Background: Transcatheter edge-to-edge mitral valve repair (TEER) has become an established treatment strategy for high-grade mitral regurgitation (MR) in high-risk heart failure patients. Data regarding outcomes of distinct heart failure collectives are lacking.
Methods: In this multicenter observational cohort study, 890 patients from 4 tertiary heart centers were enrolled over a period from 2011 to 2022. Baseline symptoms (NYHA class), left ventricular ejection fraction (LVEF) and heart failure therapy were investigated in addition to other clinical and procedural data. Patients were divided into cohorts with preserved (>50%) and reduced LVEF (<50%) and subjected to propensity score matching (PSM) using independent predictors of mortality determined by multivariable Cox regression analysis. Long-term outcome was compared using Kaplan-Meier method for mortality after successful TEER.
Results: 644 patients were propensity score-matched in a 1:1-ratio. Patients with LVEF >50% showed lower NTproBNP values and were more likely to have degenerative MR etiology than patients with LVEF <50%. Guideline-directed medical therapy (GDMT) for patients with reduced LV function was performed in 50.6% (163/322). Pharmacotherapy of patients with LVEF >50% was highly heterogeneous. Regarding long-term survival, no statistically significant difference was observed between both cohorts after 5 years [38.9% (LVEF<50%) vs. 39.2% (LVEF>50%), p=0.65] with a median follow-up duration of 386 days (IQR 905). Multivariable Cox regression analysis revealed coexisting high-grade tricuspid regurgitation (TR), male sex, chronic obstructive pulmonary disease (COPD), NYHA class IV and GFR <30mL/Min as independent predictors of mortality. An independent influence of LVEF on mortality could not be demonstrated.
Conclusion: LV function had no relevant impact on or a predictive value for long-term prognosis after successful TEER, as patients with preserved LVEF (>50%) had a similar prognosis as patients with reduced LVEF (<50%). Given the only moderate use of GDMT, there is further potential to improve the prognosis of TEER patients with reduced LV function by more consistent use of GDMT. The use of SGLT-2 inhibitors could also improve the prognosis of TEER patients with preserved LV function.
Table 1: Clinical characteristics of patients with preserved vs. reduced LVEF
| Overall (n=644) |
LVEF <50% (n=322) |
LVEF >50% (n=322) |
p-value | |
| Age (years) | 80 ± 7 | 80 ± 7 | 80 ± 7 | 0.4 |
| Male sex | 55.4% (357) | 59% (190) | 51.9% (167) | 0.06 |
| STS Risk Score (%)* | 6.2% (7.4) | 7.8% (8.5) | 5.1% (5.4) |
<0.001 |
| NYHA class IV | 18.6% (120) | 18.9% (61) | 18.3% (59) | 0.2 |
| CAD | 54.6% (352) | 56.8% (183) | 52.5% (169) | 0.3 |
| GFR (mL/Min) | 52 ± 26 | 51 ± 22 | 54 ± 30 | 0.1 |
| NT-proBNP (ng/L)* | 1992 (4770) | 2996 (6181) | 1516 (2823) | <0.001 |
| TR grade III | 19.3% (124) | 18.6% (60) | 19.9% (64) |
0.8 |
| Degenerative MR etiology |
40.7% (262) | 35.4% (114) | 46% (148) | <0.001 |
Table 2: Implemented heart failure therapy in patients with preserved vs. reduced LVEF
| Overall (n=644) |
LVEF <50% (n=322) |
LVEF >50% (n=322) |
p-value | |
| ACE-/AT1 Inhibitors | 74.5% (480) | 67.4% (217) | 81.7% (263) | <0.001 |
| ARN Inhibitor | 12.3% (79) | 18.3% (59) | 6.2% (20) | <0.001 |
| Beta Blockers | 87.9% (566) | 90.1% (290) | 85.7% (276) | 0.1 |
| Loop diuretics | 90.2% (581) | 92.2% (297) | 88.2% (284) | 0.1 |
| Aldosteron antagonists | 47.4% (305) | 58.4% (188) | 36.3% (117) | <0.001 |
| SGLT-II-Inhibitors | 5% (32) | 5.3% (17) | 4.7% (15) | 0.9 |
Figure 1: Long-term survival among patients with preserved vs. reduced LVEF after PSM
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