Impact of Rhythm vs. Rate Control in Atrial Fibrillation on the Long-Term Outcome of Patients Undergoing Transcatheter Edge-to-Edge Mitral Valve Repair.

Christian Waechter,Dimitar Divchev,Thomas Deneke,Juan Cheko,Hans-Helge Mueller,Holger Nef,Ulrich Luesebrink,Philipp Halbfass,Jan Kikec,Sebastian Kerber,Sebastian Barth,Dieter Fischer,Bernhard Schieffer,Georgios Chatzis,Felix Ausbuettel

doi:10.3390/jcm10215044

Abstract

Atrial fibrillation (AF) is a highly prevalent comorbidity in patients with severe mitral valve regurgitation (MR) undergoing transcatheter mitral valve repair (TMVR) and has been shown to significantly worsen their outcome. However, data on the impact of AF treatment strategy in this rapidly growing cohort of patients is unknown. In a multicenter, observational cohort study, 542 consecutive patients undergoing TMVR were enrolled, and subsequently, comprehensive survival analyses according to AF status and therapy were performed using propensity score matching and Cox regression. In the analyzed cohort, 373 (73.3%) of the TMVR patients had concomitant AF. Of these patients, 212 (59%) were on rate control therapy and 161 (41%) were on rhythm control therapy. At 3 years, significantly reduced cumulative survival was observed for patients on rhythm compared to patients on rate control (46.7% (75/161) vs. 56.5% (91/161), p = 0.032). Amiodarone was used to a substantial extent for rhythm control and found to be an independent mortality predictor (Hazard Ratio 1.5, 95%CI 1.1–2.1, p = 0.04). The adverse outcome of concomitant AF in TMVR patients was confirmed (AF: 47.3% (126/266) vs. non-AF: 58.3% (78/133), p = 0.047). Rhythm control achieved almost exclusively pharmacologically is associated with an adverse outcome compared to the rate control of AF in TMVR. This raises awareness of the importance of AF and its treatment, as this seems to be a promising key point for improving the prognosis of TMVR patients.

Highlights

With a prevalence of nearly 10% in the population over 75 years of age, mitral regurgitation (MR) is one of the most common valvular heart diseases in industrialized countries [1]
The following results can be highlighted synoptically: (i) the concomitance of atrial fibrillation (AF) did not affect the procedural success, the rate of Major adverse cardiac and cerebrovascular events (MACCE) or the in hospital-mortality, but (ii) is significantly associated with a worse long-term clinical outcome compared to sinus rhythm; (iii) patients with permanent or non-permanent AF subtypes did not differ in the long-term clinical outcomes, but the underlying AF treatment regime seems to have a substantial impact on this; (iv) pharmacologically rhythm-controlled patients exhibited a significantly adverse long-term clinical outcome compared to rate-controlled patients
We have explored the effects of AF type, AF treatment and concomitant influencing factors using complex statistical models

Summary

Introduction

With a prevalence of nearly 10% in the population over 75 years of age, mitral regurgitation (MR) is one of the most common valvular heart diseases in industrialized countries [1] Especially in this elderly population of patients, the oftentimes high degree of advanced heart failure and other comorbidities often prohibit the prognostically favorable surgical repair due to unacceptably high perioperative risk. This emphasizes in particular the complex pathophysiological interactions of these two important diseases In this context, a plethora of recent research show that patients undergoing transcatheter mitral valve repair (TMVR) with concomitant AF have a significantly increased mortality in the medium and long term [5,6,7,8]. The aim of the present study is to elucidate the impact of different strategies for the treatment of concomitant AF on the outcome of TMVR patients

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