Transcatheter edge-to-edge repair vs medical therapy in atrial functional mitral regurgitation: a propensity score-based comparison from the OCEAN-Mitral and REVEAL-AFMR registries.

Abstract

Atrial functional mitral regurgitation (AFMR) commonly affects elderly and frail individuals. The prognostic impact of transcatheter edge-to-edge repair (TEER) for AFMR has not been investigated. Patients with AFMR who underwent TEER were selected from the OCEAN-Mitral registry, and medically managed controls were selected from the REVEAL-AFMR registry, using an identical AFMR definition. The primary endpoint was a composite of all-cause mortality and heart failure hospitalization. The secondary endpoint was all-cause mortality. A total of 1081 patients (mean age 80.1 ± 8.2 years, 60.5% female) with moderate or severe AFMR were included, of whom 441 underwent TEER and 640 remained on medical treatment. Overlap weighting based on the propensity score yielded well-balanced characteristics (n = 441 vs 640; all standardized mean differences <0.01), where TEER was associated with a lower incidence of the primary (hazard ratio [HR] 0.65, 95% confidence interval [CI] 0.43-0.99, P = .044) and secondary endpoints (HR 0.58, 95% CI 0.35-0.99, P = .044). In an exploratory subgroup analysis, favourable outcomes might be pronounced in patients with ≤mild residual AFMR after TEER, while event rates in those with ≥ moderate residual AFMR were comparable with the medication group. As sensitivity analyses, inverse probability of treatment weighting (n = 158 vs 173), propensity score matching (n = 104 vs 104), and multivariable Cox regression (n = 441 vs. 640) all confirmed favourable associations of TEER with both endpoints. In real-world data, TEER for patients with moderate or severe AFMR were associated with a lower incidence of adverse events compared with medical treatment.