Survival of Transcatheter Mitral Valve Repair Compared With Surgical and Conservative Treatment in High-Surgical-Risk Patients

Study Questions:

How does survival after MitraClip for transcatheter mitral valve repair compare with surgery and with conservative treatment in high-surgical-risk patients with symptomatic severe mitral valve regurgitation (MR)?

Methods:

Consecutive patients (n = 139) treated with MitraClip were included in this study. For comparison, surgically (n = 53) and conservatively (n = 59) treated patients were retrospectively identified. Surgical risk was based on the logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) or the presence of relevant risk factors, as judged by a heart team.

Results:

The logistic EuroSCORE was higher in the transcatheter repair (MitraClip) group (23.9 ± 16.1%) than in the surgically (14.2 ± 8.9%) or conservatively (18.7 ± 13.2%, p < 0.0001) treated patients. Left ventricular ejection fraction was higher in surgical patients (43.9 ± 14.4%, p = 0.003), with similar values for the transcatheter repair (36.8 ± 15.3%) and conservatively treated (34.5 ± 16.5%) groups. After 1 year of follow-up, the transcatheter repair and surgery groups had similar rates of survival (85.8% and 85.2%, respectively), compared to 67.7% survival in conservatively treated patients. The same trend was observed after the second and third years. After weighting for propensity score and controlling for risk factors, both the transcatheter repair (hazard ratio [HR], 0.41; 95% confidence interval [CI], 0.22-0.78; p = 0.006) and surgical (HR, 0.52; 95% CI, 0.30-0.88; p = 0.014) groups had better survival than the conservatively treated group. The transcatheter repair and surgical groups did not differ (HR, 1.25; 95% CI, 0.72-2.16; p = 0.430).

Conclusions:

The authors concluded that, despite a higher logistic EuroSCORE, high-surgical-risk patients with symptomatic severe MR treated with MitraClip transcatheter mitral valve repair show similar survival rates compared with surgically treated patients; both MitraClip and surgery displayed survival benefit compared with conservative treatment.

Perspective:

The MitraClip might allow intervention for some inoperable patients with MR. Because the relative reduction in MR afforded by the MitraClip in general is not what would be acceptable by surgical standards, it should not be seen as an alternative to surgical intervention for MR, and (at least in my opinion) should not be seen as an equivalent to TAVR for patients with aortic stenosis. This study, limited by its retrospective nature and propensity-matched comparative groups, suggests that there could be some mortality benefit associated with MitraClip therapy for high-risk patients with severe symptomatic MR.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention

Keywords: Follow-Up Studies, Propensity Score, Survival Rate, Stroke Volume, Risk Factors, Confidence Intervals, Heart Valve Prosthesis Implantation, Mitral Valve


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