Morbidity and Mortality from Mitral Valve Surgery After TEER: First CUTTING-EDGE Data

Team of cardiologists perform transcatheter closure treatment

Mitral transcatheter edge-to-edge repair (TEER) has an excellent safety profile, and efficacy is improving with greater experience, but some patients require subsequent mitral valve (MV) surgery. The international CUTTING-EDGE registry, a partnership of 34 centers, was created to allow in-depth evaluation of the mechanisms, timing and outcomes of TEER failure that requires surgical reintervention.

Tsuyoshi Kaneko, MD, cardiac surgeon in the Heart & Vascular Center at Brigham and Women’s Hospital, served as the first author of the initial analysis of CUTTING-EDGE data. Two key findings, reported in JACC: Cardiovascular Interventions, are that 93% of patients required MV replacement and one-year cumulative mortality for the entire cohort was 24%.

Baseline Characteristics

The analysis included 332 patients who underwent MV surgery between July 2009 and July 2020 for TEER performed between July 2005 and July 2020. 99% of patients had moderate-to-severe or severe mitral regurgitation (MR) at the time of TEER, and 44% were considered at high or extreme surgical risk by their local heart team.

55% of patients had at least moderate tricuspid regurgitation (TR) at the time of surgery, and 42% required concomitant tricuspid valve (TV) surgery.

Procedural Characteristics

In accord with eligibility criteria for the registry, patients fit into one or more of the following categories:

  • TEER aborted, followed by MV surgery during the same or a different hospital admission—21% (median Society of Thoracic Surgery score, 4.3%)
  • Acute MV surgery after TEER (same admission)—18% (median STS score, 8.2%)
  • Delayed MV surgery after TEER (separate admission)—61% (median STS score, 4.6%)

The most common surgical indications were recurrent MR (34%) and residual MR (29%). 10% of patients who had surgery during the same admission had emergency surgery (initiated within six hours of diagnosis of the indication).

307 patients (93%) required MV replacement, and 20 (6.5% of this subgroup) had mechanical valves placed.

Primary Outcomes

The median follow-up after MV surgery was 9.0 months. The primary outcomes were:

  • The median interval from TEER to MV surgery—3.5 months (IQR, 0.5–11.9 months)
  • In-hospital mortality after MV surgery—15% of patients
  • 30-day mortality—17%
  • One-year mortality—31%
  • Mid-term cumulative survival—24% at one year, and 32% at three years

On multivariable analysis, chronic obstructive pulmonary disease, chronic kidney disease, TR severity pre-TEER and MR severity pre-surgery were independent risk factors for 30-day and one-year mortality.

Secondary Outcomes

The researchers also report data on:

  • In-hospital major bleeding—16% of patients
  • In-hospital stroke—3%
  • In-hospital new-onset atrial fibrillation—13%
  • Length of ICU stay—median, 60 hours
  • Length of hospital stay—median, 12 days
  • 30-day stroke rate—3%
  • 30-day readmission rate—5%
  • One-year stroke rate—6%

Guidance for Surgeons

Overall, the observed-to-expected ratio for 30-day mortality was 3.6, suggesting the risk of MV surgery after TEER might be much higher than predicted by the STS risk score. This could be attributable to patient comorbidities or frailty not captured in the STS score and the clinical scenario of TEER failure resulting in surgical acuity.

The findings of TR prompt these recommendations:

  • Patients with lower surgical risk should be evaluated for combined MV and TV surgery rather than mitral TEER alone
  • When patients with significant MR and TR undergo TEER, they should have frequent clinical and echocardiographic follow-ups, and aggressive medical therapy to control TR is warranted
  • If a patient has residual or recurrent MR after TEER, subsequent MV reintervention should be performed before significant TR or right ventricular dysfunction develops

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