1) Transcatheter edge-to-edge repair (MitraClip) is recommended for treating severe secondary mitral regurgitation in heart failure patients with an ejection fraction of 20-50% and LVESD ≤70 mm who show reduced MR after the procedure. 2) TAVR improves left ventricular function and symptoms in patients with low-flow severe aortic stenosis but is still associated with high 1-year mortality of 20%. 3) The effect of isolated tricuspid valve intervention on outcomes in heart failure patients with reduced ejection fraction is currently undefined.

1. Interventional and Surgical
Treatment of Valve Disease in
Heart Failure Patients
Andrew Wang, MD
a.wang@duke.edu

2. Disclosures
• Research grants: Abbott Vascular

3. Outline
• Mitral regurgitation
– Is disproportionate MR an important predictor of benefit of
repair?
• Aortic stenosis
– Does it improve outcome to treat moderate AS if LV
systolic function is reduced?
• Tricuspid regurgitation
– Should the “forgotten valve” be remembered and treated?

4. Transcatheter Edge-to-Edge Repair (TEER)
• MitraClip approved for severe PRIMARY MR in 2013
– Prohibitive operative risk as determined by CT surgeon
• MitraClip approved for severe SECONDARY MR in 2019
– LVEF 20-50%
– LVESD ≤70 mm
– Maximized GDMT as determined by HF cardiologist

5. COAPT Trial: Fewer HF Hospitalizations
N Engl J Med 2018;379:2307-18.
NNT (24 mo) =
3.1 [95% CI 1.9, 7.9]

6. COAPT Trial: Lower All-cause Mortality
N Engl J Med 2018;379:2307-18.
NNT (24 mo) =
5.9 [95% CI 3.9, 11.7]
46.1%
29.1%

7. 2020 ACC/AHA Valvular Heart Disease Guideline
• Severe, secondary MR
• LVEF 20-50%
• NYHA 2-4 while on GDMT
• LVESD ≤70 mm
• PASP ≤70 mm Hg
 Class 2A Recommendation for TEER

8. COAPT
(n=614)
MITRA-FR
(n=304)
EROA, mm2 41 ± 15 31 ± 10
- <30 mm2 14% (80/591) 52% (157/301)
- 30 – 40 mm2 46% (270/591) 32% (95/301)
- >40 mm2 41% (241/591) 16% (49/301)
LVEF, % 31 ± 9 33 ± 7
LVEDV, mL/m2 101 ± 34 135 ± 35
Obadia JF et al. NEJM. 2018 Aug 27. doi: 10.1056/NEJMoa1805374; Stone GW et al. NEJM. 2018 Sept 23.
Disproportionate MR: Reconciling Discrepancy

9. COAPT: Disproportionate Degree of MR
JACC: CARDIOVASCULAR IMAGING, VOL. 12, NO. 2, 2019

10. COAPT Sub-study: Similar improvements in
KCCQ and 6 MWD after TEER
Proportionate MR
• ERO ≤0.3 cm2
• LVEDVI >96 ml/m2
Disproportionate MR
• ERO >0.3 cm2
• LVEDVI ≤96 ml/m2
JAMA Cardiol. 2021 Apr 1;6(4):427-436.

11. Best clinical response predicted by less MR and
lower RVSP after TEER

12. Transcatheter MV Repair in Cardiogenic Shock
J Am Coll Cardiol Intv 2021;14:1–11.

13. Progressive LV dysfunction attenuated by TEER
JACC 2019;74:2969-79.

14. Low gradient, severe AS: Greater improvement after TAVR for
patients with lowest EF, regardless of contractile reserve on
dobutamine
JAMA Cardiol. 2019;4(1):64-70.

15. Moderate AS with systolic dysfunction is a bad
combination
Moderate AS
• LVEF 37%
• AVA 1.2 cm2
• Mean AVG 15.2 mm Hg
JACC 2021;77:2796-803.

16. Does valve replacement for moderate AS improve
outcome?

17. UNLOAD Randomized Trial: TAVR for moderate
AS with reduced LVEF (NCT02661451)
• N=600 randomized 1:1 TAVR vs. optimal medical therapy
• Symptomatic
• LVEF 20-50%
• Moderate AS
– mean AVG ≥20 mm Hg and <40 mm Hg
– AVA >1.0 cm2 and ≤1.5 cm2 at rest or after dobutamine stress echocardiography
• Hierarchical endpoint: all-cause death, disabling stroke, hospitalizations
related to HF, symptomatic aortic valve disease or nondisabling stroke, and
the change in the Kansas City Cardiomyopathy Questionnaire at 1 year
Am Heart J. 2016 Dec;182:80-88.

18. Severe TR: Worse prognosis but does repair or
replacement matter?

19. Therapies for Heart Failure
Medical therapy
Revascularization
ICD, CRT
LVAD
Transplant
MitraClip, TAVR

20. Summary
• MitraClip treatment of severe secondary MR is beneficial
for patients with COAPT-like characteristics (LVEF 20-
50%, LVESD ≤70 mm) in whom MR is reduced to
moderate or less.
• TAVR in low flow, severe AS improves LVEF but still
assoc with high 1 year mortality (20%).
• The effect of isolated tricuspid valve intervention in HFrEF
is undefined.

22. COAPT Grading of MR Severity
JACC: HEART FAILURE VOL. 7, NO. 6, 2019

23. MitraClip
beneficial
across all echo
subgroups
JACC: HEART FAILURE VOL. 7, NO. 6, 2019