‘User-friendly’ risk score predicts HF, mortality outcomes after TEER for functional MR
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A novel risk score comprising clinical, echocardiographic and treatment variables accurately predicted prognosis for adults with HF and severe secondary mitral regurgitation after transcatheter mitral valve repair, researchers reported.
Adults with functional mitral regurgitation and HF are at increased risk for mortality and recurrent HF hospitalization despite best medical therapy and invasive therapies including mitral transcatheter edge-to-edge repair (TEER), Gregg W. Stone, MD, director of academic affairs for the Mount Sinai Heart Health System and professor of medicine and population health sciences and policy at the Zena and Michael A. Wiener Cardiovascular Institute at the Icahn School of Medicine at Mount Sinai, and colleagues wrote in JACC: Cardiovascular Interventions. Using data from the COAPT trial, Stone and colleagues created a risk score using four clinical variables and four echocardiographic variables, with TEER as a treatment-related variable, to provide prognostic insight into 2-year rates of death or HF hospitalization.
“In the COAPT trial, TEER with the MitraClip (Abbott Vascular) was associated with significantly reduced adverse event rates, including the primary endpoint of HF hospitalization and the secondary endpoint of all-cause mortality at 24 months, compared with guideline-directed medical therapy alone in patients with HF with severe functional mitral regurgitation,” Stone and colleagues wrote. “Nonetheless, such patients remain at elevated risk for adverse events despite guideline-directed medical therapy and TEER, as evidenced in both the COAPT and MITRA-FR trials. Identifying tools to risk-stratify patients may enable more accurate prognostication and direct new therapies in this high-risk patient population.”
Importance of early recognition, referral
As Healio previously reported, 2-year data from the COAPT trial, which enrolled 614 participants with HF with reduced ejection fraction and moderate to severe or severe secondary mitral regurgitation, demonstrated that adults with HF with moderate to severe or severe functional mitral regurgitation who underwent transcatheter mitral valve repair reduced the risk for HF hospitalization and mortality compared with patients treated with medical therapy alone.
In the new analysis, Stone and colleagues generated a risk score for the 2-year rate of death or HF hospitalization from Cox proportional hazards models. Researchers assessed the predictive value of the model using the area under the curve of receiver-operating characteristic plots.
During 2-year follow-up, 64.4% of participants in the guideline-directed medical therapy group and 44% of participants in the MitraClip group died or were hospitalized for HF (P < .001). The risk score contains four clinical variables (NYHA functional class, chronic obstructive pulmonary disease, atrial fibrillation or flutter and chronic kidney disease) and four echocardiographic variables (left ventricular ejection fraction, LV end-systolic dimension, right ventricular systolic pressure and tricuspid regurgitation) in addition to MitraClip treatment.
The AUC of the risk score model was 0.74, higher than existing risk scores for this population, and “excellent” calibration was present, according to the researchers. The relative benefit of MitraClip therapy in reducing the 2-year hazard of death or HF hospitalization was consistent across the range of baseline risk (log-rank P < .001).
“The 2-year rate of death or HF hospitalization was more than twofold increased between the lower and upper quartiles of risk,” the researchers wrote. “Moreover, this instrument provides estimates of the potential absolute reductions in the 2-year rates of death or HF hospitalization in patients treated with MitraClip rather than guideline-directed medical therapy alone, according to baseline risk, although all risk strata had similar relative reductions in adverse outcomes with MitraClip treatment. These findings affirm the importance of early recognition and referral of all eligible patients with functional mitral regurgitation for MitraClip therapy (those meeting COAPT criteria), although the greatest absolute benefit of TEER will be experienced by those patients at greatest baseline risk.”
‘Simple, user-friendly tool’
In a related editorial, Michele Pighi, MD, MSc, DRCPC, of the department of cardiology at the University of Verona, Italy, and Marianna Adamo, MD, of the department of medical and surgical specialties at the University of Brescia, Italy, wrote that risk score is a “simple, user-friendly tool” to predict outcomes in patients with HF and secondary mitral regurgitation.
“A few aspects warrant further discussion; among them the lack of a validation analysis is the most important limitation of the study,” Pighi and Adamo wrote. “The implementation of the COAPT score in a separate cohort having similar features would significantly strengthen its value. Notably, as patients included in the COAPT trial are highly selected, validation in real-world settings would be paramount to confirm the reliability of the COAPT score in clinical practice.”
Reference:
Pighi M, et al. JACC Cardiovasc Interv. 2022;doi:10.1016/j.jcin.2022.08.045.
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