Transcatheter edge‐to‐edge repair in severe mitral regurgitation following acute myocardial infarction – aetiology‐based analysis

Abstract

AimsTo 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.Methods and resultsThe 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).ConclusionTranscatheter 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.