Guideline-Directed Medical Therapy and Survival after TEER for Secondary Mitral Regurgitation with Right Ventricular Impairment

BACKGROUND Right ventricular impairment is common among patients undergoing transcatheter edge -to -edge repair for secondary mitral regurgitation (SMR). Adherence to guideline -directed medical therapy (GDMT) for heart failure is poor in these patients. OBJECTIVES The aim of this study was to evaluate the impact of GDMT on long-term survival in this patient cohort. METHODS Within the EuroSMR (European Registry of Transcatheter Repair for Secondary Mitral Regurgitation) international registry, we selected patients with SMR and right ventricular impairment (tricuspid annular plane systolic excursion #17 mm and/or echocardiographic right ventricular - to - pulmonary artery coupling <0.40 mm/mm Hg). Titrated guideline -directed medical therapy (GDMT(tit) ) was de fined as a coprescription of 3 drug classes with at least onehalf of the target dose at the latest follow-up. The primary outcome was all -cause mortality at 6 years. RESULTS Among 1,213 patients with SMR and right ventricular impairment, 852 had complete data on medical therapy. The 123 patients who were on GDMT(tit) showed a signi ficantly higher long-term survival vs the 729 patients not on GDMT(tit) (61.8% vs 36.0%; P < 0.00001). Propensity score - matched analysis con firmed a signi ficant association between GDMT(tit) and higher survival (61.0% vs 43.1%; P = 0.018). GDMT(tit) was an independent predictor of all -cause mortality (HR: 0.61; 95% CI: 0.39-0.93; P = 0.02 for patients on GDMT(tit) vs those not on GDMT(tit) ). Its association with better outcomes was con firmed among all subgroups analyzed. CONCLUSIONS In patients with right ventricular impairment undergoing transcatheter edge -to -edge repair for SMR, titration of GDMT to at least one-half of the target dose is associated with a 40% lower risk of all -cause death up to 6 years and should be pursued independent of comorbidities. (J Am Coll Cardiol Intv 2024;17:1455 - 1466) (c) 2024 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).