Left ventricular geometry predicts optimal response to percutaneous mitral repair via MitraClip: Integrated assessment by two- and three-dimensional echocardiography

Catheter Cardiovasc Interv. 2019 May 1;93(6):1152-1160. doi: 10.1002/ccd.28147. Epub 2019 Feb 21.

Abstract

Objectives: To assess impact of left ventricular (LV) chamber remodeling on MitraClip (MClp) response.

Background: MitraClip is the sole percutaneous therapy approved for mitral regurgitation (MR) but response varies. LV dilation affects mitral coaptation; determinants of MClp response are uncertain.

Methods: LV and mitral geometry were quantified on pre- and post-procedure two-dimensional (2D) transthoracic echocardiography (TTE) and intra-procedural three-dimensional (3D) transesophageal echocardiography (TEE). Optimal MClp response was defined as ≤mild MR at early (1-6 month) follow-up.

Results: Sixty-seven degenerative MR patients underwent MClp: Whereas MR decreased ≥1 grade in 94%, 39% of patients had optimal response (≤mild MR). Responders had smaller pre-procedural LV end-diastolic volume (94 ± 24 vs. 109 ± 25 mL/m2 , p = 0.02), paralleling smaller annular diameter (3.1 ± 0.4 vs. 3.5 ± 0.5 cm, p = 0.002), and inter-papillary distance (2.2 ± 0.7 vs. 2.5 ± 0.6 cm, p = 0.04). 3D TEE-derived annular area correlated with 2D TTE (r = 0.59, p < 0.001) and was smaller among optimal responders (12.8 ± 2.1 cm2 vs. 16.8 ± 4.4 cm2 , p = 0.001). Both 2D and 3D mitral annular size yielded good diagnostic performance for optimal MClp response (AUC 0.73-0.84, p < 0.01). In multivariate analysis, sub-optimal MClp response was associated with LV end-diastolic diameter (OR 3.10 per-cm [1.26-7.62], p = 0.01) independent of LA size (1.10 per-cm2 [1.02-1.19], p = 0.01); substitution of mitral annular diameter for LV size yielded an independent association with MClp response (4.06 per-cm2 [1.03-15.96], p = 0.045).

Conclusions: Among degenerative MR patients undergoing MClp, LV and mitral annular dilation augment risk for residual or recurrent MR, supporting the concept that MClp therapeutic response is linked to sub-valvular remodeling.

Keywords: TTE/TEE; imaging; mitral valve disease; percutaneous intervention; structural heart disease intervention.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Cardiac Catheterization / adverse effects
  • Cardiac Catheterization / instrumentation*
  • Echocardiography, Doppler, Color*
  • Echocardiography, Doppler, Pulsed*
  • Echocardiography, Three-Dimensional*
  • Echocardiography, Transesophageal*
  • Female
  • Heart Valve Prosthesis Implantation / adverse effects
  • Heart Valve Prosthesis Implantation / instrumentation*
  • Heart Valve Prosthesis*
  • Heart Ventricles / diagnostic imaging*
  • Heart Ventricles / physiopathology
  • Hemodynamics
  • Humans
  • Male
  • Mitral Valve / diagnostic imaging
  • Mitral Valve / physiopathology
  • Mitral Valve / surgery*
  • Mitral Valve Insufficiency / diagnostic imaging
  • Mitral Valve Insufficiency / physiopathology
  • Mitral Valve Insufficiency / surgery*
  • Predictive Value of Tests
  • Prosthesis Design
  • Recovery of Function
  • Risk Factors
  • Time Factors
  • Treatment Outcome
  • Ventricular Function, Left*
  • Ventricular Remodeling*