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Leaflet-to-Annulus Index and Residual MR After Edge-to-Edge Mitral Repair
Study Questions:
What is the impact of leaflet-to-annulus mismatch on residual mitral regurgitation (MR) after percutaneous edge-to-edge mitral repair?
Methods:
In a single-center, retrospective, observational cohort study, data from consecutive patients with primary or secondary MR undergoing isolated transcatheter mitral valve repair using the MitraClip between September 2010 and March 2019 were analyzed. Residual MR was defined as post-procedural MR ≥2+, and patients were stratified into two groups according to the amount of residual MR. The leaflet-to-annulus index (LAI) was calculated using preprocedural two- and three-dimensional transesophageal echocardiography as the ratio of the sum of the anterior mitral leaflet length and posterior mitral leaflet length to the anteroposterior length of the mitral annulus ([anterior mitral leaflet length + posterior mitral leaflet length] / anteroposterior mitral annulus length) using a mid-esophageal long-axis view in mid-systole. All-cause death within a 1-year follow-up was examined.
Results:
Of 420 consecutive patients, 117 (27.9%) had residual (≥2+) MR. Patients with residual MR had a significantly lower preprocedural LAI than did those with MR <2+ (median, 1.14; interquartile range [IQR], 1.07-1.20 vs. 1.18; IQR, 1.12-1.29; p < 0.001). Multivariable analysis revealed that LAI was significantly associated with residual MR (odds ratio, 0.95; p < 0.001). After 1-year follow-up, patients with residual MR had a significantly worse prognosis than did patients with MR <2+ (estimated mortality rate, 17.4% vs. 7.3%; log-rank p = 0.002), and the presence of residual MR was independently correlated with 1-year mortality (hazard ratio, 2.74; p = 0.004).
Conclusions:
LAI is associated with residual MR after MitraClip implantation, which is independently correlated with 1-year mortality. The authors concluded that this index might be a useful tool to identify patients with the need for concomitant annuloplasty before edge-to-edge repair.
Perspective:
A substantial number of patients have residual MR after MitraClip repair, and features that can be identified before the procedure for better patient selection or for the use of concomitant procedures such as transcatheter annuloplasty may help improve results. The EVEREST II (Endovascular Valve Edge-to-Edge Repair Study II) trial used preintervention geometric parameters of coaptation length <2 mm, coaptation depth >11 mm, flail gap ≥10 mm, and flail width ≥15 mm. This study, with a mix of patients with primary and secondary MR, found that a lower LAI (mid-systolic anterior mitral leaflet length + posterior mitral leaflet length]/anteroposterior mitral annulus length) was associated with residual MR, with incremental value over the measures used in EVEREST II; however, there was substantial overlap in LAI values between patients with and without residual MR, and no report of a cutoff value to predict <2+ MR after intervention. Additional work is needed to help define which patients are most likely to have favorable echocardiographic results and clinical outcomes following MitraClip transcatheter edge-to-edge mitral repair.
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound, Mitral Regurgitation
Keywords: Cardiac Surgical Procedures, Cardiology Interventions, Diagnostic Imaging, Echocardiography, Three-Dimensional, Echocardiography, Transesophageal, Endovascular Procedures, Heart Valve Diseases, Heart Valve Prosthesis, Mitral Valve Annuloplasty, Mitral Valve Insufficiency, Systole
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