TMVR may improve survival in cardiogenic shock, mitral regurgitation
In cardiogenic shock, successful transcatheter mitral valve repair for moderate to severe mitral regurgitation showed signs of improving short- and intermediate-term survival, according to findings presented at the virtual TCT Connect.
“In the present study, transcatheter mitral valve repair using the MitraClip system (Abbott) appears to be a viable therapeutic salvage strategy, demonstrating procedural safety and efficacy in mitral regurgitation reduction in patients with significant mitral regurgitation and cardiogenic shock,” Richard G. Jung, BSc, of the MD/PhD program at the University of Ottawa in Ontario, Canada, and colleagues wrote in a simultaneous publication in JACC: Cardiovascular Interventions. “Although heterogenous in mitral regurgitation etiology, successful device implantation was associated with decreased risk for mortality over the first year, supporting the hypothesis that mitral regurgitation reduction in the acute phase of shock may represent a therapeutic target addressable using a percutaneous approach.”
For this multicenter patient-level analysis, 141 individuals with cardiogenic shock and moderate to severe mitral regurgitation treated with transcatheter mitral valve repair were included (mean age, 69 years; 55% men; 65% with HF hospitalization in the previous year). The primary outcome was in-hospital mortality and the secondary outcomes included 90-day mortality, HF hospitalization and the combined endpoint of 90-day mortality and HF hospitalization stratified by procedure success.
Following transcatheter mitral valve repair, 88.7% of the cohort had a mitral regurgitation grade of 1 or 2 and no procedural complications were reported.
Median follow-up was 90 days.
In-hospital death occurred in 15.6% of the cohort, 90-day mortality in 29.5% and 1-year mortality in 42.6%.
According to the study, HF hospitalization occurred in 18.4% of patients and the composite of 90-day mortality and HF hospitalization occurred in 30.8%.
Investigators reported 11.3% of patients failed to achieve device success, defined as postprocedural change in mitral regurgitation by 1 grade and an absolute grade of 2+.
Compared with patients with failed mitral regurgitation reduction, those with successful transcatheter mitral valve repair experienced:
- lower in-hospital mortality (HR = 0.36; 95% CI, 0.13-0.98);
- lower 90-day mortality (HR = 0.36; 95% CI, 0.16-0.78);
- lower 1-year mortality (HR = 0.46; 95% CI, 0.22-0.94);
- lower 90-day HF hospitalization (HR = 0.2; 95% CI, 0.06-0.73); and
- lower composite 90-day mortality and HF hospitalization (HR = 0.41; 95% CI, 0.19-0.9).
“The present study demonstrates that successful transcatheter mitral valve repair can be performed as a salvage therapy in patients with no further options,” Jung and colleagues wrote. “Successful repair was associated with improved outcomes in this high-risk cohort and presents a novel therapeutic option in select patients.
“Prospective randomized studies are warranted to assess whether valvular intervention in those with cardiogenic shock and significant mitral regurgitation improves mortality in this high-risk cohort.”
“Although we are eagerly waiting for novel therapeutic approaches to improve the often dramatic clinical course and poor prognosis of patients in cardiogenic shock, we need to accept that it is too early to draw any firm conclusion on a potential benefit of transcatheter treatment of mitral regurgitation in cardiogenic shock,” Philipp Lurz, MD, PhD, and Christian Besler, MD, of the Heart Center Leipzig of the University Leipzig in Leipzig, Germany, wrote in a related editorial. “For sure, the findings by Jung et al are encouraging and should stimulate more intense research in the field, but there is still a long way to go. Let`s hope transcatheter mitral valve repair finally finds a role in cardiogenic shock management, in the interest of our patients.”
References:
- Jung RG, et al. J Am Coll Cardiol. 2020;doi:10.1016/j.jcin.2020.08.037.
- Lurz P, et al. J Am Coll Cardiol. 2020;doi:10.1016/j.jcin.2020.09.030.
Collapse
Jung RG, et al. Abstracts. Presented at: TCT Connect; Oct. 14-18, 2020 (virtual meeting).
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