Shingo Kuwata (University Heart Center, Zurich, Switzerland) and others report in Eurointervention that atrial fibrillation is a “frequent comorbidity” in patients with mitral regurgitation who are undergoing percutaneous mitral valve repair with MitraClip (Abbott Vascular). Therefore, they evaluated the feasibility of combining a MitraClip procedure with left atrial appendage occlusion using the Amplatzer cardiac plug (St Jude Medical). In this interview, study authors Kuwata, Francesco Maisano and Fabian Nietlispach (all University Heart Center, Zurich, Switzerland) discuss their results.
What percentage of patients with mitral regurgitation will also have atrial fibrillation?
In our hospital, 166 patients underwent MitraClip therapy between March 2014 and June 2016. Of these, 125 patients (75%) also had atrial fibrillation.
What proportion of patients with both atrial fibrillation and mitral regurgitation will also have a high risk of bleeding?
Patients undergoing MitraClip procedures are typically elderly patients with several comorbidities and, hence, are at high risk for bleeding. In our study cohort, 72% had received anticoagulant therapy and 44% had received antiplatelet therapy. The median HASBLED—hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile INR, elderly, drugs/alcohol concomitantly—score was three.
Why is combining left atrial appendage occlusion and mitral valve repair with MitraClip in the same procedure an attractive option?
Bleeding events may account, at least in part, for the worse outcome of patients with atrial fibrillation. Preventing bleeding complications is therefore an important matter. Combining left atrial appendage occlusion and mitral valve repair with MitraClip reduces the risk of bleeding (compared to using anticoagulation in these patients) and, thus, makes sense from a theoretical standpoint.
In your study, how feasible was this approach?
Technical success was 100%. We did not observe any incidences ischaemic stroke, pericardial effusion or cardiac tamponade following the combination of left atrial appendage occlusion and mitral valve repair with MitraClip.
How did the clinical outcomes of those who underwent the combined approached compare with those who only received MitraClip alone?
At 30 days, one patient in the combined group died because of cerebral haemorrhage (combined vs. MitraClip alone—4% vs. 0%, respectively; p=0.32). There was no significant difference in post-procedural events between the combined approached group and the MitraClip alone approach group. Additionally, there was no association of left atrial appendage occlusion with device—or procedural—success.
Which patients do you think would benefit the most from such a combined approach?
The combined procedure seems to be more patient-friendly and maybe even safer than staged procedures—it involves one single vascular access puncture, one single transseptal puncture, and immediate cessation of oral anticoagulation. Combining therapy is particularly appealing in atrial fibrillation patients who have an indication for dual antiplatelet therapy (eg. due to a recent percutaneous coronary intervention).
Could the other percutaneous mitral valve repair approaches be used in combination with left atrial occlusion closure?
We have shown that left atrial appendage occlusion can be achieved even with a high transseptal puncture—the less-than-ideal transseptal puncture. We think that the combination with left atrial appendage closure be used in the other percutaneous mitral valve repair.