Mitral Surgery After Transcatheter Edge-to-Edge Repair: Society of Thoracic Surgeons Database Analysis.

Background: Transcatheter edge-to-edge (TEER) mitral repair may be complicated by residual or recurrent mitral regurgitation. An increasing need for surgical reintervention has been reported, but operative outcomes are ill defined.
Objectives: This study evaluated national outcomes of mitral surgery after TEER.
Methods: The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database was used to identify 524 adults who underwent mitral surgery after TEER between July 2014 and June 2020. Emergencies (5.0%; n = 26), previous mitral surgery (5.3%; n = 28), or open implantation of transcatheter prostheses (1.5%; n = 8) were excluded. The primary outcome was 30-day or in-hospital mortality.
Results: In the study cohort of 463 patients, the median age was 76 years (interquartile range [IQR]: 67 to 81 years), median left ventricular ejection fraction was 57% (IQR: 48% to 62%), and 177 (38.2%) patients had degenerative disease. Major concomitant cardiac surgery was performed in 137 (29.4%) patients: in patients undergoing isolated mitral surgery, the median STS-predicted mortality was 6.5% (IQR: 3.9% to 10.5%), the observed mortality was 10.2% (n = 23 of 225), and the ratio of observed to expected mortality was 1.2 (95% confidence interval [CI]: 0.8 to 1.9). Predictors of mortality included urgent surgery (odds ratio [OR]: 2.4; 95% CI: 1.3 to 4.6), nondegenerative/unknown etiology (OR: 2.2; 95% CI: 1.1 to 4.5), creatinine of >2.0 mg/dl (OR: 3.8; 95% CI: 1.9 to 7.9) and age of >80 years (OR: 2.1; 95% CI: 1.1 to 4.4). In a volume outcomes analysis in an expanded cohort of 591 patients at 227 hospitals, operative mortality was 2.6% (n = 2 of 76) in 4 centers that performed >10 cases versus 12.4% (n = 64 of 515) in centers performing fewer (p = 0.01). The surgical repair rate after failed TEER was 4.8% (n = 22) and was 6.8% (n = 12) in degenerative disease.
Conclusions: This study indicates that mitral repair is infrequently achieved after failed TEER, which may have implications for treatment choice in lower-risk and younger patients with degenerative disease. These findings should inform patient consent for TEER, clinical trial design, and clinical performance measures.
Competing Interests: Funding Support and Author Disclosures Dr. O’Gara has served on the executive committees of the APOLLO Transcatheter Mitral Valve Replacement Trial for Medtronic and the EARLY TAVR trial for Edwards Lifesciences, outside the submitted work. Dr. Gammie is a consultant for Edwards Lifesciences; the founder of Protaryx Medical, and the founder of HARPOON medical. Dr. Badhwar discloses institutional research support for clinical trials and has served as a consultant (nonremunerative) for Abbott. Dr. Gillinov is a consultant to AtriCure, Medtronic, Abbott, CryoLife, Edwards Lifesicences, and ClearFlow; the Cleveland Clinic has rights to royalties from AtriCure. Dr. Trento has received research support from Edwards Lifesciences. Dr. Mack discloses nonfinancial support from Edwards Lifesciences, Medtronic, and Abbott. Dr. Adams discloses royalties/research support from Edwards Lifesciences and Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
(Copyright © 2021. Published by Elsevier Inc.)