TEER availability does not impact surgical repair volume but improves outcomes
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Access to transcatheter edge-to-edge repair for degenerative mitral regurgitation did not impact annualized surgical mitral valve repair volume, though data suggest access led to improvements in surgery outcomes and 5-year mortality rates.
“The introduction of TEER at an institution does not appear to be ‘competing’ with surgical repair for volume,” Andrew M. Vekstein, MD, an integrated cardiothoracic surgery resident at Duke University Medical Center, told Healio. “Rather, the presence of transcatheter options optimizes care of patients with degenerative mitral regurgitation and appears to improve outcomes for patients still directed towards surgery.”
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In an analysis of 278 institutions that became transcatheter edge-to-edge repair (TEER)-capable from 2011 to 2018, researchers noted that the introduction of transcatheter options could impact surgical management of degenerative mitral regurgitation through optimized multidisciplinary patient evaluation, more strategic patient selection based on valve anatomy or other changes in care.
“In a parallel scenario for severe aortic stenosis, the commercial introduction of transcatheter aortic valve replacement in prohibitive and high-risk individuals was initially associated with an unanticipated increase in both TAVR and surgical AVR volume, accompanied by a decline in surgical AVR mortality over time,” Vekstein and colleagues wrote. “Whether the adoption of TEER is associated with similar trends in volume and patient outcomes for surgical mitral valve repair remains unknown.”
Improvements in 30-day, 5-year outcomes
Vekstein and colleagues analyzed data from 13,959 patients who underwent surgical mitral valve repair across 278 institutions, which became TEER-capable during the study period, using the Society of Thoracic Surgeons Adult Cardiac Surgery Database (ACSD) linked to Medicare administrative claims. Researchers assessed volume, 30-day and 5-year outcomes, including mortality, HF rehospitalization and mitral valve reintervention across TEER centers before and after availability of the first institutional TEER procedure. Researchers used a difference-in-difference approach comparing parallel trends in CABG outcomes to account for temporal improvements in perioperative care.
The findings were published in the Journal of the American College of Cardiology.
Within the cohort, 48.8% of surgeries took place before the first TEER at an institution and 51.2% took place after the first TEER.
Across institutions, there was no significant change in median annualized institutional surgical mitral valve repair volume before vs. after the availability of TEER (median annualized volume, 32 vs. 29; P = .06). However, researchers observed a decline in higher-risk surgical mitral valve repair procedures during the study period (P for trend < .001).
The introduction of TEER was associated with a reduced OR for mortality after surgical mitral valve repair at 30 days (adjusted OR = 0.73; 95% CI, 0.54-0.99) and during 5 years’ follow-up (aHR = 0.75; 95% CI, 0.66-0.86).
The improvements in 30-day and 5-year mortality were greater than equivalent trends in CABG, according to researchers.
“We found no significant change in surgical volumes with the introduction of TEER, but reduced risk of death in both in the short and long term for patients having surgery after TEER became available,” Vekstein told Healio. “The results suggest that patients may be undergoing more comprehensive and collaborative evaluation by both cardiologists and cardiac surgeons in the heart team after an institution develops a TEER program, with improved surgical outcomes as a result.”
View expanded TEER ‘with caution’
In a related editorial, Matthew W. Sherwood, MD, MHS, co-director of the structural heart program, the cardiac catheterization lab and Left Atrial Appendage Closure program at Inova Heart and Vascular Institute in Fairfax, Virginia, and adjunct assistant professor of medicine at Duke University, and Wayne B. Batchelor, MD, MHS, director of interventional cardiology, director of interventional cardiology research, innovation and education and associate director of Inova Heart and Vascular Institute, and adjunct professor of medicine at Duke University, wrote that the rapid expansion of TEER may be welcome but it should be “viewed with caution,” as the trend may reflect treatment decisions that may not all be evidence-based. There are several ongoing randomized controlled trials evaluating the comparative efficacy and safety of TEER vs. surgical mitral valve repair in patients at low or moderate surgical risk, including the PRIMARY trial, CTSNET and REPAIR MR.
“Completion of these trials will provide the much-needed evidence to direct therapeutic decisions for low-risk and intermediate-risk patients with degenerative mitral regurgitation,” Sherwood and Batchelor wrote. “Until then, TEER procedures for degenerative mitral regurgitation should be limited to those deemed to be at higher risk where there exists proven benefit.”
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For more information:
Andrew M. Vekstein , MD, can be reached at andrew.vekstein@duke.edu; Twitter: @andrewvekstein.
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