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. 2024 Oct 21;20(20):e1298-e1308.
doi: 10.4244/EIJ-D-24-00297.

Findings from transoesophageal echocardiographic follow-up after mitral transcatheter edge-to-edge repair

Joanna Bartkowiak  1   2 , Mohammad Kassar  1 , Salomon J Brülisauer  3 , Laura Bubulyte  1 , Daryoush Samim  1 , Andrea Ruberti  1 , Raouf Madhkour  1 , Lutz Büllesfeld  4 , Stephan Windecker  1 , Thomas Pilgrim  1 , Nicolas Brugger  1 , Fabien Praz  1
Affiliations

Findings from transoesophageal echocardiographic follow-up after mitral transcatheter edge-to-edge repair

Joanna Bartkowiak et al. EuroIntervention. .

Abstract

Background: Transoesophageal echocardiography (TOE) provides accurate evaluation of mitral valve (MV) function following mitral transcatheter edge-to-edge repair (M-TEER) and may better detect complications in case of suboptimal result.

Aims: We aimed to evaluate midterm anatomical changes and structural complications after M-TEER using TOE and investigate their association with clinical outcomes at 2 years.

Methods: A follow-up TOE at 6 months was systematically recommended to all patients included in our institutional prospective M-TEER registry until December 2021. We assessed changes in the incidence of mitral regurgitation (MR), MV stenosis (≥5 mmHg), and partial or complete single leaflet device attachment (SLDA) between the index procedure and follow-up and evaluated MV area and annular dimensions in a subset of patients with available three-dimensional (3D) datasets. The clinical endpoint was a composite of mortality and heart failure (HF) rehospitalisation at 2 years.

Results: Among the 373 patients included in the registry between February 2012 and December 2021, 128 patients (34%) underwent elective TOE at 6 months. Using TOE, severe MR was observed in 13.3% (n=17) of the patients. The number of patients with an elevated MV gradient increased from 17 (13.3%) after the procedure to 23 (18%) at 6 months, and a new partial or complete SLDA was detected in 7.8% (n=10). Based on 3D TOE measurements, significant increases in MV area, annular area, annular perimeter, and intercommissural (but not anteroposterior) diameter were observed compared to intraprocedural images. A mean MV gradient ≥5 mmHg (hazard ratio [HR] 2.30, 95% confidence interval [CI]: 1.10-4.81; p=0.023) and the presence of severe MR at 6 months (HR 3.26, 95% CI: 1.18-8.99; p=0.023) were associated with the primary endpoint, which was met in 34 (26.6%) patients at 2 years.

Conclusions: TOE follow-up allowed the detection of complications that would not be diagnosed using transthoracic echocardiography only and should therefore be used liberally in the patients presenting with a suboptimal result. A mean MV gradient ≥5 mmHg and severe MR, diagnosed at the 6-month TOE follow-up, were associated with adverse clinical outcomes.

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Conflict of interest statement

J. Bartkowiak reports a research grant from Novartis Foundation. M. Kassar reports a research grant from Swiss Heart Foundation. D. Samim reports institutional grants from Edwards Lifesciences. S. Windecker reports research, travel or educational grants to the institution from Abbott, Abiomed, Amgen, AstraZeneca, Bayer, B. Braun, Biotronik, Boehringer Ingelheim, Boston Scientific, Bristol-Myers Squibb, Cardinal Health, Cardiovalve (now Venus Medtech), Cordis Medical, CorFlow Therapeutics, CSL Behring, Daiichi Sankyo, Edwards Lifesciences, Farapulse Inc., Fumedica, Guerbet, Idorsia, Inari Medical, Infraredx, Janssen-Cilag, Johnson & Johnson, MedAlliance, Medicure, Medtronic, Merck Sharp & Dohme, Miracor Medical, Novartis, Novo Nordisk, Organon, OrPha Swiss, Pharming Technologies B.V., Pfizer, Polares, Regeneron, Sanofi-Aventis, Servier, Sinomed, Terumo, Vifor, and V-Wave; and served as advisory board member and/or member of the steering/executive group of trials funded by Abbott, Abiomed, Amgen, AstraZeneca, Bayer, Boston Scientific, Biotronik, Bristol-Myers Squibb, Edwards Lifesciences, MedAlliance, Medtronic, Novartis, Polares, Recardio, Sinomed, Terumo, and V-Wave with payments to the institution but no personal payments; he is also a member of the steering/executive committee group of several investigator-initiated trials that receive funding from industry without impact on his personal remuneration; he is Vice-President of the ESC and Associate Editor of JACC CV Interventions. T. Pilgrim reports research, travel, and educational grants to the institution from Boston Scientific, Biotronik, Medtronic, and Edwards Lifesciences; and speaker fees from Biotronik, Boston Scientific, Edwards Lifesciences, Abbott, and Medtronic; he is a member of clinical event adjudication committee for HighLife SAS DSMB for a study from Biosensors; and received equipment, materials, drugs, medical writing, gifts or other services from ATSens; he participates on a data safety monitoring board or advisory board for Biosensors (EMPIRE trial). F. Praz reports compensation for travel expenses from Abbott, Edwards Lifesciences, Medira, Siemens Healthineers, and InQB8 Medical Technologies; as well as a research grant to the institution from Abbott. The other authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1. Changes in mitral regurgitation (MR) severity.
MR was assessed at baseline (TTE or TOE), at the end of the TEER procedure (TOE), at discharge (TTE) and at six months (TOE). P-values represent the results of McNemar analysis comparing binary variables of severe versus non-severe MR. TEER: transcatheter edge-to-edge repair; TOE: transoesophageal echocardiography; TTE: transthoracic echocardiography
Figure 2
Figure 2. Procedural and follow-up TOE of the mitral valve in the same patient.
Three-dimensional (3D) echocardiograms of the mitral valve were obtained from the same patient at 2 timepoints: (A) at the end of the medical procedure (procedural TOE) and (B) at 6-month follow-up (follow-up TOE), along with corresponding measurements. The results show an increase in both anteroposterior and lateromedial diameters, leading to a consecutive increase in the annular area. 2D: two-dimensional; TOE: transoesophageal echocardiography
Figure 3
Figure 3. Kaplan-Meier analyses with log-rank test for the combined endpoint after M-TEER.
A) Kaplan-Meier analysis with log-rank test for the combined endpoint (death or heart failure rehospitalisation) after M-TEER for different mitral regurgitation (MR) severity grades at 6 months (6M) with corresponding hazard ratios. B) Kaplan-Meier analysis with log-rank test for the combined endpoint (death or heart failure rehospitalisation) after M-TEER in patients with high (≥5 mmHg) and low (<5 mmHg) mean mitral valve gradients (MVG) at 6 months (6M) with the corresponding hazard ratio (HR). M-TEER: mitral transcatheter edge-to-edge repair
Central illustration
Central illustration. TOE follow-up at 6 months after M-TEER.
mGr: mean gradient; MR: mitral regurgitation; M-TEER: mitral transcatheter edge-to-edge repair; SLDA: single leaflet device attachment; TOE: transoesophageal echocardiography
See this image and copyright information in PMC

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