Clin Res Cardiol (2021). 10.1007/s00392-021-01933-9

Achieving optimal results in edge-to-edge Transcatheter Mitral Valve repair (TMVr) – Is indirect annuloplasty the key step?
M. Paukovitsch1, M. Jandek1, W. Rottbauer1, L. Schneider1, S. Markovic1
1Klinik für Innere Medizin II, Universitätsklinikum Ulm, Ulm;

Background: Transcatheter Mitral Valve repair (TMVr) using edge-to-edge-therapy causes alterations of mitral valve (MV) and mitral annular geometry. In which way such alterations influence the procedural result is till to explore.

Objectives:  To create a better understanding of changes in MV geometry during TMVr. We hypothesized that results of edge-to-edge TMVr measured as residual mitral regurgitation (MR) largely depend on specific changes of MV geometry. 

Methods: We analyzed 106 consecutive patients (October 2019-May 2021) undergoing first time TMVr with implantation of a single device. Intraprocedural transesophageal echocardiography (TEE) data was used to determine changes in MV geometry before and after device implantation. Measurements were performed using a commercially available MV assessment tool (TOMTEC, Munich). Preprocedural und postprocedural measurements of patients with optimal (residual MR ≤1) and non-optimal results (residual MR >1) were compared. 

Results: There were no differences regarding baseline patient characteristics such as age (80 {IQR:75-84} vs. 77 years {IQR: 65.5-84.5}; p=0.19), gender (male 40% vs. 57.1%, p=0.16) and EuroScoreII (4.3 {IQR: 2.6-6.6} vs. 3.0 {IQR:1.4-6.4}; p=0.15) between patients with optimal and non-optimal results. Functional MR (FMR) was the dominating etiology in our cohort (62.4% vs. 71.4%, p=0.44). Left-ventricular function (LVEF 40.3% vs. 42.7%; p=0.78) and preprocedural mean grade of MR (3.7±0.5 vs. 3.8±0.4; p=0.18) were similar in both groups. In MV assessment showed both preprocedural and postprocedural anterior-posterior (A-P) and anterolateral-posteromedial (AL-PM) diameters as well as annulus circumference (AC) to be significantly larger in patients with non-optimal results. Similarly, the size of the c-shaped annulus and the intertrigonal distance were determined to be larger in patients with a non-optimal result (see table below).  A significant reduction of A-P and AL-PM diameters was achieved in all patients. Contrarily, in patients with non-optimal results neither a reduction in annulus circumference nor annulus area was observed. The postprocedural non-planar angle was significantly smaller in patients with an optimal result.

Conclusion: Indirect annuloplasty appears to be crucial to achieve optimal results in edge-to-edge TMVr, especially in patients with larger annulus diameters and FMR.

Comparison of Mitral Valve (MV) geometry between patients with optimal and non-optimal results before and after device implantation

Parameter

Optimal Result

Non-Optimal Result

A-P Diameter pre

3.8±0.5

4.1±0.4

0.01

A-P Diameter post

3.5±0.5

3.9±0.5

<0.01

Mean difference

0.3±0.3

0.3±0.4

 

<0.01

0.01

 

AL-PM pre

4.0±0.4

4.3±0.5

0.02

AL-PM post

4.1±0.5

4.4±0.5

0.02

Mean difference

0.1±0.3

0.1±0.3

 

p

<0.01

0.04

 

Annulus circumference pre

13.0±1.3

14.0±1.3

<0.01

Annulus circumference post

12.7±1.3

13.8±1.3

<0.01

Mean difference

0.3±0.7

0.2±0.8

 

p

<0.01

0.31

 

Annulus area pre

12.1±2.6

14.0±2.8

<0.01

Annulus area  post

11.6±2.6

13.6±2.7

<0.01

Mean difference

0.6±1.2

0.4±1.7

 

p

<0.01

0.33

 

C-shaped Annulus pre

9.8±1.3

10.5±1.7

0.04

C-shaped Annulus post

9.9±1.2

10.7±1.1

<0.01

Mean difference

0.02±0.9

0.2±1.2

 

p

0.80

0.45

 

Intertrigonal Distance pre

2.6±0.4

2.9±0.5

<0.01

Intertrigonal Distance post

2.4±0.4

2.6±0.3

0.13

Mean difference

0.2±0.5

0.4±0.5

 

p

<0.01

<0.01

 

Nonplanar-angle pre

150.5±13.9

155.3±14.4

0.17

Nonplanar-angle post

147.4±14.7

155.2±17.0

0.04

Mean difference

3.0±14.8

0.1±19.4

 

p

0.06

0.98

 

 

 

 


https://dgk.org/kongress_programme/ht2021/P512.htm