Patients with heart failure and atrial fibrillation (AF) at the time of mitral transcatheter edge-to-edge repair (M-TEER) for severe mitral regurgitation are more than twice as likely to die or be rehospitalized for heart failure, compared to patients without AF. These are the findings from a Mount Sinai Fuster Heart Hospital study that links the presence of AF at the time of the procedure to worse outcomes following the procedure.
The results, published July 17 in the Journal of the American Heart Association, suggest that AF may have to be treated more aggressively before patients undergo this type of transcatheter procedure in order to improve outcomes.
"We found that even when the transcatheter mitral valve procedure is successful, having atrial fibrillation at the day of the procedure doubles the risk of death or rehospitalization for heart failure. AF is a powerful risk marker that we need to take into consideration when planning and performing these procedures," says corresponding author Stamatios Lerakis, MD, PhD, Professor of Medicine (Cardiology) at the Icahn School of Medicine at Mount Sinai. "We know that mitral regurgitation and AF are interconnected. The one begets more of the other and vice versa. This study suggests that rhythm control ahead of time may be critical for the outcome of patients undergoing these procedures."
"Our study emphasizes the importance of atrial fibrillation as a major prognostic factor in patients with heart failure and severe mitral regurgitation, even after effective transcatheter edge-to-edge repair. These findings support early treatment of heart failure and mitral regurgitation before atrial fibrillation develops, in addition to considering ablation should atrial fibrillation occur," says author Gregg W. Stone, MD, Professor of Medicine (Cardiology) at the Icahn School of Medicine at Mount Sinai.
Mitral regurgitation is the second most common valvular disease, affecting more than 2 million adults in the United States. It develops when the mitral valve, which controls the flow of blood from the left atrium into the left ventricle, becomes distorted from the enlarged left ventricle so that its leaflets do not completely close. This causes blood to leak backward, increases pressure in the heart, and puts patients at increased risk of hospitalization and death. In most patients, this condition can be treated with a minimally invasive procedure called M-TEER in which the leaflets of the mitral valve are clipped together.
Atrial fibrillation—a rapid and irregular heartbeat—is found in up to one-third of patients with mitral regurgitation. Mount Sinai researchers wanted to better understand how M-TEER impacts outcomes of patients who have AF. They analyzed 156 patients with symptomatic heart failure and severe mitral regurgitation treated with M-TEER at Mount Sinai Fuster Heart Hospital. All these patients were evaluated by the heart team before undergoing M-TEER.
The researchers divided patients into two groups: those with AF at the time of the procedure (38 percent), and those with no AF at the time of the procedure (62 percent). After the procedure, researchers tracked patient survival, heart failure hospitalizations, and heart structure/function changes using echocardiography over a median follow-up of more than a year.
M-TEER was equally successful in both groups (AF and no AF). However, those with AF fared worse in the months following: they were more likely to experience a return of valve leakage and their hearts didn't recover as well.
More specifically, within two years following the procedure, more than 52 percent of AF patients were either rehospitalized for heart failure or had died, compared to 33 percent of patients with no AF. Their hearts didn't recover as well—they showed no improvement in heart size and additionally, severe valve leakage returned in 19 percent of AF patients versus 8 percent of patients without AF.
"Previous research has shown conflicting results on M-TEER and AF patients—and while this is a single center study from Mount Sinai Fuster Heart Hospital with a relatively small sample size, it still brings up an important problem," says author Carlo Mannina, MD, a cardiology fellow at Mount Sinai Morningside. "This definitely needs further investigation."
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