Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany; Munich Heart Alliance, Partner Site German Center for Cardiovascular Disease, Munich, Germany.
Department of Cardiology, European Hospital Georges Pompidou and Paris Cardiovascular Research Center, INSERM U970, Paris, France.
JACC Cardiovasc Imaging. 2021 Apr;14(4):715-725. doi: 10.1016/j.jcmg.2020.05.042. Epub 2020 Aug 26.
The purpose of this paper was to evaluate the impact of proportionality of secondary mitral regurgitation (SMR) in a large real-world registry of transcatheter edge-to-edge mitral valve repair (TMVr) BACKGROUND: Differences in the outcomes of recent randomized trials of TMVr for SMR may be explained by the proportionality of SMR severity to left ventricular (LV) volume.
The ratio of pre-procedural effective regurgitant orifice area (EROA) to LV end-diastolic volume (LVEDV) was retrospectively assessed in patients undergoing TMVr for severe SMR between 2008 and 2019 from the EuroSMR registry. A recently proposed SMR proportionality scheme was adapted to stratify patients according to EROA/LVEDV ratio in 3 groups: MR-dominant (MD), MR-LV-co-dominant (MLCD), and LV-dominant (LD). All-cause mortality was assessed as a primary outcome, secondary heart failure (HF) outcomes included hospitalization for HF (HHF), New York Heart Association (NYHA) functional class, N-terminal pro-B-type natriuretic peptide (NT-proBNP), 6-min-walk distance, quality of life and MR grade.
A total of 1,016 patients with an EROA/LVEDV ratio were followed for 22 months after TMVr. MR was reduced to grade ≤2+ in 92%, 96%, and 94% of patients (for MD, MLCD, and LD, respectively; p = 0.18). After adjustment for covariates including age, sex, diabetes, kidney function, body surface area, LV ejection fraction, and procedural MR reduction (grade ≤2+), adjusted rates of 2-year mortality in MD patients did not differ from those for MLCD patients (17% vs. 18%, respectively), whereas it was higher in LD patients (23%; p = 0.02 for comparison vs. MD+MLCD). The adjusted first HHF rate differed between groups (44% in MD, 56% in MLCD, 29% in LD; p = 0.01) as did the adjusted time for first death or HHF rate (66% in MD, 82% in MLCD, 68% in LD; p = 0.02). Improvement of NYHA functional class was seen in all groups (p < 0.001). Values for 6-min-walk distances, quality of life and NT-proBNP improved in most patients.
MD and MLCD patients had a comparable, adjusted 2-year mortality rate after TMVr which was slightly better than that of LD patients. Patients treated with TMVr had symptomatic improvement regardless of EROA/LVEDV ratio.
本文旨在评估经导管缘对缘二尖瓣修复术（TMVr）治疗二尖瓣反流（MR）的大型真实世界注册研究中继发性 MR 比例的影响。
TMVr 治疗 MR 近期随机试验结果的差异可能与 MR 严重程度与左心室（LV）容积的比例有关。
回顾性评估 2008 年至 2019 年期间因严重 MR 接受 TMVr 的患者的术前有效反流口面积（EROA）与 LV 舒张末期容积（LVEDV）比值，来自 EuroSMR 注册中心。根据 EROA/LVEDV 比值，采用最近提出的 MR 比例方案将患者分为 3 组：MR 主导（MD）、MR-LV 共同主导（MLCD）和 LV 主导（LD）。全因死亡率为主要终点，次要心衰（HF）结局包括 HF 住院（HHF）、纽约心脏协会（NYHA）功能分级、N 末端 pro-B 型利钠肽（NT-proBNP）、6 分钟步行距离、生活质量和 MR 分级。
共 1016 例患者 EROA/LVEDV 比值，TMVr 后随访 22 个月。92%、96%和 94%的患者（分别为 MD、MLCD 和 LD）MR 减少至≤2+级（p=0.18）。调整年龄、性别、糖尿病、肾功能、体表面积、LV 射血分数和手术 MR 减少（≤2+级）等混杂因素后，MD 患者 2 年死亡率与 MLCD 患者无差异（分别为 17%和 18%），而 LD 患者死亡率更高（23%；MD+MLCD 组比较 p=0.02）。各组间调整后的首次 HHF 发生率不同（MD 组 44%、MLCD 组 56%、LD 组 29%；p=0.01），首次死亡或 HHF 发生率也不同（MD 组 66%、MLCD 组 82%、LD 组 68%；p=0.02）。所有组的 NYHA 心功能分级均有改善（p<0.001）。大多数患者的 6 分钟步行距离、生活质量和 NT-proBNP 值均有改善。
TMVr 治疗后 MD 和 MLCD 患者的 2 年死亡率相似，略低于 LD 患者。无论 EROA/LVEDV 比值如何，接受 TMVr 治疗的患者症状均有改善。
