Intraprocedural Doppler and Invasive Hemodynamic Profiling Predict Clinical Outcomes After Mitral TEER

Abstract

AbstractBackgroundWhether intraprocedural changes in left atrial pressure and Doppler Echocardiographic parameters are synergistic in predicting outcomes after mitral transcatheter edge-to-edge repair (TEER) is not currently known. We sought to evaluate real-time changes in invasive hemodynamics and non-invasive Doppler to develop intraprocedural profiles and assess their impact on clinical outcomes after TEER for MR.MethodsIntraprocedural changes in hemodynamics and Doppler flow with transesophageal echocardiography were assessed in 181 patients with significant MR (51.9% primary MR) undergoing TEER between 2014 and 2022. Independent predictors of the primary composite endpoint of 1-year mortality and heart failure hospitalization (HFH) were identified using multivariable Cox-regression. With receiver operating characteristic curve-derived thresholds for the predictors of the primary end-point, patients were stratified into hemodynamic profiles based on the number of predictors present, and their impact on outcomes was examined.ResultsMedian follow-up was 21.3 months (IQR:11.3-36.5), with 1-year mortality and HFH rates of 19.3% and 12.7%, respectively. Residual mean left atrial pressure (mLAP) [HR=1.073/mmHg (1.03-1.12)], a lesser degree of MR reduction [HR=0.65/grade (0.45-0.93)], and lesser increment in PV systolic time velocity integral (S-VTI) [HR=0.95/cm (0.91-0.99)] were independent predictors of 1-year mortality/HFH. MR reduction by <3 grades (33.1%), S-VTI increment ≤8cm (33.9%), and residual mLAP >15mmHg (43.6%) were the most predictive thresholds. Optimal profile (0 predictors), Mixed (1 predictor) and Poor profile (≥2 predictors) were present in 28.7%, 39.2% and 32.0% of cases respectively. Two-year cumulative event-free survival was 60.1% overall, and higher in patients with optimal profile compared to mixed/poor groups (84.7% vs 55.5% vs 43.3%, P<0.001). There was an incremental risk of mortality/HFH with each profile overall [HR=1.75/profile (1.34-2.29)], and within primary MR [HR=1.64/profile (1.15-2.36)] and secondary MR [HR=1.77/profile (1.17-2.68)] cohorts. There was also an incremental risk of mortality alone with each profile [HR=1.65/profile (1.22-2.22)]. Hemodynamic profile was an independent predictor of 1-year mortality [HR=1.98/profile (1.21-3.25)] after TEER, along with baseline tricuspid regurgitation severity [HR=1.55/grade (1.10-2.19)], and post-procedural transmitral mean gradient>5mmHg [HR=2.32 (1.17-4.61)].ConclusionIntraprocedural hemodynamic profiling integrating changes in invasive hemodynamics and non-invasive doppler provide prognostic information in patients undergoing TEER and may provide real-time intraprocedural guidance to optimize long-term clinical outcomes.