Clinical impact of early changes in guideline-directed medical therapy after mitral valve transcatheter edge-to-edge repair.

Abstract

Background and aims: Mitral transcatheter edge-to-edge repair (M-TEER) is an established therapy for functional mitral regurgitation (FMR) and reduced left ventricular ejection fraction (LVEF). Although guideline-directed medical therapy (GDMT) is ideally optimized before M-TEER, this procedure may facilitate early post-procedural GDMT changes. However, the clinical impact of early in-hospital GDMT modifications remains unclear.

Methods: We analysed 1638 patients with FMR and LVEF <50% enrolled in a multicentre Japanese registry. The patients were stratified according to the number of GDMT classes prescribed at discharge (single [n = 183]; double [n = 505]; triple [n = 630]; quadruple [n = 320]). Changes from before M-TEER to discharge were categorized as increased (n = 271), unchanged (n = 1219), or decreased (n = 148). Associations between GDMT patterns and subsequent outcomes were evaluated. The primary endpoint was a composite of all-cause mortality and heart failure rehospitalization at 1 year.

Results: Primary endpoints were achieved in 357 patients (22%). Event rates decreased across groups (single, 32%; double, 24%; triple, 21%; quadruple, 14%; P < 0.001). After adjusting for confounders, a greater number of GDMT classes at discharge independently predicted better prognosis (hazard ratio [HR]: 0.83; 95% confidence interval [CI]: 0.73-0.95), whereas pre-M-TEER GDMT was not significant. Compared with decreased GDMT, an unchanged status was not associated with improved outcomes, while an increased status significantly improved prognosis (HR 0.62, 95% CI 0.39-0.99).

Conclusion: In patients with FMR and LVEF <50%, a higher number of GDMT classes at discharge and in-hospital uptitration of the GDMT class were associated with better outcomes, suggesting that early post-procedural GDMT optimization warrants further investigation.