Background:  The higher life expectancy and the combination of advanced medical and interventional therapies led to an increased burden of degenerative and functional mitral valve disease in the geriatric population. Mitral valve repair or replacement is preferred management and is often associated with significant morbidity and mortality in patients with advanced age and comorbidities. Patients who are at high surgical risk or prohibitive risk for surgery are referred to a transcatheter edge-to-edge mitral valve repair (TEER), however, there is an existing gray area regarding the inclusion of patients with different prohibitive risks such as the Society of Thoracic Surgeons Predicted Risk of Mortality Score (STS score) for mitral valve replacement or repair, porcelain aorta, frailty, hostile chest, and severe pulmonary artery hypertension (PAH). Therefore, we observed the outcomes of patients in different age groups and their prohibitive risks after TEER.

Methods: This is a retrospective cohort study of 156 patients that underwent TEER. We compared octogenarians and nonagenarians without prohibitive risks (53/156 (34%), average age 88.87~91.54, mean 90.21) to younger patients (103/156 (66%), average age 72.76~74.7, mean 73.3) and with prohibitive risks (STS > 8 and > 6 for mitral valve replacement or repair, porcelain aorta, frailty, hostile chest, and severe PAH). The patients had similar basic characteristics in terms of gender, prior diseases such as stroke, peripheral arterial disease, diabetes, heart failure, chronic lung disease, KCCQ12 score, MR severity, and ejection fraction. Assessed outcomes were post-TEER MR reduction, total-in-hospital stay, and mortality.

Results: After the TEER, no difference was found in terms of reduction in the severity of MR (p=0.45), total-in-hospital stay (p=0.91), and mortality (p=0.29) between the groups with and without prohibitive risks for MitraClip regardless of age. Octogenarians and nonagenarians without prohibitive risks exhibited a reduction in the severity of MR, average total in-hospital stay of 4.37~9.29 (mean 6.83), and survival of 100 % compared to other groups who equally had good outcomes. 

Conclusions: TEER is an equally feasible procedure with excellent short-term outcomes in octogenarians and nonagenarians without prohibitive risks compared to younger patients with prohibitive risks. This warrants future studies about long-term outcomes and benefits of referring patients with advanced age and who are not at prohibitive risk of surgery to TEER.

References:

1. Lee CW, Sung SH, Huang WM, Tsai YL, Chen HY, Hsu CP, et al. Can Elderly Patients with Severe Mitral Regurgitation Benefit from Trans-catheter Mitral Valve Repair? Korean Circ J. 2019 Feb 20;49(6):532–41.

2. Feldman T, Kar S, Elmariah S, Smart SC, Trento A, Siegel RJ, et al. Randomized Comparison of Percutaneous Repair and Surgery for Mitral Regurgitation: 5-Year Results of EVEREST II. Journal of the American College of Cardiology. 2015 Dec 29;66(25):2844–54.