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Impact of Transcatheter Mitral Valve Repair on Surgical Repair Outcomes
Quick Takes
- The introduction of transcatheter edge-to-edge repair (TEER) for degenerative mitral regurgitation has not significantly impacted annualized mitral valve repair (MVr) volume in TEER institutions from 2011–2018.
- Adoption of this technique was associated with an improvement in 30-day MVr outcomes and 5-year mortality possibly related to a shift toward lower-risk patients.
- The findings of this study suggest that a systematic evaluation by a heart team able to direct patients towards either surgical or transcatheter approaches enhances both short- and long-term surgical outcomes.
Study Questions:
What is the impact of transcatheter edge-to-edge repair (TEER) on national surgical mitral valve repair (MVr) volumes and outcomes for degenerative mitral regurgitation?
Methods:
The investigators obtained MVr volume, 30-day and 5-year outcomes, including mortality, heart failure rehospitalization, and mitral valve reintervention from the Society of Thoracic Surgeons (STS) database linked with Medicare administrative claims and were compared within TEER centers before and after the first institutional TEER procedure. A difference-in-difference approach comparing parallel trends in coronary artery bypass grafting (CABG) outcomes was used to account for temporal improvements in perioperative care. Differences in operative and long-term outcomes were assessed with univariate and multivariable regression models for patients undergoing surgical MVr after versus before (reference) TEER capability at the associated institution.
Results:
From July 2011–December 2018, 13,959 patients underwent MVr at 278 institutions, which became TEER-capable during the study period. There was no significant change in median annualized institutional MVr volume before (32 [IQR, 17-54]) vs. after (29 [IQR, 16-54]) the first TEER (p = 0.06). However, higher-risk (STS predicted risk of mortality ≥2%) MVr procedures declined over the study period (p < 0.001 for trend). The introduction of TEER was associated with reduced risk-adjusted odds of mortality after MVr at 30 days (adjusted odds ratio, 0.73; 95% confidence interval, 0.54-0.99) and over 5 years (adjusted hazard ratio, 0.75; 95% confidence interval, 0.66-0.86). These improvements in 30-day and 5-year mortality were significantly greater than equivalent trends in CABG.
Conclusions:
The authors conclude that the introduction of TEER has not significantly changed overall MVr case volumes for degenerative mitral regurgitation but is associated with a decrease in higher-risk surgical operations and improved 30-day and 5-year outcomes.
Perspective:
This study reports that the introduction of TEER for degenerative mitral regurgitation has not significantly impacted annualized MVr volume in TEER institutions from 2011–2018. However, adoption of this technique was associated with an improvement in 30-day MVr outcomes and 5-year mortality. The findings of this study suggest that a systematic evaluation by a heart team able to direct patients towards either surgical or transcatheter approaches enhances both short- and long-term surgical outcomes with a tailored treatment strategy. Additional studies are indicated to better understand the factors responsible for these improvements and optimize care for patients with mitral regurgitation. Finally, this analysis does not provide data on the comparative outcomes for surgical MVr versus TEER or the appropriateness of volume shifts from surgical MVr to TEER, and such data are also needed.
Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Interventions and Structural Heart Disease, Mitral Regurgitation
Keywords: Cardiac Surgical Procedures, Cicatrix, Coronary Artery Bypass, Heart Failure, Heart Valve Diseases, Mitral Valve Insufficiency, Patient Care Team, Patient Readmission, Risk, Transcatheter Aortic Valve Replacement
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