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Left Ventricular and Left Atrial Dilation Modify MitraClip Response - Impact of Adverse Chamber Remodeling on Mitral Regurgitation (MR) Recurrence following Percutaneous Mitral Valve Repair
Lisa Q. Rong, MD1, Javid Alakbarli, MD1, Meridith P. Pollie, BS1, Richard B. Devereux, MD1, Shing-Chiu Wong, MD1, Geoffrey Bergman, MD1, Omar Khalique, MD2, Antonino Di Franco, MD1, Robert A. Levine, MD3, Mark Ratcliffe, MD4, Jonathan W. Weinsaft, MD1, Jiwon Kim, MD1.
1Weill Cornell Medical College, New York, NY, USA, 2Columbia University Medical Center, New York, NY, USA, 3Massachusetts General Hospital, Boston, MA, USA, 4University of California, San Francisco, San Francisco, CA, USA.

OBJECTIVE: To test whether cardiac chamber remodeling modifies MitraClip (MClp) therapeutic response. MClp can effectively reduce MR, but clinical response varies. Impact of cardiac remodeling - including left atrial (LA), left ventricular (LV), and annular dilation - on MR recurrence after MClp is unknown.
METHODS: The population comprised advanced (>moderate) MR patients undergoing MClp who had echocardiography done pre- and (≥1 month) post-procedure: Cardiac function/geometry and mitral annular size were measured on pre-procedural echo. MR quantification included regurgitant fraction (RF) and EROA; aggregate grade was scored on a 5-point scale. Optimal MClp response was defined as ≤mild on follow-up.
RESULTS: 50 patients (62% male, 819yo, 56% CAD, 26% prior MI) with advanced (≥moderate) MR (90% degenerative [34% prolapse | 48% mitral annular calcification | 56% mitral thickening], RF: 5619%, ERO 0.580.28) underwent MClp. MR severity, LV, LA, and mitral annular dimensions on echo (1.31.0 months) pre-MClp were similar between patients with and without each degenerative MR subtype (all p=NS). At 3.32.8 months follow-up, 94% of patients had some MClp response (≥1 grade reduction); 58% had <moderate MR; 38% had optimal MClp response (≤mild MR) (∆MR grade 3.60.8 [1.71.0 in non-responders, p<0.001]). Optimal MClp responders (≤mild MR) had smaller pre-MClp LV end-diastolic volume (9227 vs 11125ml/m2, p=0.01), paralleling lesser mitral annular diameter (3.00.4 vs 3.40.5cm, p=0.002) and a trend towards smaller inter-papillary distance (2.10.8 vs 2.50.6cm, p=0.06). LVEF (5016 vs 4814%, p=0.65) and mass (10426 vs 12134gm/m2, p=0.07) were similar between MClp response groups. Conversely, pre-MClip LA size (6431 vs 9147ml/m2, p=0.02) was lower among optimal responders, despite similar PA pressure (5819 vs 5315mmHg, p=0.37). In multivariate analysis, sub-optimal MClp response was associated with larger LV size (p=0.03) independent of LA area (p=0.04; Table).
CONCLUSIONS: Among MR patients undergoing clinical MClp, lesser LV and LA dilation independently predict optimal therapeutic response. Pre-procedural LV dilation parallels risk for recurrent MR, supporting the concept that adverse LV remodeling impacts degenerative MR therapeutic response.

Structural Predictors of MR Recurrence After MitraClip
VariableOdds Ratio (95% Confidence Interval)p
LV End-Diastolic Diameter2.83 (1.09 - 7.36)0.03
LA Area (4-chamber)1.09 (1.00 - 1.18)0.04
Model Chi square=11.7; p=0.003


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