TY - JOUR
T1 - Heart failure medical therapy prior to mitral transcatheter edge-to-edge repair
T2 - the STS/ACC Transcatheter Valve Therapy Registry
AU - Varshney, Anubodh S.
AU - Shah, Miloni
AU - Vemulapalli, Sreekanth
AU - Kosinski, Andrzej
AU - Bhatt, Ankeet S.
AU - Sandhu, Alexander T.
AU - Hirji, Sameer
AU - DeFilippis, Ersilia M.
AU - Shah, Pinak B.
AU - Fiuzat, Mona
AU - O’Gara, Patrick T.
AU - Bhatt, Deepak L.
AU - Kaneko, Tsuyoshi
AU - Givertz, Michael M.
AU - Vaduganathan, Muthiah
N1 - Publisher Copyright:
© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved.
PY - 2023/11/21
Y1 - 2023/11/21
N2 - Background and Guideline-directed medical therapy (GDMT) is recommended before mitral valve transcatheter edge-to-edge repair Aims (MTEER) in patients with heart failure (HF) and severe functional mitral regurgitation (FMR). Whether MTEER is being performed on the background of optimal GDMT in clinical practice is unknown. Methods Patients with left ventricular ejection fraction (LVEF) < 50% who underwent MTEER for FMR from 23 July 2019 to 31 March 2022 in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry were identified. Pre-procedure GDMT utilization was assessed. Cox proportional hazards models were constructed to evaluate associations between pre-MTEER therapy (no/single, double, or triple therapy) and risk of 1-year mortality or HF hospitalization (HFH). Results Among 4199 patients across 449 sites, beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, mineralocorticoid receptor antagonists, and angiotensin receptor–neprilysin inhibitors were used in 85.1%, 44.4%, 28.6%, and 19.9% before MTEER, respectively. Triple therapy was prescribed for 19.2%, double therapy for 38.2%, single therapy for 36.0%, and 6.5% were on no GDMT. Significant centre-level variation in the proportion of patients on pre-intervention triple therapy was observed (0%–61%; adjusted median odds ratio 1.48 [95% confidence interval (CI) 1.25–3.88]; P < .001). In patients eligible for 1-year follow-up (n = 2014; 341 sites), the composite rate of 1-year mortality or HFH was lowest in patients prescribed triple therapy (23.0%) compared with double (24.8%), single (35.7%), and no (41.1%) therapy (P < .01 comparing across groups). Associations persisted after accounting for relevant clinical characteristics, with lower risk in patients prescribed triple therapy [adjusted hazard ratio (aHR) 0.73, 95% CI .55–.97] and double therapy (aHR 0.69, 95% CI .56–.86) before MTEER compared with no/single therapy. Conclusions Under one-fifth of patients with LVEF <50% who underwent MTEER for FMR in this US nationwide registry were prescribed comprehensive GDMT, with substantial variation across sites. Compared with no/single therapy, triple and double therapy before MTEER were independently associated with reduced risk of mortality or HFH 1 year after intervention.
AB - Background and Guideline-directed medical therapy (GDMT) is recommended before mitral valve transcatheter edge-to-edge repair Aims (MTEER) in patients with heart failure (HF) and severe functional mitral regurgitation (FMR). Whether MTEER is being performed on the background of optimal GDMT in clinical practice is unknown. Methods Patients with left ventricular ejection fraction (LVEF) < 50% who underwent MTEER for FMR from 23 July 2019 to 31 March 2022 in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry were identified. Pre-procedure GDMT utilization was assessed. Cox proportional hazards models were constructed to evaluate associations between pre-MTEER therapy (no/single, double, or triple therapy) and risk of 1-year mortality or HF hospitalization (HFH). Results Among 4199 patients across 449 sites, beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, mineralocorticoid receptor antagonists, and angiotensin receptor–neprilysin inhibitors were used in 85.1%, 44.4%, 28.6%, and 19.9% before MTEER, respectively. Triple therapy was prescribed for 19.2%, double therapy for 38.2%, single therapy for 36.0%, and 6.5% were on no GDMT. Significant centre-level variation in the proportion of patients on pre-intervention triple therapy was observed (0%–61%; adjusted median odds ratio 1.48 [95% confidence interval (CI) 1.25–3.88]; P < .001). In patients eligible for 1-year follow-up (n = 2014; 341 sites), the composite rate of 1-year mortality or HFH was lowest in patients prescribed triple therapy (23.0%) compared with double (24.8%), single (35.7%), and no (41.1%) therapy (P < .01 comparing across groups). Associations persisted after accounting for relevant clinical characteristics, with lower risk in patients prescribed triple therapy [adjusted hazard ratio (aHR) 0.73, 95% CI .55–.97] and double therapy (aHR 0.69, 95% CI .56–.86) before MTEER compared with no/single therapy. Conclusions Under one-fifth of patients with LVEF <50% who underwent MTEER for FMR in this US nationwide registry were prescribed comprehensive GDMT, with substantial variation across sites. Compared with no/single therapy, triple and double therapy before MTEER were independently associated with reduced risk of mortality or HFH 1 year after intervention.
KW - Guideline-directed medical therapy
KW - Heart failure
KW - Mitral transcatheter edge-to-edge repair
UR - http://www.scopus.com/inward/record.url?scp=85178546546&partnerID=8YFLogxK
U2 - 10.1093/eurheartj/ehad584
DO - 10.1093/eurheartj/ehad584
M3 - Article
C2 - 37632738
AN - SCOPUS:85178546546
SN - 0195-668X
VL - 44
SP - 4650
EP - 4661
JO - European heart journal
JF - European heart journal
IS - 44
ER -