage III: 62.9%, stage IV: 48.9%; P< 0.01). On the other hand, HR symptoms tended to increase as stages increased, though differences were not statistically significant.
Finally, at multivariable analysis, kidney function, diabetes mellitus, age, NYHA functional class IV, post M-TEER MR ≥3+, and stage increase resulted predictors of all-cause mortality at 2 years.
Conclusion
M-TEER patients classified into HFrEF-SMR stages according to extra-mitral cardiac involvement should be taken into account by the heart team for decision making on therapeutic strategy. Stage classification is easy to implement and is associated to significant differences in symptoms and survival after M-TEER. In addition, this could be useful to identify patients that will benefit from early intervention.
Dr. Andrés Rodríguez.
Member of the Editorial Board of SOLACI.org.
Original Title: Staging Heart Failure Patients With Secondary Mitral Regurgitation Undergoing Transcatheter Edge-to-Edge Repair.
Reference: Lukas Stolz, MD et al J Am Coll Cardiol Intv 2022.
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