Less than one-fifth of patients undergoing mitral valve transcatheter edge-to-edge repair (TEER) for functional mitral regurgitation (MR) were prescribed comprehensive guideline-directed medical therapy (GDMT) pre-procedure, and triple or double therapy compared with single or no therapy was associated with reduced risk of mortality and heart failure (HF) hospitalization, according to a recent study published in European Heart Journal.

Using data from the STS/ACC TVT Registry, Anubodh S. Varshney, MD, et al., identified 4,199 patients from 449 sites with left ventricular ejection fraction <50% undergoing mitral valve TEER for functional MR between July 23, 2019 and March 31, 2022. Researchers determined rates of GDMT use before intervention and then evaluated associations between pre-procedure therapy – none, single, double or triple therapy – with risk of mortality or HF hospitalization at one year using Cox proportional hazards models.

Prior to intervention, beta-blockers, ACE inhibitors/ARBs, mineralocorticoid receptor antagonists and angiotensin receptor-neprilysin inhibitors were prescribed in 85.1%, 44.4%, 28.6% and 19.9% of patients respectively. The authors found that triple therapy was prescribed for 19.2% of patients, double therapy for 38.2%, single therapy for 36.0% and no therapy in 6.5% of cases, noting significant center-level variation when looking at the proportion of patients on triple therapy (0-61%; adjusted median odds ratio, 1.48; 95% CI, 1.25-3.88; p<0.001).

Among patients where follow-up data at one year was available (n=2,014 across 341 sites), the composite rate of mortality or HF hospitalization was lowest among patients who received triple therapy pre-procedure (23.1%) when compared to other groups (double therapy: 24.8%; single therapy: 35.7%; no therapy: 41.1%; p<0.01 comparing across groups). In models adjusted for relevant clinical characteristics, lower risk for patients with triple therapy (adjusted hazard ratio [aHR], 0.73; 95% CI, 0.55-0.97) and double therapy (aHR, 0.69, 95% CI, 0.56-0.86) persisted in contrast to single or no therapy.

“These findings reinforce guideline recommendations to optimize GDMT prior to [mitral valve TEER] in a broad and generalizable real-world patient population,” state the authors. “Notably, in patients who cannot tolerate triple therapy, double therapy appears to be associated with substantial benefit over more limited regimens.”