The AF population is sicker than those in sinus rhythm and needs more attentive care, both before and after the procedure.
Having atrial fibrillation (AF) at the time of transcatheter edge-to-edge repair (TEER) for severe secondary mitral regurgitation (MR) increases the chances of death and complications over 2 years, according to results from a single-center study.
Despite no difference in procedural success, patients with AF on the day of their procedure had a mortality rate of 15.3%, nonsignificantly higher than the 7.1% rate among those who were in sinus rhythm on procedure day (P = 0.10). AF also was associated with a higher rate of heart failure (HF) hospitalization (47.5% vs 29.9%; P = 0.04) as well as impaired cardiac remodeling, the researchers report in a paper published recently in the Journal of the American Heart Association.
Severe MR recurrence over the follow-up period was seen in 8.2% of patients in sinus rhythm on the day of their procedure and in 18.6% of those with AF (P = 0.05).
“Of course, this is just one study, but we are a busy center and the patients we treated in this study are [generalizable] to patients in other centers treated with this therapy,” Lerakis added. “We need bigger studies, maybe with centers putting their data together, but we feel like we can say that AF is a bad player in this situation.”
According to Lerakis and colleagues, the findings point to the need to optimize these patients before TEER. Their theory is that those with AF at the time of procedure likely have a higher burden of rhythm disorders, possibly from living for a long time with AF, that will jeopardize the repair.
“The takeaway message is that you have to deal with the A-fib before you fix the MR,” Lerakis noted. “I would say pay more attention and [consider] putting them on antiarrhythmic drugs or [doing] an ablation because it is going to be better in the long run.”
Commenting for TCTMD, Gagan D. Singh, MD (UC Davis Health, Sacramento, CA), said while rhythm control before the procedure is an important goal, it isn’t always possible, especially for patients who have lived with AF for many years.
“In an ideal world, if you had somebody who came in with mitral regurgitation and A-fib and they’ve only been in A-fib for about a year, absolutely go ahead and see if you can restore sinus rhythm in them first,” he said. “The problem is that in a lot of these patients, we don’t know the duration of their history of A-fib. The data are thought-provoking and hypothesis-generating but I don’t think they are going to change any of our practice patterns yet.”
Singh said the concept of AF burden being a factor in M-TEER outcomes is an important thing to consider going forward.
“It makes you wonder if you had caught some of those in the A-fib group 3 or 4 years ago, would they have a different trajectory? That’s certainly an unknown. What’s also an unknown is if you are able to restore sinus rhythm and then treat their MR, does that change their overall trajectory?” he added.
A Signal That Should Be Verified
For the retrospective study, Lerakis and colleagues, with lead author Carlo Mannina, MD (Icahn School of Medicine at Mount Sinai), analyzed data on 156 consecutive patients (mean age 81 years; 52.6% women) with grade 3+ or 4+ MR undergoing M-TEER at their center from 2021 through 2023.
Compared with those who were in sinus rhythm on the day of their procedure, patients with AF were more likely to have secondary MR, higher body mass index, and history of stroke. They also were more likely to be on beta-blockers and loop diuretics. However, patients with AF had lower quantitative severity of MR than those in sinus rhythm, as measured by the effective regurgitant orifice area and regurgitant volume.
An MR grade of moderate or less was achieved in 98.3% of patients with AF and in 96.9% of those in sinus rhythm, while an MR grade of mild or less was achieved in 93.2% and 86.6%, respectively.
At 2 years, the composite of death or HF hospitalization occurred in 52.5% of patients with AF and 33% of those in sinus rhythm (P = 0.01).
You can’t just do the procedure and say goodbye. Gagan D. Singh
On multivariable analysis, AF remained a significant independent predictor of death or HF hospitalization over the follow-up period (HR 2.03; 95% CI 1.12–3.69). Similarly, in a landmark analysis beginning at 30 days, AF was associated with adverse outcomes between 30 days and 2 years.
At a median follow-up of 6 months, echocardiography showed severe MR to be more frequent in the AF group than in the sinus rhythm group (18.6% vs 8.2%; P = 0.05).
Additional sensitivity analyses included all patients who had a history of AF regardless of whether AF was present on the day of the procedure. While a history of AF was associated with increased risk of death or HF hospitalization on univariable analysis, it was no longer significant after adjustment for clinical covariates (P = 0.08).
To TCTMD, Lerakis said the investigators would like to see data from other centers to support their hypothesis that AF patients fare worse if their AF is present on the day of the procedure.
“For now this is a signal . . . that maybe we need to be more aggressive with treating the A-fib before you send the patient for the MitraClip procedure,” he added. “More data and more studies will definitely help [clarify] this.”
Singh said he sees the takeaway message slightly differently, especially given some of the differences between the AF patients compared with those in sinus rhythm on procedure day, particularly their overall lower ejection fractions and higher atrial volumes.
“It just proves to us that these are sicker patients, and they need to be followed more closely. They need more guidance, more medical therapy, and much closer observation after the completion of their procedure,” he said. “What I’ve learned from this paper is you can’t just do the procedure and say goodbye. You do the procedure and you follow them regularly. Not just the 30 days or the 1 year. You need to make sure they are taking their medications . . . and just overall keep a close tab on them going forward.”