Urgent Transcatheter Edge-to-Edge Repair (TEER) of severe mitral regurgitation in patients with cardiogenic shock: A systematic review and meta-analysis of 5,428 patients

Abstract

Abstract Background Patients presenting with severe mitral valve regurgitation (MR) and cardiogenic shock (CS) demonstrate a poor prognosis and high mortality rate. Transcatheter edge-to-edge repair (TEER) of the mitral valve regurgitation with MitraClip may alter patient management while alleviating hemodynamic instability. Aim To perform a systematic review of the published literature and meta-analysis on the use of MitraClip in patients with severe MR and CS. Methods We performed a systematic review and meta-analysis according to the PRISMA guidelines. We systematically explored published literature in MEDLINE (Pubmed) before January 8, 2023, for studies assessing urgent TEER with MitraClip in patients presenting with severe MR and CS. CS was defined as 1) CS according to ICD-10; 2) inotrope use; or 3) mechanical circulatory support before TEER. The primary outcome was device success and all-cause mortality rates while the secondary outcome was the incidence of myocardial infarction (MI), stroke, and hospitalization for heart failure (HF), during in-hospital/30-days and long-term periods. We calculated I² to test heterogeneity. We used random-effects modeling for the meta-analyses to assess the primary and secondary outcomes. Results In total 25 studies, including 5,428 patients met the predefined eligibility criteria and were included in this meta-analysis. During the in-hospital/30-day period, device success was achieved in 86% (95% CI: 80%-91%, I2 =49%) with MR ≤2+ to be described in 87% (95% CI: 79%-93%, I2 =75.8%) of the cases, while the overall all-cause mortality was 14% (95% CI: 10%-19%, I2 =84%). The incidence of MI and stroke hovered at 4% (95% CI: 1%-13%, I2 =92%) and 2% (95% CI: 1%-2%, I2 =0%), respectively. During a mean follow-up of 10.6 ± 6.4 months, the all-cause mortality was increased to 31% (95% CI: 24%-39%, I2 =92%), while hospitalization for HF is needed in 18% (95% CI: 9%-29%, I2 =80%) of the patients. In the subgroup analysis of patients in CS due to acute MI who underwent urgent TEER, 11 studies and 352 patients were included. Device success was achieved in 92% (95% CI: 75%-100%, I2 =77.8%) and the in-hospital/30-day mortality was 13% (95% CI: 5%-21%, I2 =60%). In a mean follow-up of 10.2 ± 8.3 months, long-term all-cause mortality fluctuated at the same rate of around 11% (95% CI: 2%-23%, I2 =70%). Conclusion The use of MitraClip in patients with MR and concurrent CS is associated with improved in-hospital/30-day and long-term survival. Our findings indicate that using MitraClip in the acute phase is a safe approach that can significantly reduce all-cause mortality, MI, stroke, and re-hospitalization for HF in this patient population.