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Heart Failure Medical Therapy Prior to Mitral Valve TEER
Quick Takes
- Despite guidelines recommending heart failure (HF) guideline-directed medical therapy (GDMT) before mitral valve TEER (MTEER), less than one-fifth of patients were prescribed optimal therapies before the procedure.
- Patients prescribed triple and double therapy had independently lower risks of the composite of HF hospitalization or mortality at 1 year after MTEER compared with no/single therapy.
- The wide variation in GDMT use across centers suggests that the gaps are multifactorial and will need a variety of strategies to improve GDMT use, targeting patient, clinician, and health care system factors.
Study Questions:
What is the impact of pre-procedure guideline-directed medical therapy (GDMT) utilization on post-procedure outcomes in patients with heart failure (HF) and left ventricular ejection fraction (LVEF) <50% who underwent mitral valve transcatheter edge-to-edge repair (MTEER) for functional mitral regurgitation?
Methods:
The investigators identified patients with LVEF <50% who underwent MTEER for functional mitral regurgitation from July 23, 2019 to March 31, 2022 in the Society of Thoracic Surgeons/American College of Cardiology (STS/ACC) Transcatheter Valve Therapy Registry. Pre-procedure GDMT utilization was assessed. Cox proportional hazards models were constructed to evaluate associations between pre-MTEER therapy (no/single, double, or triple therapy) and risk of 1-year mortality or HF hospitalization (HFH).
Results:
Among 4,199 patients across 449 sites, beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, mineralocorticoid receptor antagonists (MRAs), and angiotensin receptor–neprilysin inhibitors (ARNIs) were used in 85.1%, 44.4%, 28.6%, and 19.9% before MTEER, respectively. Triple therapy was prescribed for 19.2%, double therapy for 38.2%, single therapy for 36.0%, and 6.5% were on no GDMT. Significant center-level variation in the proportion of patients on pre-intervention triple therapy was observed (0%–61%; adjusted median odds ratio, 1.48; 95% confidence interval [CI], 1.25–3.88; p < 0.001). In patients eligible for 1-year follow-up (n = 2,014; 341 sites), the composite rate of 1-year mortality or HFH was lowest in patients prescribed triple therapy (23.0%) compared with double (24.8%), single (35.7%), and no (41.1%) therapy (p < 0.01 comparing across groups). Associations persisted after accounting for relevant clinical characteristics, with lower risk in patients prescribed 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) before MTEER compared with no/single therapy.
Conclusions:
The authors report that compared with no/single therapy, triple and double therapy before MTEER were independently associated with reduced risk of mortality or HFH 1 year after intervention.
Perspective:
This study reports that despite guidelines recommending HF GDMT before MTEER, less than one-fifth of patients were prescribed a beta-blocker, renin-angiotensin system inhibitor or ARNI, and MRA (triple therapy) before the procedure. Furthermore, patients who were on more comprehensive GDMT before MTEER had lower adverse event rates 1-year post-procedure. In adjusted models, patients prescribed triple and double therapy had independently lower risks of the composite of HFH or mortality at 1 year after MTEER compared with no/single therapy. There is a need for structured efforts to improve GDMT optimization before and after MTEER using a Heart Team approach and other strategies. The wide variation in GDMT use across centers suggests that the gaps are multifactorial and will need a variety of strategies to improve GDMT use, targeting patient, clinician, and health care system factors.
Clinical Topics: Heart Failure and Cardiomyopathies, Valvular Heart Disease, Acute Heart Failure, Mitral Regurgitation, Cardiac Surgery and Heart Failure
Keywords: Mitral Valve Insufficiency, Heart Failure, STS/ACC TVT Registry
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