Institutions Offering Transcatheter Edge-to-Edge Repair May Have Improved Survival After Surgical Mitral Valve Repair

Adoption of mitral transcatheter edge-to-edge repair (TEER) was associated with stable volumes of surgical mitral valve repair (MVr), a shift towards operating on patients with lower surgical risk, and lower post-surgical short-term and long-term mortality for patients with degenerative mitral regurgitation (DMR).¹

Transcatheter edge-to-edge repair has emerged as a promising strategy for both degenerative and functional mitral regurgitation.² For DMR, the 2020 ACC/AHA Guidelines for valvular heart disease (VHD) offer a Class 2a recommendation for M-TEER in severely symptomatic patients (NYHA class III or IV) with primary severe MR and high or prohibitive surgical risk if mitral valve anatomy is favorable and life expectancy is at least 1 year.³ Similarly, the 2021 ESC/EACTS Guidelines for VHD give M-TEER a Class 2b recommendation in symptomatic patients who fulfil the echocardiographic criteria of eligibility, are judged inoperable or at high surgical risk by the Heart Team and for whom the procedure is not considered futile.⁴ TEER offers a safe, effective, and minimally invasive alternative to surgery in appropriately selected patients. For institutions considering launching a TEER program, the impact on surgical MVr volume and outcomes is not known. Until now.

To answer this question, Lowenstern and colleagues evaluated the STS/American College of Cardiology Transcatheter Valve Therapies registry and STS Adult Cardiac Surgery Database (ACSD) linked with Medicare administrative claims data to compare surgical MVr volume and outcomes within TEER centers before and after the first institutional TEER procedure. From July 2011 through December 2018, 13,959 patients underwent MVr across 278 centers for whom medical linkage data was available. There was no significant change in the median annualized MVr volume per institution before (32 [IQR: 17-54]) versus after (29 [IQR: 16-54]) the first TEER (P = 0.06). During this time there was a significant decrease in the proportion of patient deemed intermediate or high risk with a parallel increase in low-risk cases for MVr. Following introduction of TEER, patients undergoing surgical MVr had lower 30-day mortality (1.1% vs 1.7%; P = 0.032) and lower long-term mortality (3% vs 5% at 1 year, 7% vs 9% at 3 years, and 12% vs 15% at 5 years) when comparing outcomes before first TEER and afterwards. These finding held true when comparing against trends in outcomes after coronary artery bypass surgery to negate the influence of general improvements in surgical technique and peri-operative care.

In summary, after introduction of TEER, surgical volume for MVr remained steady and both short-term and long-term MVr mortality decreased. Study investigators proposed two possible contributors: improved patient selection by a multi-disciplinary team built around TEER programs and offering MVr to progressively lower risk patients. Importantly, outcomes data for patients undergoing TEER is not evaluated and so the aggregate outcomes for all patients undergoing mitral valve interventions – surgical and transcatheter – are unavailable. While this study does not offer comparative data on surgical MVr versus TEER outcomes, several ongoing randomized trials are underway to address this.

While there are several limitations to this retrospective registry and claims data-based study, the results should offer some encouragement on the “halo effect” of establishing a TEER program on surgical MVr volume and operative outcomes.

References

1. Lowenstern AM, Vekstein AM, Grau-Sepulveda M, Badhwar V, Thourani VH, Cohen DJ, Sorajja P, Goel K, Barker CM, Lindman BR, Glower DG, Wang A, Vemulapalli S. Impact of Transcatheter Mitral Valve Repair Availability on Volume and Outcomes of Surgical Repair. J Am Coll Cardiol [Internet]. 2023 [cited 2023 Feb 8];81:521–532. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0735109722075568
2. Goyal A, Krishnaswamy A. Percutaneous Valve Interventions in Heart Failure. Curr Treat Options Cardiovasc Med 2020 2211 [Internet]. 2020 [cited 2022 Feb 19];22:1–23. Available from: https://link.springer.com/article/10.1007/s11936-020-00841-x
3. Otto CM, Nishimura RA, Bonow RO, Carabello BA, rwin JP, Gentile F, Jneid H, Krieger ric V., Mack M, McLeod C, O’Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021;143:E72–E227.
4. Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W. 2021 ESC/EACTS Guidelines for the management of valvular heart disease: Developed by the Task Force for the management of valvular heart disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Rev Esp Cardiol (Engl Ed). 2022;75:524.