Some Mitral TEER Patients Slipping Through the Cracks in the First Month

All-cause mortality after transcatheter-edge-to-edge repair for mitral regurgitation (M-TEER) is just 3.0% at 30 days, but roughly two out of every five deaths that occur within this early window happen after the patient has been discharged from the hospital, according to a new TVT Registry analysis.

Those discharged who died within 30 days were sicker than those who survived, but there were several modifiable predictors of early mortality, including not being discharged on guideline-directed medical therapy (GDMT), report investigators.

“As operators, we may perform the procedure, the patient has survived, and there were no complications and we feel the patient’s ready to go home or rehab,” said lead investigator Kannu Bansal, MD (Saint Vincent Hospital, Worcester, MA). “However, we need to be cognizant that these patients are frail and they may need closer follow-up. If there’s a concern that they’re not fully optimized on GDMT, it might be better to do that in the hospital setting to prevent [later] rehospitalization and mortality.”

Of the patients who died outside the hospital within 30 days, nearly two-thirds did so from cardiovascular causes.

Andrew Goldsweig, MD (Baystate Health/UMass Chan Medical School, Springfield, MA), who wasn’t involved in the study, said this “concerning signal” suggests that some patients may be going home when they’re still at high risk for cardiovascular events.

“One would hope that patients discharged alive following M-TEER would be optimized from a cardiovascular standpoint and have a minimal rate of short-term out-of-hospital cardiovascular death,” he told TCTMD. “As a field, we interventional cardiologists must do a better job of optimizing cardiovascular risk prior to discharge, not discharging patients who are at significant risk of cardiovascular death.”

Goldsweig pointed out that M-TEER is typically reserved for patients at high or prohibitive risk for mitral valve surgery. A 2001 analysis of patients undergoing M-TEER in the US found that the median STS predicted risk of mortality at 30 days for surgical valve repair was 5.35%.

“That the overall real-world mortality was only 3.0% suggests that either M-TEER truly carries lower mortality risk than mitral valve surgery and/or lower-risk patients now account for the majority of M-TEER patients,” said Goldsweig. However, with one-third of out-of-hospital deaths occurring from noncardiovascular causes, the study also suggests that this is a high-risk group with significant comorbidities that might not be captured by the STS risk score, he said. 

Modifiable and Nonmodifiable Risks

With every new procedure, the initial focus is on in-hospital mortality to make sure it is safe, said Bansal. Prior studies have shown that early mortality rates after M-TEER are declining over time, with one recent analysis of the Society of Thoracic Surgeons/American College of Cardiology TVT Registry showing that 30-day mortality was 3.5%. In-hospital mortality rates are dropping as well, but there has been little information about out-of-hospital mortality within 30 days, he said. 

The new paper, which was published this week in JACC: Cardiovascular Interventions, included 61,139 consecutive patients who underwent isolated M-TEER at 539 sites between 2014 and 2024.

Overall, 1,813 (3.0%) died either in or out of the hospital within 30 days, with 744 patients dying after discharge. The rate of out-of-hospital mortality within 30 days was 1.2%, a percentage that was similar between those treated for functional and degenerative mitral regurgitation (MR).

For those who died out of hospital but within 30 days, the median time until death was 11 days.

Lower baseline hemoglobin, lower baseline Kansas City Cardiomyopathy Questionnaire (KCCQ) overall summary scores, home oxygen use, lower LVEF, presentation as NSTEMI, and lower body surface area were all independent predictors of 30-day out-of-hospital mortality. A higher acuity presentation, in-hospital complications, and procedural factors, such as moderate or worse residual mitral MR, use of more than one device, and postprocedural gradient greater than 5 mm Hg, were also associated with a higher risk of early mortality after discharge, as was not being treated with an ACE inhibitor/ARB at discharge.

In an editorial, Vera Fortmeier, MD, and Tanja Rudolph, MD (both Ruhr University Bochum, Bad Oeynhausen, Germany), say the “insightful” analysis shows that patients who fail to survive to 30 days after discharge represent an elderly group with multiple comorbidities. These data also show that “prognosis after M-TEER is determined not solely by the mitral valve damage but more critically by potentially irreversible cardiac damage beyond the mitral valve itself,” they write.

Importance of GDMT

With the low 30-day mortality rate, Bansal said these data confirm that M-TEER is a safe procedure. However, it’s also telling that there are some discharged patients who “don’t make it past 30 days,” he added.

“We discharge them and ask them to follow up with their doctor within 2 or 3 weeks, but the median time of death that we noted in our paper was [less than] 2 weeks,” he said. “So, half of the population who get discharged don’t make it past 2 weeks. They might not even be seen in a follow-up visit. So, are we having that follow-up visit too late or are we sending them home too soon [from the hospital]? That’s a question we have to ask ourselves.”

The study, said Bansal, also highlights the importance of appropriate patient selection for M-TEER. Patients who died out of the hospital had significantly lower baseline KCCQ scores by roughly 15 points than those who survived. In such patients, operators need to question whether treatment is justified. 

“Complications, such as bleeding, are somewhat out of our hands,” said Bansal. “These things can be unexpected, but GDMT and patient selection, I think those things definitely deserve credit and should be noticed a little more.”

As a field, we interventional cardiologists must do a better job of optimizing cardiovascular risk prior to discharge. Andrew Goldsweig

To TCTMD, Goldsweig noted that many of the predictors of out-of-hospital mortality after discharge are the “usual suspects,” such as severity of illness or comorbidities. These factors, he said, emphasize the importance of choosing patients appropriately.  

However, quite a few were modifiable risk factors that can be addressed to improve outcomes further, which is a positive takeaway from the study, he said. Avoiding procedural complications and emphasizing that moderate residual MR shouldn’t be left behind would help prevent some of these early deaths. Additionally, neurohormonal blockade with an ACE inhibitor/ARB “must be prescribed for all patients,” said Goldsweig.

In their editorial, Fortmeier and Rudolph say the days of “fire and forget” after M-TEER are gone, and that clinicians need to optimize GDMT to ensure the best possible outcome. They note that data from COAPT and EURO-SMR suggest many patients can tolerate uptitration of heart failure therapies after M-TEER, likely the result hemodynamic stabilization.

“The findings underscore the need for rigorous implementation of GDMT protocols starting on day 1 after the procedure,” they write. “Heart failure clinics, patient education programs, and electronic health record alerts should be leveraged to ensure that GDMT is initiated and titrated effectively.”