Prognostic Impact of LA Pressure During MitraClip Therapy

Study Questions:

What is the additional utility of measuring left atrial (LA) pressure as a complement to transesophageal echocardiography (TEE) and Doppler imaging for MitraClip (MC) therapy?

Methods:

The investigators analyzed 50 patients undergoing MC therapy with continuous left-sided heart pressure measurements. LA V-wave pressure (LAvP), LA mean pressure (LAmP), LV systolic pressure, and LV end-diastolic pressure were measured continuously. LA pressures were indexed to LV pressures to account for changes in afterload during the procedure. The ability of invasive left-sided heart pressures during MC therapy to predict residual symptoms after the procedure (New York Heart Association [NYHA] functional class ≥III at 30 days) were tested by evaluating the area under the curve in the analysis of its receiver-operating characteristic curve.

Results:

Most patients (70%) had degenerative mitral regurgitation (MR). TEE MR grade decreased from 3+ to 0+. LAvP (p < 0.001), LAmP (p = 0.007), LV end-diastolic pressure (p = 0.001), LAvP index (p < 0.001), and LAmP index (p = 0.001) decreased significantly, and LV systolic pressure (p = 0.009) significantly increased after MC therapy. In multivariate Cox regression analysis, intraprocedural increase of LAmP index, but not post-MC ≥2+ residual MR, was significantly associated with rehospitalization due to heart failure (hazard ratio, 3.377; 95% confidence interval, 3.180-3.585; p = 0.007) and with NYHA functional class III-IV (hazard ratio, 1.497; 95% confidence interval, 1.006-2.102; p = 0.005) in the follow-up period.

Conclusions:

The authors concluded that there is value of real-time monitoring of LA pressure during MC therapy to predict clinical outcomes.

Perspective:

This analysis suggests an adjunctive value of real-time monitoring of left heart hemodynamics during MC therapy in predicting clinical outcomes. Although MC therapy is generally associated with improved hemodynamics, LA hemodynamics worsened, with an increase of LAmP and LAmP index in a small proportion of patients, despite improved echocardiographic MR grade. This unfavorable change in LA dynamics was a prognostic factor for negative clinical outcomes at short-term follow-up, independently from echocardiographic findings, and may identify patients who need additional therapies. Larger prospective trials with longer-term follow-up are indicated to confirm these preliminary results.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Valvular Heart Disease, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound, Mitral Regurgitation

Keywords: Atrial Pressure, Blood Pressure, Diagnostic Imaging, Echocardiography, Doppler, Echocardiography, Transesophageal, Heart Failure, Heart Valve Diseases, Hemodynamics, Mitral Valve Insufficiency, Secondary Prevention, Transcatheter Aortic Valve Replacement


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