Clinical impact of early changes in guideline-directed medical therapy after mitral valve transcatheter edge-to-edge repair

Background and Aims Mitral transcatheter edge-to-edge repair (M-TEER) is an established therapy for functional mitral regurgitation (FMR) and reduced left ventricular ejection fraction (LVEF). Although guideline-directed medical therapy (GDMT) is ideally optimized before M-TEER, this procedure may facilitate early post-procedural GDMT changes. However, the clinical impact of early in-hospital GDMT modifications remains unclear. Methods We analyzed 1,638 patients with FMR and LVEF <50% enrolled in a multicenter Japanese registry. The patients were stratified according to the number of GDMT classes prescribed at discharge (single [n=183]; double [n=505]; triple [n=630]; quadruple [n=320]). Changes from before M-TEER to discharge were categorized as increased (n=271), unchanged (n=1,219), or decreased (n=148). Associations between GDMT patterns and subsequent outcomes were evaluated. The primary endpoint was a composite of all-cause mortality and heart failure rehospitalization at one year. Results Primary endpoints were achieved in 357 patients (22%). Event rates decreased across groups (single, 32%; double, 24%; triple, 21%; quadruple, 14%; P<0.001). After adjusting for confounders, a greater number of GDMT classes at discharge independently predicted better prognosis. (hazard ratio [HR]: 0.83; 95% confidence interval [CI]: 0.73–0.95), whereas pre-M-TEER GDMT was not significant. Compared with decreased GDMT, an unchanged status was not associated with improved outcomes, while an increased status significantly improved prognosis (HR 0.62, 95% CI 0.39–0.99). Conclusion In patients with FMR and LVEF <50%, a higher number of GDMT classes at discharge and in-hospital uptitration of the GDMT class were associated with better outcomes, suggesting that early postprocedural GDMT optimization warrants further investigation.