Surgical repair rates and mortality after failed transcatheter repair

Outcomes of mitral surgery after transcatheter edge-to-edge mitral repair – Analysis from Society of Thoracic Surgeons database

By Chikwe J, O’Gara P, Fremes S et al

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. This study evaluated national outcomes of mitral surgery after TEER.

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, previous mitral surgery, or open implantation of transcatheter prostheses were excluded. The primary outcome was 30-day or in-hospital mortality.

In the study cohort of 463 patients, the median age was 76 years, median left ventricular ejection fraction was 57%, 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.

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.

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Chikwe J, O’Gara P, Fremes S, Sundt TM 3rd, Habib RH, Gammie J, Gaudino M, Badhwar V, Gillinov M, Acker M, Rowe G, Gill G, Goldstone AB, Schwann T, Gelijns A, Trento A, Mack M, Adams DH. Mitral Surgery After Transcatheter Edge-to-Edge Repair: Society of Thoracic Surgeons Database Analysis. J Am Coll Cardiol. 2021 Jul 6;78(1):1-9. doi: 10.1016/j.jacc.2021.04.062. Epub 2021 May 1. PMID: 33945832.