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Mitral Surgery After Transcatheter Edge-to-Edge Repair
Quick Takes
- In an analysis of the STS Adult Cardiac Surgery Database, surgical mitral repair after failed transcatheter edge-to-edge repair is infrequently achieved in only 4.8%.
- Operative mortality was 10.6% overall and lowest (2.6%) at the highest quintile volume centers that performed >10 cases over a 6-year period.
Study Questions:
What are outcomes after mitral surgery after failed transcatheter edge-to-edge repair (TEER)?
Methods:
This is a retrospective review of the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) of patients who underwent mitral valve surgery from July 2014–June 2020 after failed TEER. Patients who had emergency status, open implantation of a transcatheter prosthesis, or history of previous mitral surgery were excluded. Primary mitral valve etiology was recorded, as were baseline patient characteristics, operative variables, and postoperative outcomes. STS Predicted Risk of Mortality (PROM) was calculated. Primary outcome was operative mortality. Secondary outcomes were stroke, unplanned re-operation, multiorgan failure, and mitral repair rate following failed TEER. Multivariable logistic regression analysis was used to define predictors of operative mortality.
Results:
Out of a total 524 patients, 463 patients remained in the study cohort after exclusion. Median age was 76 years (interquartile range [IQR], 67-81 years), and median left ventricular ejection fraction was 57% (IQR, 48-62%). Concomitant procedures, including atrial septal defect closure, ablation for atrial fibrillation, tricuspid valve repair/replacement, aortic valve replacement, or coronary artery bypass grafting, were performed in 51.2% (n = 237). Median STS PROM was 7.7% (IQR, 45.-12.1%) in the 326 patients for whom it could be calculated. 57.3% had moderate or severe tricuspid regurgitation, 66.5% had history of atrial fibrillation, 4.5% had active or treated endocarditis, and 26.6% had previous cardiac surgery. 38.2% had degenerative mitral valve disease.
Mitral valve repair rate was 4.8% (n = 22). In those who underwent mitral valve replacement, 91.8% received a bioprosthetic valve. Operative mortality was 10.6% (n = 49) overall and lowest in patients with degenerative disease who underwent elective surgery (2.8%). In patients who underwent isolated mitral valve repair, the ratio of observed to expected mortality was 1.2 (95% confidence interval [CI], 0.8-1.9). Stroke occurred in 1.3%, new dialysis in 7.7%, and unplanned re-operation in 13.4%.
Multivariable predictors of operative mortality included age >80 years (odds ratio [OR], 2.1; 95% CI, 1.1-4.1; p = 0.02), urgent status (OR, 2.4; 95% CI, 1.3-4.6; p = 0.01), preoperative creatinine >2.0 mg/dl (OR, 3.8; 95% CI, 1.9-7.9; p < 0.01), and nondegenerative or unknown etiology (OR, 2.2; 95% CI, 1.1-4.5; p = 0.03). Hospital case volume impacted operative mortality, which was only 2.6% in the highest quintile (>10 cases over the study period) versus 12.4% in centers that performed fewer.
Conclusions:
Mitral valve repair after failed TEER was achieved in only 4.8% of patients, and operative mortality was lowest at centers that performed >10 mitral valve operations after failed TEER over a 6-year period.
Perspective:
Slightly over 500 mitral valve operations after failed TEER were performed over 6 years in the United States, a small number in the grand scheme of the STS ACSD; however, that number is expected to increase given the trend in increasing number of TEER procedures. The authors suggest that the low rate of mitral valve repair after failed TEER and the lower operative mortality (in this higher-risk patient population) achieved at high-volume centers could inform future practice in several ways. First, higher-risk patients who are candidates for both surgical mitral repair and TEER may achieve better outcomes at high-volume centers. Second, in lower-risk patients who are candidates for both options, the higher likelihood of surgical mitral repair, and its associated benefits, when pursued as the first intervention should be carefully considered by both the patient and clinician, even if the minimally invasive aspect of TEER is more appealing.
Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Congenital Heart Disease and Pediatric Cardiology, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and CHD and Pediatrics, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Interventions, Acute Heart Failure, Interventions and Structural Heart Disease, Mitral Regurgitation
Keywords: Atrial Fibrillation, Cardiac Surgical Procedures, Coronary Artery Bypass, Creatinine, Endocarditis, Geriatrics, Heart Failure, Heart Septal Defects, Atrial, Heart Valve Diseases, Mitral Valve Insufficiency, Renal Dialysis, Stroke, Stroke Volume, Tricuspid Valve Insufficiency, Ventricular Function, Left
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