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Vincent F, Redfors B, Kotinkaduwa LN, Kar S, Lim DS, Mishell JM, Whisenant BK, Lindenfeld J, Abraham WT, Mack MJ, Stone GW. Cerebrovascular events after transcatheter mitral valve repair or guideline-directed medical therapy in patients with mitral regurgitation and heart failure in the COAPT trial. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Our knowledge regarding the risk of cerebrovascular events (CVE) in patients with heart failure (HF) and severe secondary mitral regurgitation (SMR) treated by transcatheter mitral valve repair (TMVr) is limited.
Purpose
To examine the incidence, predictors, timing, and prognostic impact of CVE in patients with heart failure and SMR treated with TMVr vs guideline-directed medical therapy (GDMT) alone.
Methods
In the COAPT trial, 614 patients with HF with moderate-to-severe or severe SMR were randomized to TMVr with the MitraClip + GDMT vs GDMT alone. After 2 years, patients who were randomized to GDMT alone could crossover and undergo TMVr. CVE (defined as stroke or TIA) were adjudicated by an independent clinical events committee.
Results
A total of 43 CVE occurred in 42 patients within 3-year follow-up (34 strokes and 9 TIAs; 1 patient had both). CVE occurred in 10.0% (n=20) of patients randomized to TMVR and 11.3% (n=22) of patients randomized to GDMT alone (p=0.53) (Figure). Of the 22 CVE in the GDMT alone group, 3 occurred after the patient had crossed over to TMVr. The incidence rates in the TMVr and GDMT groups were similar within the first 3 months (incidence rate ratio [IRR] 0.78, 95% CI 0.17–3.48, p=0.74) and between 3 months and 3 years (IRR 0.83, 95% CI 0.43–1.60, p=0.58) after randomization. After multivariable adjustment, baseline estimated glomerular filtration rate (eGFR) was associated with CVE in the overall population (HR per 5 ml/min increase in eGFR 0.91, 95% CI 0.84–0.99, p=0.03). Peripheral vascular disease was associated with CVE in patients treated by GDMT (HR=3.21, 95% CI [1.35, 7.67]) but not TMVr (HR 0.53 95% CI 0.12–2.24; p-interaction=0.04). In contrast, baseline chronic oral anticoagulation use was associated with a reduced risk of CVE in patients in the TMVr group (HR 0.18, 95% CI 0.05–0.63) but not in the GDMT alone group (HR 1.66, 95% CI 0.70–3.94; p-interaction=0.004). In a time-adjusted multivariable analysis, CVE was associated with a higher risk of death (HR 2.51, 95% CI 1.54–4.08; p=0.0002), a risk that was marked in the first 30 days after the event (HR 14.21, 95% CI 7.30–27.97, p<0.0001), and declined thereafter (HR 1.37, 95% CI 0.72–2.59, p=0.34).
Conclusions
In patients with HF and severe SMR, CVE at 3 years was not infrequent, increased linearly over time, was similar after treatment with the MitraClip and GDMT alone, and was associated with a marked increase in all-cause death. Whether anticoagulation is especially effective at preventing CVE in patients treated by TMVr, as suggested by this report, warrants further study.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Abbott Figure 1
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Affiliation(s)
- F Vincent
- Cardiovascular Research Foundation, New York, United States of America
| | - B Redfors
- Cardiovascular Research Foundation, New York, United States of America
| | - L N Kotinkaduwa
- Cardiovascular Research Foundation, New York, United States of America
| | - S Kar
- Los Robles Regional Medical Center, Thousand Oaks, United States of America
| | - D S Lim
- University of Virginia, Charlottesville, United States of America
| | - J M Mishell
- Kaiser Permanente, San Francisco Medical Center, San Francisco, United States of America
| | - B K Whisenant
- Intermountain Medical Center, Salt Lake City, United States of America
| | - J Lindenfeld
- Vanderbilt University Medical Center, Nashville, United States of America
| | - W T Abraham
- The Ohio State University, Columbus, United States of America
| | - M J Mack
- Baylor Scott and White The Heart Hospital, Plano, United States of America
| | - G W Stone
- Mount Sinai School of Medicine, New York, United States of America
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