TVT 2021: Aborted TEER leads to poorer outcomes in mitral valve surgery

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Gilbert Tang

Among patients undergoing mitral valve surgery after failed transcatheter edge-to-edge mitral valve repair (TEER), those whose initial TEER procedure was aborted faced poorer outcomes compared to patients who underwent successful TEER but required surgery for acute or delayed failures.

This was according to findings from the CUTTING-EDGE registry looking at the impact of timing of the surgery on outcomes of mitral valve surgery after TEER, presented by Gilbert Tang (Mount Sinai Health System, New York, USA) during a late-breaking science session at TVT 2021 (The Structural Heart Summit, 20–22 July, Miami Beach, USA & virtual).

“We know that over 100,000 TEER procedures have been done worldwide in patients with severe mitral regurgitation (MR), but multi-institutional longitudinal data on mitral valve surgery after TEER is not commonly reported. We created this registry in an attempt to look into this cohort of patients,” Tang told delegates attending the TVT meeting both in person, and via livestream.

Tang pointed to a recent Journal of the American College of Cardiology (JACC) paper, authored by Joanna Chikwe (Smidt Heart Institute at Cedars-Sinai, Los Angeles, USA) which looked at patients in the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database, and found that the majority of patients with failed TEER require replacement at the time of surgery, and the number of cases, including isolated and concomitant procedures, are rising.

Using data from the CUTTING-EDGE registry Tang and colleagues found that the rate of one-year mortality is around 31.3% in these patients. “We looked at a subgroup analysis and found that if you have moderate to severe tricuspid regurgitation (TR) pre-TEER, it is an independent predictor of mortality, however concomitant tricuspid valve surgery did not increase mortality in these patients,” Tang said.

Turning to the present study, Tang and colleagues sought to compare outcomes of mitral valve surgery after failed TEER, stratified by the timing from TEER to surgery in the CUTTING-EDGE registry.

Their study included 332 patients from 34 centres in the USA, Canada, and Europe, dating from July 2009 to July 2020. Patients who had non-mitral valve cardiac surgery after TEER were excluded.

The patients were stratified into three groups: aborted TEER, in which TEER was attempted but unsuccessful, leading to mitral valve surgery in the same or a different hospital admission; acute TEER failure, whereby mitral valve surgery after TEER was performed on the same index admission; or delayed TEER failure, where mitral valve surgery after TEER was performed on a separate admission.

Breaking down the size of each group, Tang explained that mitral valve surgery was performed in 70 (21.2%) aborted, 58 (17.6%) acute and 202 (61.2%) delayed TEER failure patients.

The study team evaluated Mitral Valve Academic Research Consortium (MVARC) outcomes at 30 days and one year, with a median follow-up of nine months (interquartile range [IQR] 1.2–25.7) after mitral valve surgery. The overall cohort had an average age of 73.8 ±10.1 years. At the time of index TEER, the median STS Predicted Risk of Mortality (PROM) score for mitral valve repair was 4% (IQR: 2.3–7.3%), with 51.3% deemed low or intermediate surgical risk by the heart team. A total of 59% had primary or mixed mitral regurgitation and 38.5% secondary MR.

Tang noted that indications for mitral valve surgery included recurrent mitral regurgitation in 33.5% of patients, residual mitral regurgitation in 28.7%, single leaflet device attachment (SLDA) in 25.1%, partial leaflet detachment in 21.8% and mitral stenosis in 14.5%. At mitral valve surgery the median STS PROM score for mitral valve replacement was 4.8% (IQR: 2.8–8.4%), and 42.2% had concomitant tricuspid valve surgery.

Tang also charted the temporal trends of TEER cases by scenario, noting that across time, the number of cases for aborted TEER remained constant.

Summarising the key findings at index TEER, Tang said that there was more mixed mitral regurgitation, worse tricuspid regurgitation and right ventricular (RV) dysfunction in the aborted TEER group and lower left ventricular ejection fraction (LVEF) in the aborted and acute groups. Tang also reported that there was no difference in TEER locations or the number of devices used among the patient groups, but noted that more first-generation MitraClip (Abbott) devices were used in the delayed TEER group, compared to more MitraClip XTR/G4 in the aborted and acute groups.

In terms of mitral valve surgery, Tang explained that worse LVEF, RV dysfunction, more residual MR, SLDA and partial leaflet detachment were observed in the aborted and acute groups, while worse TR was seen in the aborted group. More urgent and emergency surgeries were performed in the aborted and acute groups, Tang added, and there was a higher use of intra-aortic balloon pump (IABP) in the aborted TEER group, he said.

There were no differences in the need for mitral valve replacement and concomitant tricuspid valve surgery, and no differences in aortic cross-clamp and cardiopulmonary bypass (CPB) times in the three groups.

Detailing the outcomes, Tang noted that there were no differences in rates of in-hospital mortality, stroke or intensive care unit (ICU) stay, although lower rates of LVEF and more RV dysfunction were recorded in the aborted TEER group.

At 30 days, Tang reported that the highest mortality, and worst TR was found in the aborted TEER group, while there were no differences in stroke and readmission rates in the other two groups. Turning to the one-year data, he noted that the highest mortality was again seen in the aborted TEER group, and detailed that there was no difference in stroke and echo parameters.

Despite the differences in the three TEER failure scenarios, the aborted group had the highest 30-day and one-year mortality. This was driven, Tang said, mostly by baseline risk factors, TR severity and RV dysfunction.

In his concluding remarks, Tang said of the results: “The implication is that, whenever possible, an optimal procedural outcome during the initial TEER would be ideal to ending up in the aborted scenario requiring mitral valve surgery.”


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