Transcatheter Edge-to-Edge Repair in COAPT-Ineligible Patients With Functional Mitral Regurgitation

Adnan K Chhatriwalla; David J Cohen; Sreekanth Vemulapalli; Andrew Vekstein; Chetan P Huded; Dianne Gallup; Andrzej S Kosinski; Leo Brothers; JoAnn Lindenfeld; Gregg W Stone; Paul Sorajja

doi:10.1016/j.jacc.2023.11.012

Transcatheter Edge-to-Edge Repair in COAPT-Ineligible Patients With Functional Mitral Regurgitation

J Am Coll Cardiol. 2024 Jan 30;83(4):488-499. doi: 10.1016/j.jacc.2023.11.012.

Affiliations

¹ Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA. Electronic address: achhatriwalla@saint-lukes.org.
² Cardiovascular Research Foundation, New York, New York, USA; St Francis Hospital and Heart Center, Roslyn, New York, USA.
³ Duke University and Duke Clinical Research Institute, Durham, North Carolina, USA.
⁴ Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA.
⁵ Vanderbilt University Medical Center, Nashville, Tennessee, USA.
⁶ The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
⁷ Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA.

PMID: 38267110
DOI: 10.1016/j.jacc.2023.11.012

Abstract

Background: Mitral valve transcatheter edge-to-edge repair (MTEER) was approved in the United States for treatment of functional mitral regurgitation (FMR) based on results from the COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation) trial.

Objectives: The authors sought to analyze outcomes of MTEER in FMR patients who would have been excluded from COAPT.

Methods: MTEER procedures performed for FMR in the TVT (Transcatheter Valve Therapy) Registry between January 1, 2013, and April 30, 2020, were categorized as "trial-ineligible" if any of the following were present: cardiogenic shock, inotropic support, left ventricular ejection fraction <20%, left ventricular end-systolic dimension >7 cm, home oxygen use, or severe tricuspid regurgitation. Trial-ineligible and trial-eligible groups were compared through 1 year using multivariable models. The primary endpoint was 1-year death or heart failure hospitalization (HFH).

Results: Of 6,675 patients who underwent MTEER for FMR, 3,721 (55.7%) were trial-eligible and 2,954 (44.3%) were trial-ineligible. Trial-ineligible patients had lower rates of technical procedural success (86.9% vs 92.6%; P < 0.001) and more frequent in-hospital complications (11.8% vs 5.7%; P < 0.001) compared with trial-eligible patients. A clinically meaningful improvement in health status at 30 days was observed in 78.9% and 77.0% of patients in the trial-ineligible and trial-eligible groups, respectively. There was a higher risk of 1-year death or HFH (HR: 1.73; 95% CI: 1.57-1.91; P < 0.001) in trial-ineligible patients.

Conclusions: Among patients who underwent MTEER for FMR in the TVT Registry, nearly one-half would have been ineligible for the COAPT trial. Health status improvement at 30 days was similar in COAPT-ineligible and COAPT-eligible patients, but trial-ineligible patients had higher 1-year rates of death or HFH.

Keywords: edge-to-edge repair; functional mitral regurgitation; health status; heart failure.

Publication types

Research Support, N.I.H., Extramural
Research Support, Non-U.S. Gov't

MeSH terms

Heart Failure* / surgery
Humans
Mitral Valve Insufficiency* / surgery
Shock, Cardiogenic
Stroke Volume
Ventricular Function, Left