Pulmonary Hypertension in Transcatheter Mitral Valve Repair for Secondary Mitral Regurgitation
Why the study?
Pulmonary hypertension worsens prognosis in heart failure and secondary mitral regurgitation, but whether baseline pulmonary hypertension influences transcatheter mitral valve repair outcomes was unknown.
Key Points
- To assess the clinical impact, prognostic implications, and hemodynamic changes following transcatheter mitral valve repair in patients with secondary mitral regurgitation complicated by pulmonary hypertension.
- Evaluated patients with significant secondary mitral regurgitation undergoing transcatheter mitral valve repair.
- Analyzed procedural success, hemodynamic alterations, and clinical outcomes stratified by baseline pulmonary hypertension severity.
- Baseline pulmonary hypertension in secondary mitral regurgitation confers an increased risk of adverse cardiovascular outcomes and heart failure hospitalization.
- Successful transcatheter repair produces significant reductions in pulmonary artery pressures and symptomatic improvement across baseline pulmonary hypertension strata.
Study Design
Type
RCT (n=614)
Randomization
randomized
PICO
P
Population
614 patients with heart failure and moderate-to-severe or severe secondary mitral regurgitation, followed for 2 years.
I
Intervention / Comparator
Transcatheter mitral valve repair (TMVr) with the MitraClip plus guideline-directed medical therapy (GDMT) vs GDMT alone
O
Primary Outcome
Change in pulmonary artery systolic pressure (PASP) from baseline to 30 days, p=0.006
Main Result
Absolute Event Rate: -4% vs -0.9%
p-value: p=0.006
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Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“While we learned that patients with higher pulmonary hypertension are at higher risk after they receive the MitraClip, they still do better than if they would not have had the intervention done. Doing an echocardiogram is critical in determining if a patient is a good candidate for MitraClip and in following these patients to evaluate results of the procedure in the long run.”
Implication
Clinical evaluation reveals outcomes of transcatheter mitral valve repair in secondary mitral regurgitation with pulmonary hypertension, highlighting prognostic and hemodynamic impacts.
Abstract
BACKGROUND Pulmonary hypertension worsens prognosis in patients with heart failure (HF) and secondary mitral regurgitation (SMR). OBJECTIVES This study sought to determine whether baseline pulmonary hypertension influences outcomes of transcatheter mitral valve repair (TMVr) in patients with HF with SMR. METHODS In the COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation) trial, 614 patients with HF with moderate-to-severe or severe SMR were randomized to TMVr with the MitraClip plus guideline-directed medical therapy (GDMT) (n = 302) versus GDMT alone (n = 312). Baseline pulmonary artery systolic pressure (PASP) estimated from echocardiography was categorized as substantially increased (≥50 mm Hg) versus not substantially increased (<50 mm Hg). RESULTS Among 528 patients, 184 (82 TMVr, 102 GDMT) had PASP of ≥50 mm Hg (mean: 59.1 ± 8.8 mm Hg) and 344 (171 TMVr, 173 GDMT) had PASP of <50 mm Hg (mean: 36.3 ± 8.1 mm Hg). Patients with PASP of ≥50 mm Hg had higher 2-year rates of death or HF hospitalization (HFH) compared to those with PASP of <50 mm Hg (68.8% vs. 49.1%; adjusted hazard ratio: 1.52; 95% confidence interval: 1.17 to 1.97; p = 0.002). Rates of death or HFH were reduced by TMVr versus GDMT alone, irrespective of baseline PASP (pinteraction = 0.45). TMVr reduced PASP from baseline to 30 days to a greater than GDMT alone (adjusted least squares mean: -4.0 vs. -0.9 mm Hg; p = 0.006), a change that was associated with reduced risk of death or HFH between 30 days and 2 years (adjusted hazard ratio: 0.91 per -5 mm Hg PASP; 95% confidence interval: 0.86 to 0.96; p = 0.0009). CONCLUSIONS Elevated PASP is associated with a worse prognosis in patients with HF with severe SMR. TMVr with the MitraClip reduced 30-day PASP and 2-year rates of death or HFH compared with GDMT alone, irrespective of PASP.
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Cite This Study
Ben‐Yehuda et al. (2020) conducted an RCT in Heart failure with secondary mitral regurgitation (n=614). Transcatheter mitral valve repair (TMVr) with the MitraClip plus guideline-directed medical therapy (GDMT) vs. GDMT alone was evaluated on Change in pulmonary artery systolic pressure (PASP) from baseline to 30 days (p=0.006).