Mitral annular disjunction (MAD) is “highly prevalent” in patients undergoing transcatheter edge-to-edge repair (TEER) for degenerative mitral regurgitation (MR) and may be linked to worse clinical outcomes, according to new patient cohort data. The study, published online Monday and in the Dec. 11 issue of JACC: Cardiovascular Interventions, analyzed the prevalence, correlates, and implications of MAD, as assessed by two-dimensional transthoracic echocardiography, in real-world patients referred to TEER for significant degenerative MR. Led by Alon Shechter, MD, MHA, from Cedars-Sinai Medical Center, Los Angeles; Rabin Medical Center, Petach Tikva, Israel, and Tel Aviv University, Israel; the team noted that while MAD has been “increasingly recognized,” linked to heightened arrhythmia, and shown to affect about a third of individuals with mitral valve prolapse, correlations to long-term survival outcomes are “debatable.” “Despite its high prevalence and association with altered MV [mitral valve] geometry, there are currently scarce data regarding the implications of MAD in patients referred for MV interventions, and particularly TEER,” said the authors. “In our high-volume, single-center cohort of patients undergoing TEER for degenerative MR, MAD was highly prevalent and marked a more complex valvular anatomy and intervention, as well as a slightly less favorable postprocedural clinical course,” they added. Study details Shechter and colleagues retrospectively analyzed data from 271 consecutive patients undergoing an isolated, first-ever TEER for whom there were viewable preprocedural echocardiograms. The median age of participants was 82 years [Q1-Q3: 75-88], and 60.9% were men. The primary outcome was the composite of all-cause mortality, heart failure hospitalizations, or mitral reinterventions at 1-year post-procedure, noted the authors, adding that secondary outcomes included individual components of the primary outcome, as well as the maintenance of New York Heart Association functional class I to II and residual MR of up to moderate degree at 1 month and 1 year after the intervention. The cohort was stratified by MAD status at baseline, said the team, reporting that 62 patients (22.9%) were referred to TEER with MAD. MAD was similarly distributed in the two sexes (n = 40/165, 24.2% among males and n = 22/106, 20.8% among females; P = 0.505), they said, adding that MAD measured a median of 8.0 mm (Q1-Q3: 6.0-9.0) in length. “Overall, no major differences in clinical characteristics were observed at baseline between the MAD and no-MAD groups,” said Shechter and colleagues. Cohort analysis showed that those with MAD had more extensive prolapse and larger valve dimensions versus those without MAD. The authors added that although this resulted in longer procedure times and utilizing more devices per case, the technical success rate and residual MR were comparable between the two groups. However, MAD presence was associated with higher mortality risk (hazard ratio [HR]: 2.64; 95% confidence interval [CI]: 1.82-5.52; P = 0.014), while increased MAD length was associated with lower odds of functional class ≤II (odds ratio [OR]: 0.65; 95% CI: 0.47-0.88; P = 0.006). Furthermore, the team noted that among 47 MAD patients with retrievable 1-month data, MAD regressed in 91.5% and by an overall 50% (Q1-Q3: 22%-100%) compared with baseline (P < 0.001). Indeed, they reported that greater MAD shortening conferred attenuated risk for the primary outcome. “In our experience, TEER for degenerative MR accompanied by MAD was feasible and safe; however, its postprocedural course was somewhat less favorable,” concluded Shechter and colleagues, noting that MAD shortening following TEER was observed in most patients and “proved prognostically beneficial” and that the “findings suggest MAD as a clinically meaningful factor in this population.” “Considering that no patient at our institution received the diagnosis in real time, the study also highlights MAD as an under-reported phenomenon in this subset of patients, constituting an easily correctable awareness gap,” they added. Source: Shechter A, Vaturi M, Hong GJ, et al. Implications of Mitral Annular Disjunction in Patients Undergoing Transcatheter Edge-to-Edge Repair for Degenerative Mitral Regurgitation. JACC Cardiovasc Interv 2023;16:2835-2849. Image Credit: magicmine – stock.adobe.com