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. 2022 May 15;18(1):43-49.
doi: 10.4244/EIJ-D-21-00667.

A staging classification of right heart remodelling for patients undergoing transcatheter edge-to-edge mitral valve repair

Jasmin Shamekhi  1 , Atsushi Sugiura  1 , Maximilian Spieker  2 , Christos Iliadis  3 , Marcel Weber  1 , Can Öztürk  1 , Marc Ulrich Becher  1 , Vedat Tiyerili  1 , Sebastian Zimmer  1 , Patrick Horn  2 , Ralf Westenfeld  2 , Roman Pfister  3 , Victor Mauri  3 , Jan-Malte Sinning  4 , Malte Kelm  2 , Stephan Baldus  3 , Georg Nickenig  1
Affiliations

A staging classification of right heart remodelling for patients undergoing transcatheter edge-to-edge mitral valve repair

Jasmin Shamekhi et al. EuroIntervention. .

Abstract

Background: In patients with severe mitral regurgitation (MR) who are scheduled for transcatheter mitral valve repair (TMVR), risk stratification is predominantly based on surgical risk scores.

Aims: We sought to characterise and define stages of right heart remodelling in patients undergoing TMVR and evaluate the impact of this staging classification on survival.

Methods: According to echocardiographic parameters, 929 patients undergoing MitraClip treatment were classified into three stages: severe MR without right heart damage (stage 0), with moderate-to-severe tricuspid regurgitation (TR) (stage 1), with right ventricular dysfunction defined as a reduced fractional area change <35% and a tricuspid annular plane systolic excursion <17 mm, or with increased right atrial area >25 cm2 and/or indexed right ventricular volume >30 ml/m2 (stage 2). We compared clinical outcomes and performed a multivariate analysis to evaluate the predictive value of the extent of cardiac damage.

Results: Rates of one-year all-cause mortality increased with more advanced stages of right heart remodelling (stage 0: 8% vs stage 1: 9.7% vs stage 2: 18.1%; p<0.001). In the multivariate analysis, advanced cardiac damage was an independent predictor of one-year all-cause mortality (stage 2: p=0.007).

Conclusions: A simple staging classification objectively characterises the extent of right heart remodelling caused by MR and allows risk prediction in patients undergoing a MitraClip procedure.

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Conflict of interest statement

J.M. Sinning has received speaker honoraria and research grants from Abbott, Abiomed, Medtronic, Boston Scientific, and Edwards Lifesciences. R. Pfister has received “modest” speaker and consultant honoraria by Abbott and Edwards Lifesciences, outside the submitted work. C. Iliadis has received travel support from Abbott and speaker and consultant honoraria from Abbott and Edwards Lifesciences, outside the submitted work. M. Kelm reports receiving fees from Bunnenberg Stiftung, grants from DFG CRC 1116, during the conduct of the study, grants from Philips, Abbott, Medtronic, Boston Scientific, Mars, and Boehringer Ingelheim, personal fees from Daiichi Sanyko Deutschland GmbH and Ancora Heart, grants and personal fees from Amgen, and grants from B.Braun, outside the submitted work. The other authors have no conflicts of interest to declare.

Figures

Central illustration
Central illustration. Right heart remodelling and the extent of cardiac damage is associated with mortality in patients undergoing a MitraClip procedure to treat severe mitral valve regurgitation.
TMVR: transcatheter mitral valve repair
Figure 1
Figure 1. Study flow chart.
TMVR: transcatheter mitral valve repair
Figure 2
Figure 2. Staging classification according to right heart remodelling in patients undergoing a MitraClip procedure due to severe MR.
MR: mitral valve regurgitation; TAPSE: tricuspid annular plane systolic excursion; TR: tricuspid valve regurgitation
Figure 3
Figure 3. Prevalence of right heart remodelling stages in the patient population.
According to preprocedural echocardiography, 237 (26%) patients were in stage 0, 196 (21%) patients were in stage 1, and 496 (53%) patients were in stage 2.
Figure 4
Figure 4. Kaplan-Meier survival analysis of one-year all-cause mortality in patients undergoing a MitraClip procedure according to right heart remodelling.
All-cause mortality rates within one year were associated with an advanced stage of right heart remodelling (stage 0: 8% vs stage 1: 9.7% vs stage 2: 18.1%; p<0.001).
Figure 5
Figure 5. Kaplan-Meier survival analysis of one-year all-cause mortality in patients undergoing a MitraClip procedure according to right heart remodelling and MR aetiology.
In patients with degenerative MR (A) as well as in patients with functional MR (B), right heart damage (stage 2) was significantly associated with mortality (DMR: stage 0: 9.4% vs stage 1: 5.5% vs stage 2: 19.2%; p=0.005; FMR: stage 0: 6.9% vs stage 1: 12.6% vs stage 2: 17.9%; p=0.007). MR: mitral valve regurgitation
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