Prognostic Value of Right Ventricular Afterload in Patients Undergoing Mitral Transcatheter Edge-to-Edge Repair.

BACKGROUND: Pulmonary hypertension (PH) and secondary mitral regurgitation (MR) are associated with adverse outcomes after mitral transcatheter edge-to-edge repair. We aim to study the prognostic value of invasively measured right ventricular afterload in patients undergoing mitral transcatheter edge-to-edge repair. METHODS AND RESULTS: We identified patients who underwent right heart catheterization ≤1 month before transcatheter edge-to-edge repair. The end points were all-cause mortality and a composite of mortality and heart failure hospitalization at 2 years. Using the receiver operating characteristic curve-derived threshold of 0.6 for pulmonary effective arterial elastance ([Ea], pulmonary artery systolic pressure/stroke volume), patients were stratified into 3 profiles based on PH severity (low elastance [HE]: Ea <0.6/mean pulmonary artery pressure (mPAP)) <35; High Elastance with No/Mild PH (HE-): Ea ≥0.6/mPAP <35; and HE with Moderate/Severe PH (HE+): Ea ≥0.6/mPAP ≥35) and MR pathogenesis (Primary MR [PMR])/low elastance, PMR/HE, and secondary MR). The association between this classification and clinical outcomes was examined using Cox regression. Among 114 patients included, 50.9% had PMR. Mean±SD age was 74.7±10.6 years. Patients with Ea ≥0.6 were more likely to have diabetes, atrial fibrillation, New York Heart Association III/IV status, and secondary MR (all P<0.05). Overall, 2-year cumulative survival was 71.1% and was lower in patients with secondary MR and mPAP ≥35. Compared with patients with low elastance, cumulative 2-year event-free survival was significantly lower in HE- and HE+ patients (85.5% versus 50.4% versus 41.0%, respectively, P=0.001). Also, cumulative 2-year event-free survival was significantly higher in patients with PMR/low elastance when compared with PMR/HE and patients with secondary mitral regurgitation (85.5% versus 55.5% versus 46.1%, respectively, P=0.005). CONCLUSIONS: Assessment of the preprocedural cardiopulmonary profile based on mPAP, MR pathogenesis, and Ea guides patient selection by identifying hemodynamic features that indicate likely benefit from mitral-transcatheter edge-to-edge repair in PH or lack thereof.

Echocardiographic Profiling Predicts Clinical Outcomes After Mitral Transcatheter Edge-to-Edge Repair.

BACKGROUND: Prior studies investigating the impact of residual mitral regurgitation (MR), tricuspid regurgitation (TR), and elevated predischarge transmitral mean pressure gradient (TMPG) on outcomes after mitral transcatheter edge-to-edge repair (TEER) have assessed each parameter in isolation. We sought to examine the prognostic value of combining predischarge MR, TR, and TMPG to study long-term outcomes after TEER. METHODS AND RESULTS: We reviewed the records of 291 patients who underwent successful mitral TEER at our institution between March 2014 and June 2022. Using well-established outcomes-related cutoffs for predischarge MR (≥moderate), TR (≥moderate), and TMPG (≥5 mm Hg), 3 echo profiles were developed based on the number of risk factors present (optimal: 0 risk factors, mixed: 1 risk factor, poor: ≥2 risk factors). Discrimination of the profiles for predicting the primary composite end point of all-cause mortality and heart failure hospitalization at 2 years was examined using Cox regression. Overall, mean age was 76.7±10.6 years, 43.3% were women, and 53% had primary MR. Two-year event-free survival was 61%. Predischarge TR≥moderate, MR≥moderate, and TMPG≥5 mm Hg were risk factors associated with the primary end point. Compared with the optimal profile, there was an incremental risk in 2-year event-rate with each worsening profile (optimal as reference; mixed profile: hazard ratio (HR), 2.87 [95% CI, 1.71-5.17], P<0.001; poor profile: HR, 3.76 [95% CI, 1.84-6.53], P<0.001). Echocardiographic profile was statistically associated with the 2-year mortality end point (optimal as reference; mixed profile: HR, 3.55 [95% CI, 1.81-5.96], P<0.001; poor profile: HR, 3.39 [95% CI, 2.56-7.33], P=0.02). CONCLUSIONS: The echocardiographic profile integrating predischarge TR, MR, and TMPG presents a novel prognostic stratification tool for patients undergoing mitral TEER.

Acknowledging the impact of seasonal blood pressure variation in hypertensive CKD and non-CKD patients living in a Mediterranean climate.

BACKGROUND: This study aims to assess seasonal blood pressure (BP) variation in chronic kidney disease (CKD) and non-CKD patients living in a Mediterranean climate, and to find out if this variation entails significant adjustment of treatment and if it impacts renal outcomes and mortality. METHODS: This retrospective study included all hypertensive patients seen between February 2006 and April 2020 in two Lebanese clinics. Regression analyses were used to assess the association of seasonal BP variability and treatment adjustment with eGFR change from baseline, dialysis initiation and death. RESULTS: A total of 398 patients of 64.2 ±13.9 years were followed for 51.1 ±44.3 months, 67% had eGFR< 60 mL/min. Mean systolic and diastolic BP was 137.7 ±14.7 and 76.5 ±9.5 mmHg respectively. Systolic and diastolic BP were significantly lower in the warm season in CKD and non-CKD patients (P<0.001). The majority (91.4%) needed seasonal treatment modifications. After adjustment to age, sex, baseline eGFR, BP and number of antihypertensive drugs, we found a significant loss of eGFR with treatment modifications in both seasons, double risk of dialysis with the increase of antihypertensive treatment in both seasons and a 2.5 more risk of death with reduced treatment in the warm season. CONCLUSION: This study confirmed the seasonal BP variability in CKD and non-CKD patients from a Mediterranean climate. All types of treatment adjustment were associated with eGFR loss. Low BP in the warm season was highly associated with death.

Association of renal resistive indices with kidney disease progression and mortality.

BACKGROUND: Renal resistive indices (RRI) have been shown to predict the progression of kidney disease. This study aims to evaluate the association of RRI with mortality and dialysis initiation after adjustment to therapeutic and life style interventions. METHODS: This is a retrospective study that included all chronic kidney disease patients followed for at least two years in three nephrology clinics between 2006 and 2019 and who had a RRI level in their files. Kaplan Meier and log rank test compared the survival of patients with normal versus high RRI. Cox regression analysis evaluated the association between RRI and death or dialysis initiation after adjustment to treatments and life style modifications. RESULTS: A total of 192 patients were analyzed: 68 had RRI < 0.7 and 124 had RRI ≥ 0.7. Their mean age was 66.5 ± 13.1 years at first visit, 78.1% were males. There was a negative correlation between baseline eGFR and RRI (p < 0.001; Spearman correlation coefficient = -0.521). The survival was significantly better in patients with RRI < 0.7 with a Log Rank test < 0.001. The univariate cox regression analysis showed a significant association between RRI and mortality (HR = 1.08; 95%CI: 1.04-1.11; p < 0.001) that remained significant after adjustment to cardiovascular risk factors and interventions such as salt reduction, blood pressure control, statins and RAAS inhibitors (HR = 1.04; 95%CI: 1.00-1.08; p = 0.036). Cox regression analysis showed a significant association between RRI and dialysis initiation (HR = 1.06; 95%CI 1.01-1.10; p = 0.011). CONCLUSION: Our study revealed that patients with an elevated RRI ≥ 0.7 are at a higher risk of mortality after adjustment to medications and lifestyle modifications. RRI can, according to this study, be considered as an independent prognostic factor in CKD patients.