National trends in utilization of transatrial transcatheter mitral valve replacement and postoperative outcomes

Jake A Awtry; William Y Shi; Siobhan McGurk; Clauden Louis; Gorav Ailawadi; Isaac George; Robert L Smith 2nd; Ashraf A Sabe; Tsuyoshi Kaneko

doi:10.1016/j.jtcvs.2023.10.010

National trends in utilization of transatrial transcatheter mitral valve replacement and postoperative outcomes

J Thorac Cardiovasc Surg. 2023 Oct 13:S0022-5223(23)00966-2. doi: 10.1016/j.jtcvs.2023.10.010. Online ahead of print.

Authors

Jake A Awtry¹, William Y Shi², Siobhan McGurk³, Clauden Louis³, Gorav Ailawadi⁴, Isaac George⁵, Robert L Smith 2nd⁶, Ashraf A Sabe⁷, Tsuyoshi Kaneko⁸

Affiliations

¹ Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Mass; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
² Division of Cardiovascular and Thoracic Surgery, Northwell Health System, New York, NY.
³ Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Mass.
⁴ Division of Cardiac Surgery, University of Michigan, Ann Arbor, Mich.
⁵ Division of Cardiac Surgery, New York Presbyterian/Columbia University Medical Center, New York, NY.
⁶ Department of Cardiothoracic Surgery, Baylor Scott and White, The Heart Hospital, Plano, Tex.
⁷ Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Mass. Electronic address: asabe@bwh.harvard.edu.
⁸ Division of Cardiothoracic Surgery, Washington University in St Louis/Barnes-Jewish Hospital, St Louis, Mo.

PMID: 37839658
DOI: 10.1016/j.jtcvs.2023.10.010

Abstract

Objective: Transatrial transcatheter mitral valve replacement reduces complexity during mitral valve replacements involving high-risk patients with mitral annular calcification. This study examines trends in transatrial transcatheter mitral valve replacement use and outcomes.

Methods: Patients in the Society of Thoracic Surgeons database from 2014 to 2021 with mitral annular calcification undergoing transatrial transcatheter mitral valve replacement were included. Exclusion criteria were hypertrophic cardiomyopathy, congenital mitral valve disease, ventricular assist device placement, or prior mitral valve surgery. Primary outcomes were operative mortality and major adverse cardiac events compared between the Early (2014-2017, N = 71) and Recent (2018-2021, N = 151) eras. Parsimonious multivariable regression assessed select possible confounders for trends in major adverse cardiac events.

Results: Overall, 222 transatrial transcatheter mitral valve replacements at 104 hospitals were identified. Annual volume increased from 6 in 2014 to 43 in 2021. Median hospital volume was 1, maximum hospital volume was 17, and 10 or more replacements were performed at 4 hospitals. Mortality and major adverse cardiac events occurred in 10.4% and 22.5% of patients, respectively. Compared with the Early era patients, Recent era patients were more often elective (79.5% vs 64.8%) and were approached via sternotomy (90.1% vs 80.3%, all P < .05). Despite similar predicted risk of mortality (9.6% ± 11.1% vs 11.0% ± 6.0%; P = .61), Recent patients had reduced mortality (3.3% vs 25.4%, P < .001) and major adverse cardiac events (18.5% vs 31.0%; P = .057). On univariate and multivariable analyses, the Recent surgical era was significantly associated with lower mortality (0.10 [0.04-0.29]; P < .001) and lower major adverse cardiac events (0.48 [0.25-0.94]; P = .032), respectively. There were no preoperative characteristics that were significant confounders for the difference in major adverse cardiac events.

Conclusions: Mortality and major adverse cardiac events after transatrial transcatheter mitral valve replacement have decreased significantly in the contemporary era independent of changes in major patient and operative characteristics. Transatrial transcatheter mitral valve replacement will have a future role in patients with mitral annular calcification.

Keywords: Society of Thoracic Surgeons database; mitral annular calcification; mitral regurgitation; mitral stenosis; transcatheter mitral valve replacement.