Left Atrial Pressure and Predictors of Survival after Percutaneous Mitral Paravalvular Leak Closure

Elad Maor The Olga & Lev Leviev Heart Center, Sheba Medical Center, Israel Sackler School of Medicine, Tel Aviv University, Israel Claire Raphael Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota, USA Sidakpal Panaich Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota, USA Mohamad Alkhouli Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota, USA Allison Cabalka Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota, USA Donald Hagler Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota, USA Peter Pollak Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota, USA Guy Reeder Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota, USA Mackram Eleid Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota, USA Charanjit Rihal Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota, USA

Background
Data on the clinical utility of left atrial (LA) hemodynamic monitoring during percutaneous mitral interventions are limited.

Objectives
To evaluate the association between intraprocedural LA pressures during percutaneous mitral paravalvular leak (PVL) closure and long term survival.

Methods
Patients who underwent mitral PVL repair with invasive LA pressure monitoring were divided at baseline to three tertiles based on their mean final LA pressure (<25%; 25-30%; >30% of mean systolic blood pressure). Primary outcome was all-cause mortality.

Results
134 patients (mean age 68 ± 12 years) were studied. Over 3 year mean follow-up, 81 (38%) patients died. The cumulative probability of death at 3 years was significantly higher among patients in the highest LA pressure tertile (56 ± 8% vs. 28 ± 5%, log rank P < 0.001). More than mild residual mitral regurgitation (MR) by transesophageal echocardiography (TEE) was associated with a 2.5-fold increased risk of death and patients in the highest LA pressure tertile had 2.2-fold higher mortality (P < 0.001 and = 0.003 respectively). After adjustment for residual MR by TEE, each 10% acute procedural reduction in LA pressures was associated with a significant 9% reduced risk of death (P = 0.023). Multivariate Cox regression with adjustment for multiple predictors of death showed that patients in lower LA pressure tertiles had 59% lower mortality (P = 0.003).

Conclusion
Lower LA pressure following mitral PVL closure is an independent predictor of improved survival, even after adjustment for residual MR. LA pressure monitoring may be a useful tool for procedural guidance during mitral PVL closure.

Elad Maor

Sheba Medical Center

Cardiology Fellow in Sheba Medical Cetner, with PhD in Biophysics from the University of California at Berkeley. Developing a novel transcatheter device for the treatment of hypertrophc obstructive cardiomyopathy