Preprocedural New York Heart Association Class IV Independently Predicts Mortality After Effective Edge-To-Edge Repair for Primary Mitral Regurgitation.
In this 2528-patient international M-TEER registry for primary MR, presenting in NYHA class IV before the procedure independently predicted 2-year all-cause mortality (31.8% vs 21.1%, HR 1.75, 95% CI 1.32–2.31, p<0.001), despite equivalent procedural success (residual MR ≤1+ in 66.7% vs 64.6%) and comparable rehospitalization rates.
Baseline LVEF and RV function did not differ between groups, so the mortality signal is not obviously explained by conventional ventricular metrics.
This is a non-randomized registry spanning 2009 to 2023, a period over which device iterations and operator experience changed substantially, and residual confounding by frailty, sarcopenia, and extracardiac disease — none captured well in registries — almost certainly contributes to the class IV penalty.
Still, the finding is clinically coherent: fixing the valve does not reverse whatever systemic decompensation drove the patient to class IV in the first place.
BACKGROUND: In patients with primary mitral regurgitation (MR) (PMR), advanced symptoms classified as New York Heart Association (NYHA) class IV are typically driven by valve deterioration. Transcatheter edge-to-edge repair (mitral valve transcatheter edge-to-edge repair [M-TEER]) reliably achieves effective reduction of mitral regurgitation in high-risk patients. However, whether or not preprocedural NYHA class IV continues to predict outcomes after successful MR reduction remains unclear. METHODS: The Outcomes of Patients tReated wIth Mitral Transcatheter Edge-to-edge Repair for Primary Mitral Regurgitation Registry includes PMR patients undergoing M-TEER at 27 international sites between 2009 and 2023. Clinical outcomes were compared between patients in NYHA class IV and those in NYHA class II/III. RESULTS: A total of 2528 patients were included (median age 82 years [interquartile range (IQR) 76-85], 45.9% female), and 19.7% presented in NYHA class IV. Baseline left ventricular ejection fraction and right ventricular function did not differ significantly between groups. Procedural success (residual MR ≤ 1+: 66.7% vs. 64.6%, p = 0.55) and 2-year rehospitalization rates (17.9% vs. 20.4%, log-rank p = 0.78) were comparable. In contrast, 2-year all-cause mortality was higher in NYHA class IV patients (31.8% vs. 21.1%, log-rank p < 0.0001). Multivariable Cox regression confirmed preprocedural NYHA class IV as an independent predictor of mortality (hazard ratio [HR] 1.75; 95% CI 1.32-2.31; p < 0.001). CONCLUSIONS: In PMR, preprocedural NYHA class IV remains an independent predictor of all-cause mortality after effective MR reduction with M-TEER, despite comparable postprocedural results.
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