Surgical versus Transcatheter Mitral Valve Repair in Ischemic Mitral Regurgitation: A Propensity Score Matching Analysis
Andrea Amabile1, Brandon Muncan2, Arnar Geirsson1, Andreas P. Kalogeropoulos2, Markus Krane1
1Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut, United States, 2Cardiology, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York, United States
The adoption of transcatheter mitral valve repair (TMVr) for the treatment of mitral regurgitation (MR) has progressively increased. The 2020 ACC/AHA valve guidelines provided a class 2a recommendation for TMVr in patients with chronic, severe, secondary MR related to left ventricular systolic dysfunction who remain symptomatic after optimization of guidelines-directed medical therapy and have proper anatomy. In this frame, high-power and well-controlled studies directly comparing outcomes in TMVr versus surgical mitral valve repair in patients with ischemic MR are lacking. We aimed to investigate such outcomes by leveraging a global, multi-institutional network database.
Using validated ICD-10 and CPT codes, the TriNetX Analytics Research Data Network (a global federated database of electronic health records from 57 healthcare organizations) was queried to identify patients diagnosed with chronic, severe, ischemic MR and undergoing either TMVr or surgical mitral valve repair between January 1, 2015 and December 31, 2020. To adjust for baseline differences, 1:1 propensity score matching was performed via logistic regression using the nearest-neighbor approach and matching for 18 covariates including demographics, comorbidities, surgical history, preoperative medications, left ventricular function and heart failure status. We compared 1- and 3-year survival rates and 1- and 3-year freedom from mitral valve reoperation rates in the matched cohorts using Kaplan-Meier estimates and adjusted Cox proportional hazards models.
A total of 2,289 patients met inclusion criteria (1,361 in the surgical mitral valve repair group and 928 in the TMVr group). After 1:1 propensity score matching, a total of 530 patients undergoing surgical mitral valve repair were compared to 530 patients undergoing TMVr. All characteristics were adequately matched between the cohorts (standardized mean difference < 0.1), as reported in Table 1. At 1- and 3-years respectively, survival rate was 90.4% and 82.9% for surgical patients and 81.2% and 61.1% for TMVr patients. When compared to TMVr, patients undergoing surgical mitral valve repair were significantly less likely to face mortality at 3 years (HR: 0.42, 95%CI: 0.31-0.56, p<0.0001).
At 1- and 3-years respectively, freedom from mitral valve reoperation was 97.9%, and 97.9% for surgical patients and 93.4% and 92.6% for TMVr patients. When compared to TMVr, patients undergoing surgical mitral valve repair were significantly less likely to undergo mitral valve reintervention at 3 years (HR: 0.29, 95%CI: 0.14-0.58, p=0.0002).
In a real-world, propensity score matching analysis of a large cohort of patients with chronic ischemic MR, surgical mitral valve repair had significantly better survival rates and significantly lower reintervention rates at 1- and 3-years compared to TMVr.
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