Highlights
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Mitral transcatheter edge-to-edge repair requires preprocedure echocardiography.
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In certain circumstances, timeliness of transesophageal echos can be a limitation.
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Using transthoracic echo results, heart teams may decide to proceed with repair.
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Safety, procedural, and valve outcomes are not compromised for these patients.
Introduction
Transcatheter edge-to-edge repair (TEER) is a percutaneous procedure to reduce mitral regurgitation (MR) by creating a double-orifice valve and improve leaflet coaptation. TEER is indicated for patients with significant, symptomatic primary MR who are at prohibitive risk for surgery and patients with moderate-severe or greater secondary MR with symptomatic heart failure despite medical therapy. , MR severity is routinely judged based on a transthoracic echocardiogram (TTE); however, not all patients with significant MR are anatomically suitable for TEER. Factors that often deem a patient unsuitable can be difficult to assess on TTE and include rheumatic disease, radiation heart disease, mitral annular calcification, calcified or fibrotic leaflets, small mitral valve area, leaflet perforation, complex leaflet anatomy, restricted posterior leaflet, and cleft leaflets.
Transesophageal echocardiography (TEE) provides significantly improved visualization of the mitral valve anatomy and function and is required for intraprocedural guidance during TEER. As such, preprocedural TEE screening has been a requirement for inclusion in landmark clinical trials establishing the effectiveness of TEER procedures. However, TEE is an invasive procedure that requires sedation or general anesthesia and carries some rare but potentially serious risks, such as bleeding, infection, dental injury, or esophageal perforation. During the height of the COVID-19 pandemic, TEE posed additional concerns and logistical challenges due to the potential spread of infection. At some institutions, shortages of anesthesiologists, nurses, imaging cardiologists, or other resource constraints can affect the availability of timely diagnostic TEE procedures. Finally, some patients, especially at centers with large, rural catchment areas, live a long distance from facilities capable of performing TEE, causing significant travel costs and time investments for patients and their families.
Recently, our valve team has encountered a variety of cases in which, due to some combination of these above factors, proceeding with TEER based on the available surface echo alone was felt to be in the patient’s best interests. The aim of this project was to retrospectively evaluate the decision to omit preprocedural TEE in carefully selected patients undergoing TEER by comparing patient characteristics, safety, and procedural outcomes.
Methods
We performed a retrospective analysis of patients who underwent TEER between January 1, 2019, and March 31, 2023, at our center with or without a preprocedural TEE. The decision to proceed to TEER without preprocedural TEE was made on a case-by-case basis, involving the patient in a standard shared decision-making process. Local site data abstracted through the Society of Thoracic Surgery/American College of Cardiology Transcatheter Valve Therapy (TVT) registry was used as the data source. Preprocedure TEE is not collected in the TVT registry and was obtained from clinic procedure planning notes and chart review. Patients with a TEE within 2 years (730 days) prior to the date of their procedure were considered to have a preprocedure TEE, while patients without a TEE in that timeframe were included in the non-TEE group. All other variables included in the study followed TVT definitions. Postprocedure outcomes including residual MR and mitral valve gradients were judged based on TTE completed within 24 hours after the procedure. Clinical characteristics, MR severity, procedural characteristics, and safety outcomes were compared between groups.
Results
Of 196 patients, 29 (14.8%) had no preprocedural TEE imaging. All patients in whom a preprocedural TEE had not been completed underwent a complete intraoperative TEE evaluation prior to obtaining vascular access. Patient characteristics were similar between groups, with the notable exceptions of higher body mass index (26.9 vs. 24.9, p = 0.02) and higher incidence of chronic lung disease (20.4 vs. 3.4%, p = 0.05) in the TEE group ( Figure 1 ). There were no significant differences in baseline left ventricular ejection fraction or severity of MR between groups. Median procedure times were similar in the TEE vs. no TEE groups (95 [75, 121] vs. 89 [75, 126] minutes, p = 0.87). Procedural success was similar between groups with residual moderate-severe or severe MR in only 5.4% of patients in the TEE group vs. 3.6% in the no-TEE group ( p = 1.0) and residual mild or less MR in 79.4% of patients in the TEE group vs. 85.7% in the no-TEE group ( p = 0.60). Postclip mean mitral gradient was higher in TEE patients compared to the no-TEE group (5.4 ± 2.5 vs. 4.5 ± 1.7 mmHg, respectively, p = 0.02). No differences were seen in procedural complications, mortality, postoperative length of stay, or 30-day all-cause readmissions. There was one patient in the no-TEE group in whom the procedure was aborted prior to clip placement due to failure to advance the guiding sheath through the iliac vein after successful transseptal puncture.
