Haberman Dan, Estévez-Loureiro Rodrigo, Czarnecki Andrew, Melillo Francesco, Adamo Marianna, Villablanca Pedro, Sudarsky Doron, Praz Fabien, Perl Leor, Freixa Xavier, Scotti Andrea, Fefer Paul, Spargias Konstantinos, Fam Neil, Manevich Lisa, Masiero Giulia, Nombela-Franco Luis, Pascual Isaac, Crimi Gabriele, Ninios Vlasis, Beeri Ronen, Benito-Gonzalez Tomas, Arzamendi Dabit, Fernández-Peregrina Estefanıa, Giannini Francesco, Mangieri Antonio, Poles Lion, George Jacob, Echarte Morales Julio Cesar, Caneiro-Queija Berenice, Denti Paolo, Schiavi Davide, Latib Azeem, Chrissoheris Michael, Danenberg Haim, Tarantini Giuseppe, Dvir Danny, Maisano Francesco, Taramasso Maurizio, Shuvy Mony
Heart Center, Kaplan Medical Center, Rehovot. Affiliated to the Hebrew University, Jerusalem, Israel.
Division of Interventional Cardiology, Hospital Álvaro Cunqueiro, Vigo, Spain.
Eur J Heart Fail. 2025 May;27(5):912-921. doi: 10.1002/ejhf.3582. Epub 2025 Jan 14.
To evaluate the association between transcatheter edge-to-edge repair (TEER) and outcomes in patients with significant mitral regurgitation (MR) following acute myocardial infarction (MI), focusing on the aetiology of acute post-MI MR in high-risk surgical patients.
The International Registry of MitraClip in Acute Mitral Regurgitation following Acute Myocardial Infarction (IREMMI) includes 187 patients with severe MR post-MI managed with TEER. Of these, 176 were included in the analysis, 23 (13%) patients had acute papillary muscle rupture (PMR) and 153 (87%) acute secondary MR. The mean age was 70 ± 10 years and 41% were female. PMR patients had fewer cardiovascular risk factors: hypertension (52% vs. 73%, p = 0.04), diabetes (26% vs. 48%, p < 0.01) but a higher left ventricular ejection fraction (45± 15% vs.35± 10%, p < 0.01) compared secondary MR patients. PMR patients were more likely to present in cardiogenic shock (91% vs. 51%, p = 0.001), require mechanical circulatory support (74% vs. 34%, p = 0.01), and had a higher EuroSCORE II (23± 13% vs. 13± 11%, p = 0.011). The median time from MI to TEER was shorter in PMR (6 days) versus secondary MR (20 days) (p < 0.01). Procedural success was similar (87% vs. 92%, p = 0.49) with comparable MR grade reduction. However, PMR patients had significantly higher in-hospital mortality rates (adjusted odds ratio [OR] 3.05, 95% confidence interval [CI] 1.15-8.12, p = 0.02), 30-day mortality rates (unadjusted OR 3.99, 95% CI 1.42-11.26, p = 0.01) and a higher rate of conversion to surgical mitral valve replacement (22% vs. 3%, p < 0.01) (unadjusted OR 8.17, 95% CI 2.15-30.96, p < 0.001). Aetiology of MR, cardiogenic shock, and procedure timing significantly impacted in-hospital mortality. After adjusting for EuroSCORE II and cardiogenic shock, MR aetiology remained the strongest predictor (adjusted OR 6.71; 95% CI 2.06-21.86, p < 0.01).
Transcatheter edge-to-edge repair may be considered a salvage or bridge procedure in decompensated post-MI MR patients of both aetiologies; however, patients with PMR have a higher risk of mortality and conversion to surgery.
评估经导管缘对缘修复术（TEER）与急性心肌梗死（MI）后严重二尖瓣反流（MR）患者预后之间的关联，重点关注高危手术患者急性心肌梗死后二尖瓣反流的病因。
急性心肌梗死后急性二尖瓣反流的MitraClip国际注册研究（IREMMI）纳入了187例接受TEER治疗的心肌梗死后严重二尖瓣反流患者。其中，176例纳入分析，23例（13%）患者发生急性乳头肌破裂（PMR），153例（87%）为急性继发性二尖瓣反流。平均年龄为70±10岁，41%为女性。与继发性二尖瓣反流患者相比，PMR患者的心血管危险因素较少：高血压（52%对73%，p = 0.04）、糖尿病（26%对48%，p < 0.01），但左心室射血分数较高（45±15%对35±10%，p < 0.01）。PMR患者更易出现心源性休克（91%对51%，p = 0.001），需要机械循环支持（74%对34%，p = 0.01），且欧洲心脏手术风险评估系统II（EuroSCORE II）评分更高（23±13%对13±11%，p = 0.011）。PMR患者从心肌梗死到TEER的中位时间（6天）短于继发性二尖瓣反流患者（20天）（p < 0.01）。手术成功率相似（87%对92%，p = 0.49），二尖瓣反流程度降低相当。然而，PMR患者的院内死亡率显著更高（调整后的优势比[OR] 3.05，95%置信区间[CI] 1.15 - 8.12，p = 0.02），30天死亡率（未调整的OR 3.99，95% CI 1.42 - 11.26，p = 0.01），且转为外科二尖瓣置换术的比例更高（22%对3%，p < 0.01）（未调整的OR 8.17，95% CI 2.15 - 30.96，p < 0.001）。二尖瓣反流的病因、心源性休克和手术时机对院内死亡率有显著影响。在调整EuroSCORE II和心源性休克后，二尖瓣反流病因仍是最强的预测因素（调整后的OR 6.71；95% CI 2.06 - 21.86，p < 0.01）。
对于两种病因的失代偿性心肌梗死后二尖瓣反流患者，经导管缘对缘修复术可被视为一种挽救或过渡手术；然而，PMR患者的死亡风险和转为手术治疗的风险更高。
