Intraprocedural Doppler and Invasive Hemodynamic Profiling Predict Clinical Outcomes After Mitral TEER

Background Whether intraprocedural changes in left atrial pressure and Doppler Echocardiographic parameters are synergistic in predicting outcomes after mitral transcatheter edge-to-edge repair (TEER) is not currently known. We sought to evaluate real-time changes in invasive hemodynamics and non-invasive Doppler to develop intraprocedural profiles and assess their impact on clinical outcomes after TEER for MR. Methods Intraprocedural changes in hemodynamics and Doppler flow with transesophageal echocardiography were assessed in 181 patients with significant MR (51.9% primary MR) undergoing TEER between 2014 and 2022. Independent predictors of the primary composite endpoint of 1-year mortality and heart failure hospitalization (HFH) were identified using multivariable Cox-regression. With receiver operating characteristic curve-derived thresholds for the predictors of the primary end-point, patients were stratified into hemodynamic profiles based on the number of predictors present, and their impact on outcomes was examined. Results Median follow-up was 21.3 months (IQR:11.3-36.5), with 1-year mortality and HFH rates of 19.3% and 12.7%, respectively. Residual mean left atrial pressure (mLAP) [HR=1.073/mmHg (1.03-1.12)], a lesser degree of MR reduction [HR=0.65/grade (0.45-0.93)], and lesser increment in PV systolic time velocity integral (S-VTI) [HR=0.95/cm (0.91-0.99)] were independent predictors of 1-year mortality/HFH. MR reduction by <3 grades (33.1%), S-VTI increment ≤8cm (33.9%), and residual mLAP >15mmHg (43.6%) were the most predictive thresholds. Optimal profile (0 predictors), Mixed (1 predictor) and Poor profile (≥2 predictors) were present in 28.7%, 39.2% and 32.0% of cases respectively. Two-year cumulative event-free survival was 60.1% overall, and higher in patients with optimal profile compared to mixed/poor groups (84.7% vs 55.5% vs 43.3%, P<0.001). There was an incremental risk of mortality/HFH with each profile overall [HR=1.75/profile (1.34-2.29)], and within primary MR [HR=1.64/profile (1.15-2.36)] and secondary MR [HR=1.77/profile (1.17-2.68)] cohorts. There was also an incremental risk of mortality alone with each profile [HR=1.65/profile (1.22-2.22)]. Hemodynamic profile was an independent predictor of 1-year mortality [HR=1.98/profile (1.21-3.25)] after TEER, along with baseline tricuspid regurgitation severity [HR=1.55/grade (1.10-2.19)], and post-procedural transmitral mean gradient>5mmHg [HR=2.32 (1.17-4.61)]. Conclusion Intraprocedural hemodynamic profiling integrating changes in invasive hemodynamics and non-invasive doppler provide prognostic information in patients undergoing TEER and may provide real-time intraprocedural guidance to optimize long-term clinical outcomes. ### Competing Interest Statement Dr Zaid has nothing to disclose Dr Wessly has nothing to disclose Dr Hatab has nothing to disclose Dr Khan has nothing to disclose Dr Faza has nothing to disclose Dr Little has nothing to disclose Dr Reardon is a consultant for Medtronic, Boston Scientific, Abbott, W L Gore & Associates Dr Atkins is a consultant for W L Gore & Associates Dr Kleiman is a local principal investigator in trials sponsored by Boston Scientific, Medtronic, Abbott, and Edwards Lifesciences Dr Zoghbi has nothing to disclose Dr Goel is a Consultant for Medtronic, W L Gore & Associates, and on the Speakers Bureau for Abbott Structural Heart ### Funding Statement No external funding was received to complete this work ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This study received the appropriate approval from the Houston Methodist Institutional Review Board and guidelines were followed accordingly. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The data that support the findings of this study are available on request from the corresponding author [SG]. * LAP : Left atrial pressure MR : Mitral Regurgitation MV : Mitral Valve PV : Pulmonary Vein TEE : Transesophageal Echocardiography TEER : Transcatheter edge-to-edge repair VTI : Velocity time integral