Staging patients with HF, secondary mitral regurgitation improves outcomes after TEER
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In patients with HF undergoing mitral valve transcatheter edge-to-edge repair, a novel staging classification of valve disease based on extravalvular cardiac damage may improve symptomatic outcomes and survival, researchers reported.
Patient selection before mitral valve transcatheter edge-to-edge repair (M-TEER) is important to optimize treatment outcomes, and recent data suggest grouping patients with HF with reduced ejection fraction and secondary mitral regurgitation into pathophysiological stages has significant prognostic relevance, Jörg Hausleiter, MD, FESC, vice director of the department of cardiology at Ludwig-Maximilians Universität München in Munich, and colleagues wrote in JACC: Cardiovascular Interventions. “This study demonstrates that additional factors beyond the assessment of valvular aspects of secondary mitral regurgitation have a significant prognostic impact on survival,” Hausleiter told Healio. “These ‘extra-valvular’ aspects allow for a staging of the patient’s disease status which is comparable with the staging process of cancers.”
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Higher staging, less improvement
Hausleiter and colleagues analyzed data from 849 patients with HFrEF with secondary mitral regurgitation (HFrEF-SMR) who underwent M-TEER between 2008 and 2019. Researchers stratified patients to one of four groups based on echocardiographic and clinical assessment: LV involvement (stage 1), left atrial involvement (stage 2), RV volume/pressure overload (stage 3) or biventricular failure (stage 4). Researchers assessed the impact of HFrEF-SMR stages on 2-year all-cause mortality and analyzed the symptomatic outcome with NYHA functional class at follow-up.
Within the cohort, 9.5% of patients presented with LV involvement, 46% presented with left atrial involvement, 15% presented with RV pressure/volume overload and 29% presented with biventricular failure.
Researchers found that an increase in HFrEF-SMR stage was associated with a 39% increased risk for 2-year all-cause mortality after M-TEER (HR = 1.39; 95% CI, 1.23-1.58; P < .01). Additionally, higher HFrEF-SMR stages were associated with less symptomatic improvement at follow-up.
“The staging may help to better estimate the outcomes of patients and hopefully, that M-TEER will not be withheld from suitable patients and patients will be referred earlier in the disease process for effective therapies such as M-TEER,” Hausleiter told Healio. “Going forward, we need to have an even better outcome estimation for the individual patient that goes beyond the four stages categories. This individualized risk assessment will allow for better, earlier and refined treatment of these patients.”
The researchers noted that the optimal timing of M-TEER remains difficult because parameters including LVEF and NYHA functional class did not differ between stages. “Possibly, the staging of HFrEF-SMR patients may help to identify dedicated patient groups, which might be subjected to advanced therapies beyond M-TEER in the future,” the researchers wrote.
‘Consider valvular disease as a cardiac disease’
In a related editorial, Philippe Généreux, MD, co-director of the Structural Heart Program at Morristown Medical Center, Atlantic Health System, Morristown, New Jersey, wrote that the data further legitimizes the concept of staging of cardiac damage for patients with valve disease.
Généreux noted that a multiparametric approach, including biomarkers and potentially more advanced imaging, could alleviate the study’s limitation of a lack of data needed to classify many excluded patients into the appropriate stages.
“The growing burden of evidence all seems to point toward the same direction: the need to consider valvular disease as a cardiac disease instead of a singular entity affecting a cardiac valve,” Généreux wrote. “Different stratification schemes such as the recently proposed extravalvular cardiac damage classification offer a more patient-centric approach, integrating not only valve severity, but also its cardiac consequences.”
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For more information:
Jörg Hausleiter, MD, FESC, can be reached at joerg.hausleiter@med.uni-muenchen.de; Twitter: @j_hausleiter.
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