Cardiovascular Division, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA. Electronic address: https://twitter.com/rimhalabymd.
Cardiovascular Division, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
JACC Cardiovasc Interv. 2021 Apr 26;14(8):879-889. doi: 10.1016/j.jcin.2021.01.049.
The authors sought to evaluate the association between mean mitral valve gradient (MVG) and clinical outcomes among patients who underwent MitraClip treatment for secondary mitral regurgitation (SMR) in the COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation) trial.
In the COAPT trial, patients with heart failure (HF) and severe SMR who remained symptomatic despite guideline-directed medical therapy had marked 2-year reductions in mortality and HF hospitalizations after treatment with MitraClip.
MitraClip-treated patients were divided into quartiles (Q) based on discharge echocardiographic MVG (n = 250). Endpoints including all-cause mortality, HF hospitalization, and health status measures at 2 years were compared between quartiles.
Mean MVG after MitraClip was 2.1 ± 0.4 mm Hg, 3.0 ± 0.2 mm Hg, 4.2 ± 0.5 mm Hg, and 7.2 ± 2.0 mm Hg in Q1 (n = 63), Q2 (n = 61), Q3 (n = 62), and Q4 (n = 64), respectively. There was no difference across quartiles in the 2-year composite endpoint of all-cause mortality or HF hospitalization (43.2%, 49.2%, 40.6%, and 40.9%, respectively; p = 0.80), nor in improvements in New York Heart Association functional class, Kansas City Cardiomyopathy Questionnaire score, or 6-min walk time. Results were similar after adjustment for baseline clinical and echocardiographic characteristics, post-procedure MR grade, and number of clips (all-cause mortality or HF hospitalization Q4 [44.6%] vs. Q1 to Q3 [40.3%]; adjusted hazard ratio: 1.23, 95% confidence interval: 0.60 to 2.51; p = 0.57).
Among HF patients with severe SMR, higher MVGs on discharge did not adversely affect clinical outcomes following MitraClip. These findings suggest that in select patients with HF and SMR otherwise meeting the COAPT inclusion criteria, the benefits of MR reduction may outweigh the effects of mild-to-moderate mitral stenosis after MitraClip.
作者旨在评估在 COAPT 试验中，接受二尖瓣夹合术（MitraClip）治疗的继发性二尖瓣反流（SMR）患者的平均二尖瓣跨瓣压差（MVG）与临床结局之间的相关性。
在 COAPT 试验中，尽管接受了指南指导的药物治疗，但仍有症状的心力衰竭（HF）和严重 SMR 患者，在接受 MitraClip 治疗后，其 2 年死亡率和 HF 住院率显著降低。
根据出院时超声心动图的 MVG，将接受 MitraClip 治疗的患者分为四分位数（Q）（n=250）。比较四分位组之间 2 年时的全因死亡率、HF 住院率和健康状况测量指标。
MitraClip 治疗后，MVG 分别为 Q1（n=63）组的 2.1±0.4mmHg、Q2（n=61）组的 3.0±0.2mmHg、Q3（n=62）组的 4.2±0.5mmHg 和 Q4（n=64）组的 7.2±2.0mmHg。在全因死亡率或 HF 住院率的 2 年复合终点方面，四分位组之间无差异（分别为 43.2%、49.2%、40.6%和 40.9%；p=0.80），纽约心脏协会功能分级、堪萨斯城心肌病问卷评分或 6 分钟步行时间的改善也无差异。在调整了基线临床和超声心动图特征、术后 MR 分级和夹合器数量后，结果相似（全因死亡率或 HF 住院率 Q4[44.6%]与 Q1 至 Q3[40.3%]；调整后的风险比：1.23，95%置信区间：0.60 至 2.51；p=0.57）。
在严重 SMR 的 HF 患者中，出院时较高的 MVG 并未对 MitraClip 后临床结局产生不利影响。这些发现表明，在符合 COAPT 纳入标准的特定 HF 和 SMR 患者中，MR 减少的益处可能超过 MitraClip 后轻度至中度二尖瓣狭窄的影响。
