Impact of pulmonary hypertension on outcomes after TEER in patients suffering from mitral regurgitation

Abstract

Aim: Data on associations of invasively determined hemodynamic parameters with procedural success and outcomes in patients suffering from mitral regurgitation (MR) undergoing transcatheter edge-to-edge repair of the mitral valve (M-TEER) is limited.

Methods and results: We enrolled 239 patients with symptomatic MR of grade 2 + , who received M-TEER. All patients underwent extensive pre-interventional invasive hemodynamic measurements via right heart catheterization (mean pulmonary arterial pressure (mPAP), systolic- (PAPsys) and diastolic pulmonary arterial pressure (PAPdia), pulmonary arterial wedge pressure (PAWP), a-wave, v-wave, pulmonary vascular resistance (PVR), transpulmonary pressure gradient (TPG), cardiac index (CI), stroke volume index (SVI)). mPAP and PAWP at baseline were neither associated with procedural success, immediate reduction of MR, nor residual MR after 6 months of follow-up. The composite outcome (All-cause mortality (ACM) and/or heart failure induced rehospitalization (HFH)) and HFH differed significantly after M-TEER when stratified according to mPAP, PAWP, PAPdia, a-wave and v-wave. ACM was not associated with the afore mentioned parameters. Neither PVR, TPG, CI nor SVI were associated with the composite outcome and HFH, respectively. In multivariable analyses, PAWP was independently associated with the composite outcome and HFH. PVR and SVI were not associated with outcomes.

Conclusion: PAWP at baseline was significantly and independently associated with HFH and might serve as a valuable parameter for identifying patients at high risk for HFH after M-TEER. ACM and procedural success were not affected by pulmonary arterial pressure before M-TEER. We suggest that the post-capillary component of PH serves as the driving force behind the risk of HFH.

Keywords: Mitral valve transcatheter edge-to-edge repair; Outcome Assessment; Pulmonary Arterial Hypertension.

Fig. 1

Flowchart of the study cohort

Fig. 2

Good procedural result (MR < grade 2) immediately after M-TEER and at 6-months follow-up stratified according to mPAP and PAWP at baseline. A and C: MR < grade 2 (%) immediately after M-TEER. B and D: MR < grade 2 (%) after 6 months of follow-up. mPAP Q1 < 24, mPAP Q2 ≥ 24 < 30, mPAP Q3 ≥ 30 < 37, mPAP Q4 ≥ 37 mmHg. PAWP Q1 < 12, PAWP Q2 ≥ 12 < 18, PAWP Q3 ≥ 18 < 25, PAWP Q4 ≥ 25 mmHg. Abbreviations: mPAP, mean pulmonary arterial pressure; MR, mitral valve regurgitation; M-TEER, transcatheter edge-to-edge repair of the mitral valve; PAWP, pulmonary arterial wedge pressure; Q, quartile.

Fig. 3

Kaplan–Meier estimates showing composite outcome (A, B) and ACM (C, D) stratified according to mPAP and PAWP at baseline. mPAP Q1 < 24, mPAP Q2 ≥ 24 < 30, mPAP Q3 ≥ 30 < 37, mPAP Q4 ≥ 37 mmHg. PAWP Q1 < 12, PAWP Q2 ≥ 12 < 18, PAWP Q3 ≥ 18 < 25, PAWP Q4 ≥ 25 mmHg. Abbreviations: ACM, all-cause mortality; mPAP, mean pulmonary arterial pressure; PAWP, pulmonary arterial wedge pressure; Q, quartiles.

Fig. 4

Kaplan–Meier estimates showing HFH stratified according to mPAP (A), PAWP (B), PVR (C) and SVI (D), respectively, at baseline. mPAP Q1 < 24, mPAP Q2 ≥ 24 < 30, mPAP Q3 ≥ 30 < 37, mPAP Q4 ≥ 37 mmHg. PAWP Q1 < 12, PAWP Q2 ≥ 12 < 18, PAWP Q3 ≥ 18 < 25, PAWP Q4 ≥ 25 mmHg. PVR Q1 < 1.8, PVR Q2 ≥ 1.8 < 2.7, PVR Q3 ≥ 2.7 < 4.3, PVR Q4 ≥ 4.3 WU. SVI Q1 < 23.7, SVI Q2 ≥ 23.7 < 31.3, SVI Q3 ≥ 31.3 < 41.8, SVI Q4 ≥ 41.8 ml/m². Abbreviations: HFH, heart failure induced rehospitalization; mPAP, mean pulmonary arterial pressure; PAWP, pulmonary arterial wedge pressure; PVR, pulmonary vascular resistance; Q, quartiles; SVI, stroke volume index