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Impact of Transcatheter Edge-to-Edge Mitral Repair on GDMT Uptitration
Quick Takes
- More than one-third of patients undergoing M-TEER underwent uptitration of GDMT after M-TEER.
- Furthermore, uptitration of GDMT after M-TEER was independently associated with a lower risk of all-cause death and of all-cause death or HF hospitalization.
- Of note, a reduction of ≥3 MR grades was the strongest factor associated with GDMT uptitration after M-TEER.
Study Questions:
What is the frequency and what are the prognostic implications and predictors of guideline-directed medical therapy (GDMT) uptitration after transcatheter edge-to-edge mitral valve repair (M-TEER) in patients with secondary mitral regurgitation (SMR) and heart failure with reduced ejection fraction (HFrEF)?
Methods:
The investigators conducted a retrospective analysis of prospectively collected data from the EuroSMR Registry. Patients received GDMT according to local judgment and expertise and were considered eligible for M-TEER after a multidisciplinary heart team discussion. The primary events were all-cause death and the composite of all-cause death or HF hospitalization. Cumulative event-free survival estimates were obtained using the Kaplan-Meier method and compared with the log-rank test. Univariable Cox regression analysis was used to evaluate associations between baseline characteristics and study outcomes. Variables with p values <0.05 in univariable logistic regression for outcomes and with missing data <10% were entered into the multivariable Cox model.
Results:
Among the 1,641 EuroSMR patients, 810 had full data sets regarding GDMT and were included in this study. GDMT uptitration occurred in 307 patients (38%) after M-TEER. The proportion of patients receiving angiotensin-converting enzyme inhibitors (ACEI)/angiotensin receptor blockers (ARB)/angiotensin receptor-neprilysin inhibitors (ARNI), beta-blockers, and mineralocorticoid receptor antagonists (MRA) was 78%, 89%, and 62% before M-TEER and 84%, 91%, and 66% 6 months after M-TEER (all p < 0.001). Patients with GDMT uptitration had a lower risk of all-cause death (adjusted hazard ratio [HR], 0.62; 95% confidence interval [CI], 0.41-0.93; p = 0.020) and of all-cause death or HF hospitalization (adjusted HR, 0.54; 95% CI, 0.38-0.76; p < 0.001) compared with those without. Degree of MR reduction between baseline 6-month follow-up was an independent predictor of GDMT uptitration after M-TEER (adjusted OR, 1.71; 95% CI, 1.08-2.71; p = 0.022).
Conclusions:
The authors report that GDMT uptitration after M-TEER occurred in a considerable proportion of patients with SMR and HFrEF and is independently associated with lower rates for mortality and HF hospitalizations.
Perspective:
This study reports that more than one-third of patients undergoing M-TEER underwent uptitration of GDMT after M-TEER, which consisted of the initiation or increase in dose of either ACEI/ARB/ARNI and/or beta-blockers and/or MRA after the procedure. Furthermore, uptitration of GDMT after M-TEER was independently associated with a lower risk of all-cause death and of all-cause death or HF hospitalization. Of note, a reduction of ≥3 MR grades was the strongest factor associated with GDMT uptitration after M-TEER. Additional studies are indicated to confirm these results and to clarify the mechanisms behind GDMT uptitration after M-TEER and further augment rate of uptitration of GDMT.
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Valvular Heart Disease, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Interventions and Structural Heart Disease, Mitral Regurgitation
Keywords: Adrenergic beta-Antagonists, Angiotensin Receptor Antagonists, Angiotensin-Converting Enzyme Inhibitors, Cardiac Surgical Procedures, Heart Failure, Heart Valve Diseases, Mineralocorticoid Receptor Antagonists, Mitral Valve Insufficiency, Neprilysin, Pharmaceutical Preparations, Secondary Prevention, Stroke Volume, Transcatheter Aortic Valve Replacement, Treatment Outcome
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