MitraClip implantation followed by insertion of a left ventricular assist device in patients with advanced heart failure

Michael M Kreusser; Sonja Hamed; Andreas Weber; Bastian Schmack; Martin J Volz; Nicolas A Geis; Leonie Grossekettler; Sven T Pleger; Arjang Ruhparwar; Hugo A Katus; Philip W Raake

doi:10.1002/ehf2.12982

MitraClip implantation followed by insertion of a left ventricular assist device in patients with advanced heart failure

ESC Heart Fail. 2020 Dec;7(6):3891-3900. doi: 10.1002/ehf2.12982. Epub 2020 Oct 26.

Authors

Michael M Kreusser^{1

2}, Sonja Hamed¹, Andreas Weber¹, Bastian Schmack^{3

4}, Martin J Volz¹, Nicolas A Geis¹, Leonie Grossekettler¹, Sven T Pleger¹, Arjang Ruhparwar^{3

4}, Hugo A Katus^{1

2}, Philip W Raake¹

Affiliations

¹ Division of Cardiology, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg, 69120, Germany.
² DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany.
³ Department of Cardiac Surgery, University of Heidelberg, Im Neuenheimer Feld 110, Heidelberg, 69120, Germany.
⁴ Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Centre Essen, University of Duisburg-Essen, Hufelandstrasse 55, Essen, 45147, Germany.

Abstract

Aims: Mitral valve regurgitation (MR) is common in patients with advanced heart failure (HF). Percutaneous mitral valve repair (PMVR) via MitraClip (MC) has emerged as a feasible treatment strategy for these high-risk patients. However, as HF often further progresses, there is a frequent need for left ventricular assist device (LVAD) implantation in these patients. We aimed to investigate whether prior MC implantation affects the subsequent LVAD implantation and outcome.

Methods and results: Thirty-seven patients with advanced HF and significant MR who underwent LVAD implantation were retrospectively analysed. Follow-up data were collected at 1 year after LVAD implantation. Primary endpoint was all-cause mortality. Secondary endpoint included peri-operative parameters and clinical development depicted as New York Heart Association (NYHA) class and Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) level. Seventeen patients initially received a MC device (MC group), resulting in a significant reduction in MR grade. After MC, NYHA class and INTERMACS level further worsened, leading to subsequent LVAD implantation after a median time of 475 days in the MC group. At LVAD implantation, overall characteristics were comparable with those of the patients undergoing LVAD implantation without prior MC placement (no-MC group). Procedural data revealed a higher incidence of right ventricular (RV) failure needing mechanical RV assistance and a longer need for nitric oxide ventilation in the MC group after LVAD implantation. One-year survival was slightly better in the no-MC group compared with the MC group [41% (n = 7/17) vs. 65% (n = 13/20); P = 0.15], albeit event-free survival was comparable between both groups, MC and no-MC.

Conclusions: LVAD implantation after MC is feasible and safe. However, in patients with advanced HF and severe MR, PMVR may only delay a needed LVAD implantation and thereby lead to poorer peri-operative RV function and impaired outcome. Arguably, these patients might benefit from the timely management of advanced HF by the means of early LVAD implantation or heart transplantation.

Keywords: Advanced heart failure; Mechanical circulatory support; MitraClip; Percutaneous mitral valve repair; Ventricular assist devices.