Here’s a startling fact: even after undergoing a potentially life-saving procedure like mitral transcatheter edge-to-edge repair (TEER), patients with functional mitral regurgitation (MR) may still face significant risks—and it’s not just about the severity of their MR. But here’s where it gets controversial: a recent study published in JACC reveals that elevated transmitral mean pressure gradient (TMPG) is a critical factor linked to worse outcomes, regardless of how severe the MR is. This finding challenges the conventional focus on MR reduction alone and raises questions about how we assess the success of TEER procedures.
In the study, Hiroshi Tsunamoto, MD, and colleagues analyzed data from 2,360 patients with functional MR who had undergone TEER. They categorized patients into five groups based on two key factors: the severity of residual MR and the level of TMPG. These groups were: MR ≤ mild with TMPG <5 mm Hg, MR ≤ mild with TMPG ≥5 to 10 mm Hg, moderate MR with TMPG <5 mm Hg, moderate MR with TMPG ≥5 to 10 mm Hg, and MR > moderate or TMPG ≥10 mm Hg. The primary focus? All-cause death or heart failure (HF) hospitalization—a grim but crucial endpoint.
The results were eye-opening. As TMPG increased, so did the risk of poor outcomes. For instance, at the two-year mark, the risk jumped from 25% at 1 mm Hg to a staggering 47% at 6 mm Hg. Each 1 mm Hg increase in TMPG was independently tied to a higher risk of all-cause death or HF hospitalization (hazard ratio, 1.10; 95% CI, 1.02-1.17; p=0.008). And this is the part most people miss: while moderate MR didn’t significantly increase the risk compared to mild MR, severe MR (> moderate) was a strong predictor of poor outcomes. The group with the best prognosis? Those with MR ≤ mild and TMPG <5 mm Hg, who had the lowest incidence rate of just 28%.
The authors suggest that managing both MR reduction and TMPG could be a game-changer for risk stratification. But this dual-target approach isn’t without its challenges. In an accompanying editorial, Tarun Chakravarty, MD, and colleagues caution that TEER’s effectiveness in functional MR should balance MR reduction with the risk of creating mitral stenosis—a delicate hemodynamic tightrope walk.
Here’s the bold question for you: Should we rethink how we evaluate TEER success, prioritizing TMPG management alongside MR reduction? Or is this dual focus too complex for routine clinical practice? Let’s spark a debate—share your thoughts in the comments below. For those diving deeper, explore related clinical topics like heart failure, valvular heart disease, and mitral regurgitation through the provided links. Keywords for further research include mitral valve insufficiency, risk assessment, and hemodynamics.
