Guideline-Directed Medical Therapy and Survival After TEER for Secondary Mitral Regurgitation With Right Ventricular Impairment

JACC Cardiovasc Interv. 2024 Jun 24;17(12):1455-1466. doi: 10.1016/j.jcin.2024.04.025.

Abstract

Background: Right ventricular impairment is common among patients undergoing transcatheter edge-to-edge repair for secondary mitral regurgitation (SMR). Adherence to guideline-directed medical therapy (GDMT) for heart failure is poor in these patients.

Objectives: The aim of this study was to evaluate the impact of GDMT on long-term survival in this patient cohort.

Methods: Within the EuroSMR (European Registry of Transcatheter Repair for Secondary Mitral Regurgitation) international registry, we selected patients with SMR and right ventricular impairment (tricuspid annular plane systolic excursion ≤17 mm and/or echocardiographic right ventricular-to-pulmonary artery coupling <0.40 mm/mm Hg). Titrated guideline-directed medical therapy (GDMTtit) was defined as a coprescription of 3 drug classes with at least one-half of the target dose at the latest follow-up. The primary outcome was all-cause mortality at 6 years.

Results: Among 1,213 patients with SMR and right ventricular impairment, 852 had complete data on medical therapy. The 123 patients who were on GDMTtit showed a significantly higher long-term survival vs the 729 patients not on GDMTtit (61.8% vs 36.0%; P < 0.00001). Propensity score-matched analysis confirmed a significant association between GDMTtit and higher survival (61.0% vs 43.1%; P = 0.018). GDMTtit was an independent predictor of all-cause mortality (HR: 0.61; 95% CI: 0.39-0.93; P = 0.02 for patients on GDMTtit vs those not on GDMTtit). Its association with better outcomes was confirmed among all subgroups analyzed.

Conclusions: In patients with right ventricular impairment undergoing transcatheter edge-to-edge repair for SMR, titration of GDMT to at least one-half of the target dose is associated with a 40% lower risk of all-cause death up to 6 years and should be pursued independent of comorbidities.

Keywords: guideline-directed medical therapy; heart failure; right ventricle dysfunction; right ventricular–to–pulmonary artery coupling; secondary mitral regurgitation; transcatheter edge-to-edge repair.

Publication types

  • Multicenter Study
  • Observational Study

MeSH terms

  • Aged
  • Aged, 80 and over
  • Cardiac Catheterization* / adverse effects
  • Cardiac Catheterization* / mortality
  • Cardiovascular Agents* / adverse effects
  • Cardiovascular Agents* / therapeutic use
  • Echocardiography, Transesophageal
  • Europe
  • Female
  • Guideline Adherence*
  • Humans
  • Male
  • Middle Aged
  • Mitral Valve / diagnostic imaging
  • Mitral Valve / physiopathology
  • Mitral Valve / surgery
  • Mitral Valve Insufficiency* / diagnostic imaging
  • Mitral Valve Insufficiency* / mortality
  • Mitral Valve Insufficiency* / physiopathology
  • Practice Guidelines as Topic*
  • Recovery of Function
  • Registries*
  • Risk Assessment
  • Risk Factors
  • Time Factors
  • Treatment Outcome
  • Ventricular Dysfunction, Right* / diagnostic imaging
  • Ventricular Dysfunction, Right* / etiology
  • Ventricular Dysfunction, Right* / mortality
  • Ventricular Dysfunction, Right* / physiopathology
  • Ventricular Dysfunction, Right* / therapy
  • Ventricular Function, Right*

Substances

  • Cardiovascular Agents