Transcatheter Mitral Valve Repair with MitraClip for Severe Mitral Regurgitation and Cardiogenic Shock During the COVID-19 Pandemic

Transcatheter edge-to-edge mitral valve repair for mitral regurgitation in patients with cardiogenic shock: A systematic review and meta-analysis

BACKGROUND

There is currently little evidence for transcatheter edge-to-edge mitral valve repair (TEER) for mitral regurgitation (MR) in patients with cardiogenic shock (CS). Therefore, this study investigated the characteristics and outcomes of CS patients who underwent TEER for MR.

METHODS

PubMed, EMBASE were searched in July 2023. Case series and observational studies reporting clinical characteristics and outcomes in CS patients with MR who underwent TEER were included. We performed a one-group meta-analysis using a random effects model.

RESULTS

A total of 4060 patients from 7 case series and 5 observational studies were included. The mean age was 68.2 (95% confidence interval [CI]: 64.1-72.2) years, and 41.4% of patients (95% CI: 39.1%-43.7%) were female. Pre-TEER, severe MR was present in 85.3% (95% CI: 76.1%-91.3%) of patients. Mean left ventricular ejection fraction was 36.7% (95% CI: 29.2%-44.2%), and 54.6% (95% CI: 36.9%-71.2%) of patients received mechanical circulatory support. The severity of MR post-TEER was less than 2+ in 88% (95% CI: 87%-89%) of patients. In-hospital mortality was 11% (95% CI: 10%-13%), whereas 30-day and 1-year mortality rates were 15% (95% CI: 13%-16%), and 36% (95% CI: 21%-54%), respectively.

CONCLUSIONS

This systematic review and meta-analysis assessed the clinical characteristics and outcomes of TEER in CS patients with MR. TEER for MR in patients with CS has been successful in reducing MR in most of the patients, but with a high mortality rate. Randomized controlled trials of TEER for MR and CS are needed.

Transcatheter Mitral Valve Repair-Beyond the EVEREST and COAPT Criteria

Transcatheter mitral valve repair (TMVr) has emerged as a safe and effective alternative to conventional surgery in patients with primary and secondary mitral regurgitation, especially those at high surgical risk. This review summarises alternative indications for TMVr outside of the traditional criteria derived from the major randomised trials and focusses on less common mitral valve anatomies such as commissural prolapse and bileaflet prolapse, patients with mitral annuloplasty rings, as well as acutely unwell patients with papillary muscle rupture and/or cardiogenic shock. Specific technical challenges involved in treating such patient groups are summarised and described.

National Trends of Structural Heart Disease Interventions from 2016 to 2020 in the United States and the Associated Impact of COVID-19 Pandemic

The Coronavirus Disease-2019 (COVID-19) pandemic placed an enormous strain on the healthcare system. Data on the impact of COVID-19 on the utilization and outcomes of structural heart disease interventions in the United States are scarce. The National Inpatient Sample from 2016 to 2020 was queried to identify adult admissions for transcatheter aortic valve replacement (TAVR), left atrial appendage occlusion (LAAO), and transcatheter end-to-end repair (TEER). The primary outcome was temporal trends of procedure utilization rate per 100,000 admissions over quarters from 2016 to 2020. The secondary outcomes were adjusted rates of in-hospital mortality, major complications, and length of stay (LOS). Among 434,630 weighted admissions (TAVR: 305,550; LAAO: 89,300; TEER: 40,160), 95,010 admissions (22%) were during the COVID-19 era. There was a decline during the second quarter of 2020 followed by an increase to the pre pandemic levels (TAVR: 220 to 253, LAAO: 57 to 109, and TEER: 31 to 36 per 100,000 admissions, Ptrend<0.001). There were no differences in the mortality or major complication rates. Median LOS has decreased in TAVR (4 days-1 day) and in TEER (3 days-1 day) but remained stable in LAAO (1 day). This nationwide analysis showed that structural heart disease interventions decreased during the early waves of COVID-19 pandemic. There was a significant reduction in hospital LOS without differences in in-hospital mortality or complication rates during the pandemic. These data suggest that hospitals adapted to the unprecedent challenges during the pandemic to provide advanced cardiac care to patients.

Transcatheter Mitral Valve Repair in Acute and Critical Cardiac Conditions

Acute mitral valve regurgitation (MR) is an emergency condition that requires an early diagnosis of the etiology and rapid management. Surgical intervention is the first-line treatment for acute severe MR. However, many patients are denied surgical intervention due to the acute risk of surgery. Transcatheter mitral valve repair (TMVr) is a less invasive technique and becoming a potential alternative to surgery in inoperable patients but is underrepresented in the literature. This review aims to discuss the published data on the use of TMVr in unstable MR patients presenting with acute or critical cardiac conditions.

Structural Heart Interventions During COVID-19

The spread of Coronavirus Disease 2019 (COVID-19) pandemic across the globe and the United States presented unprecedented challenges with dawn of new policies to reserve resources and protect the public. One of the major policies adopted by hospitals across the nations were postponement of non-emergent procedures such as transaortic valve replacement (TAVR), left atrial appendage closure device (LAAC), MitraClip and CardioMEMS. Guidelines were based mainly on the avoidable clinical outcomes occurring during COVID-19 era. As our understanding of the SARS-CoV-2 evolved, advanced cardiac procedures may safely continue through careful advanced coordination. We aim to highlight the new guidelines published by different major cardiovascular societies, and discuss solutions to safely perform procedures to improve outcomes in a patient population with high acuity of illness during the COVID-19 pandemic era.

Percutaneous mitral valve repair with MitraClip device in hemodynamically unstable patients: A systematic review

BACKGROUND

Very few data exist on percutaneous mitral valve repair (PMVr) in unstable patients with concomitant moderate-severe mitral regurgitation (MR). The purpose of this systematic review was to evaluate baseline characteristics, management and clinical outcomes of critically ill patients undergoing PMVr with MitraClip.

METHODS

We conducted a systematic review of the published data on MitraClip from its first use in 2003 to December 2020. Studies referring to critically ill patients in cardiogenic shock or acute refractory pulmonary edema were included. A total of 40 publications including 254 patients with significant MR (Grade 4 in 91%) were included.

RESULTS

Mean age was 70 ± 12 years with mean Euroscore II and STS of 21 ± 13 and 20.5 ± 16, respectively. Clinical presentation was with cardiogenic shock and acute myocardial infarction in 72.8 and 60.0% of patients, respectively. Device success was achieved in 238 (93.7%) patients with a significant reduction in MR (Grade ≤ 2 in 91.8%, p < .001). The median weaning time from the procedure, to discontinuation of mechanical circulatory or respiratory support, was 2 days (IQR 1-4), with an in-hospital mortality and non-fatal complication rate of 12.6 and 9.1%, respectively. Kaplan-Meier curves estimated an overall mortality rate of 39.1% at 12-month follow-up, with persistent reduction in MR severity for survivors (Grade ≤ 2 in 81.3%) and one case of mitral valve reintervention.

CONCLUSIONS

Percutaneous mitral valve repair with MitraClip device is a technically feasible and potentially viable management option in high-risk patients with cardiogenic shock or refractory pulmonary edema and concomitant moderate-severe MR. Prospective trials are required to confirm these findings, and definitively determine the value of MitraClip in hemodynamically unstable patients.