Abstract 109 Transcatheter mitral valve replacement versus edge-to-edge repair in patients with secondary mitral regurgitation: Outcomes according to the COAPT eligibility criteria

Clin Res Cardiol (2022). https://doi.org/10.1007/s00392-022-02087-y
Transcatheter mitral valve replacement versus edge-to-edge repair in patients with secondary mitral regurgitation: Outcomes according to the COAPT eligibility criteria
S. Ludwig¹, D. Kalbacher², W. Ben Ali³, F. Praz⁴, R. Pfister⁵, G. Nickenig⁶, A. Coisne⁷, D. Muller⁸, R. S. von Bardeleben⁹, A. Duncan¹⁰, J. Webb¹¹, A. S. Petronio¹², M. Metra¹³, S. Massberg¹⁴, M. Neuß¹⁵, H. Thiele¹⁶, T. K. Rudolph¹⁷, T. Walther¹⁸, H. Ruge¹⁹, J. Kempfert²⁰, N. Schofer², M. Orban¹⁴, H. Reichenspurner²¹, S. Blankenberg²², J. Granada²³, T. Modine²⁴, J. Hausleiter¹⁴, L. Conradi²¹, für die Studiengruppen: CHOICE-MI, EuroSMR
¹Klinik für Kardiologie, Universitäres Herz- und Gefäßzentrum Hamburg GmbH, Hamburg; ²Allgemeine und Interventionelle Kardiologie, Universitäres Herz- und Gefäßzentrum Hamburg GmbH, Hamburg; ³Montreal Heart Institute, Montreal, CA; ⁴Inselspital - Universitätsspital Bern, Bern, CH; ⁵Klinik III für Innere Medizin, Herzzentrum der Universität zu Köln, Köln; ⁶Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn, Bonn; ⁷CHU de Lille, Lille, FR; ⁸St Vincent's Private Hospital Sydney, Darlinghurst, NSW, AU; ⁹Zentrum für Kardiologie im Herz- und Gefäßzentrum, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz; ¹⁰Royal Brompton Hospital, London, UK; ¹¹St. Paul's Hospital, Vancouver, BC, CA; ¹²University of Pisa, Pisa, IT; ¹³ASST Spedali Civili and University of Brescia, Brescia, IT; ¹⁴Medizinische Klinik und Poliklinik I, LMU Klinikum der Universität München, München; ¹⁵Herzzentrum Brandenburg / Kardiologie, Immanuel Klinikum Bernau, Bernau bei Berlin; ¹⁶Klinik für Innere Medizin/Kardiologie, Herzzentrum Leipzig - Universität Leipzig, Leipzig; ¹⁷Allgemeine und Interventionelle Kardiologie/Angiologie, Herz- und Diabeteszentrum NRW, Bad Oeynhausen; ¹⁸Klinik für Thorax-, Herz- und Thorakale Gefäßchirurgie, Universitätsklinikum Frankfurt, Frankfurt am Main; ¹⁹Deutsches Herzzentrum München, München; ²⁰Klinik für Herz-, Thorax- und Gefäßchirurgie, Deutsches Herzzentrum Berlin, Berlin; ²¹Klinik und Poliklinik für Herz- und Gefäßchirurgie, Universitäres Herz- und Gefäßzentrum Hamburg GmbH, Hamburg; ²²Klinik für Kardiologie, Universitäres Herz- und Gefäßzentrum UKE Hamburg GmbH, Hamburg; ²³Cardiovascular Research Foundation, New York City, US; ²⁴CHU de Bordeaux, Bordeaux, FR;
Background: The COAPT eligibility criteria have been proven to identify patients with secondary mitral regurgitation (SMR) that benefit from mitral valve transcatheter edge-to-edge repair (M-TEER) treatment. Transcatheter mitral valve replacement (TMVR) is a novel therapeutic option for surgical high-risk patients with SMR. The future role of TMVR among established SMR therapies is yet to be defined. Aims: In this study we aimed to compare the clinical outcomes of TMVR versus M-TEER among patients with SMR according to the adapted COAPT eligibility criteria. Methods: This study included SMR patients undergoing TMVR from the CHOICE-MI registry and M-TEER from the EuroSMR registry. The CHOICE-MI registry included 153 SMR patients treated with ten different TMVR devices (90.0% transapical access) between 05/2014 and 03/2021. Among others, a main indication for TMVR was non-eligibility for M-TEER. The EuroSMR registry included 1,383 SMR patients treated with M-TEER between 11/2008 and 09/2019. Propensity score (PS)-matching was performed for 12 demographic, clinical and echocardiographic parameters. Matched patients were subdivided into COAPT-eligible and COAPT-ineligible patients according to previously published adapted COAPT inclusion criteria. The primary endpoint was defined as all-cause mortality at 2 years. Results: After PS-matching, a total of 145 TMVR patients (75.1 years [70.3, 80.0], EuroSCORE II 6.3% [IQR 3.7, 13.4]) were compared to 488 M-TEER patients (76.6 years [70.0, 80.7], EuroSCORE II 7.6% [3.9, 14.1]). In the TMVR group, 41 patients were COAPT-eligible (28.3%) and 104 patients were COAPT-ineligible (71.7%). In the M-TEER group, 156 patients were COAPT-eligible (32.0%) and 332 patients were COAPT-ineligible (66.0%). In COAPT-eligible patients, all-cause mortality after 2 years was significantly lower in patients undergoing M-TEER (23.3%) compared to those undergoing TMVR (43.7%, p=0.0021). This difference was mainly driven by higher procedural mortality (4.9% [TMVR] vs. 0.0% [TEER], p=0.056) and 30-day mortality (13.0% [TMVR] vs. 2.5% [M-TEER], p=0.0078) in patients undergoing TMVR. In contrast, all-cause mortality was comparable between TMVR and M-TEER in the group of COAPT-ineligible patients (TMVR: 37.7%, M-TEER: 37.5%, p=0.80). TMVR was associated with superior reduction of MR in both COAPT-eligible (MR ≤1+ at discharge: 95.1% [TMVR] vs. 66.8% [M-TEER], p<0.0026) and COAPT-ineligible patients (96.6% [TMVR] vs. 62.2% [M-TEER], p<0.001). At 1-year follow-up, functional improvement did not differ between TMVR and M-TEER in COAPT-eligible patients (NYHA functional class I/II: 81.5% [TMVR] vs. 59.3% [M-TEER], p=0.20), while in COAPT-ineligible patients functional improvement was greater in patients undergoing TMVR (85.6% [TMVR] vs. 66.5% [M-TEER], p=0.0071). Conclusion: In our analysis, M-TEER in COAPT-eligible patients appears to be associated with a survival benefit over TMVR treated patients, while TMVR is associated with a better symptomatic improvement and comparable survival rates compared to M-TEER in COAPT-ineligible patients. MR resolution was higher in TMVR compared to M-TEER. These results must be considered as hypothesis-generating and warrant a prospective randomised study comparing different procedures as well as medical therapy in COAPT-ineligible patients.
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