Surgical Mitral Valve Repair vs Replacement After Failed Mitral Transcatheter Edge-to-Edge Repair: The CUTTING-EDGE Registry

The aim of this study was to compare the outcomes of mitral valve (MV) repair vs replacement after failed mitral transcatheter edge-to-edge repair (M-TEER). A total of 332 patients across 34 centers from the CUTTING-EDGE registry underwent MV surgery after M-TEER from 2009 to 2020. Outcomes were compared between MV repair and replacement. Primary outcomes included 30-day mortality and one-year survival after MV surgery. 
 Among enrolled patients (mean age 73.8 plus or minus 10.1 years, median Society of Thoracic Surgeons Predicted Risk of Mortality 3.9 percent [Q1-Q3: 2.2 percent to 6.8 percent]), 25 (7.5 percent) underwent repair and 307 (92.5 percent) underwent replacement. The replacement group had a significantly higher rate of comorbidities, including atrial fibrillation, prior cardiac surgery, more secondary mitral regurgitation, and more devices implanted at index M-TEER (P < 0.05 for all). Replacement patients showed a trend toward higher 30-day mortality (17.7 percent [52 of 294] vs 4.0 percent [1 of 25]; P = 0.094). The observed-to-expected ratio of 30-day mortality was 3.6 (95 percent CI: 1.9-5.3) overall, 3.8 (95 percent CI: 2.1-5.5) in the replacement group, and 1.7 (95 percent CI: 0.7-3.3) in the repair group. Replacement patients had higher one-year mortality (33.3 percent [65 of 195] vs 10.5 percent [2 of 19]; P = 0.041). Significantly lower survival rates were observed after replacement at two years (P = 0.033) and persisted in the risk-adjusted Cox regression analysis (HR for replacement: 4.24; 95 percent CI: 1.04-17.31; P = 0.044).  The authors concluded that MV surgery after failed M-TEER is a high-risk procedure associated with higher than expected 30-day mortality, with higher mortality associated with MV replacement. Compared with repair, replacement is associated with higher one-year mortality and lower two-year survival.