Percutaneous mitral valve repair for secondary mitral valve regurgitation: A systematic review and meta-analysis

Published:February 21, 2020DOI:


      • MitraClip in secondary MR reduces the risk of all-cause mortality.
      • MitraClip in secondary MR reduces the risk of readmission events.
      • MitraClip in high left ventricular end diastolic volume at baseline has poor outcome.
      • Elderly patients have better mortality benefits with Mitraclip intervention.
      • Patients randomized in COAPT and MITR HF trial were not homogenous.



      The first two randomized control trials (RCTs) studying the role of MitraClip in patients with secondary mitral regurgitation (MR) had antagonizing results. We, therefore, performed an updated meta-analysis of RCTs and propensity score-matched observational studies investigating the role of MitraClips in patients with secondary MR. A novel method of Kaplan Meier Curve reconstruction from derived individual patient data will be used to compare the survival probability of control groups in COAPT and MITRA HF trail, and hence, access inter-study heterogeneity.


      Medline and Cochrane databases was used for systematic search. We used the Mantel-Haenszel method with a random-effect model to calculate risk ratio (RR) with 95% confidence interval (CI) and inverse variance method with a random-effect model to calculate the mean difference (MD) with 95% confidence interval (CI). We used a fixed-effect approach for meta-regression.


      MitraClip reduced the risk of all-cause mortality [RR: 0.72, CI: 0.55–0.95, P value = 0.02, I2 = 55%, χ2P-value = 0.08] and readmission [RR: 0.62, CI: 0.42–0.92, P value = 0.02, I2 = 90%, χ2P-value<0.01] at two years follow-up. There was no effect of MitraClip on change in cardiovascular mortality and 6 m walking distance at 12 months follow-up. Meta-regression indicated left ventricular end diastolic volume and age among the factors affecting outcomes. Reconstructed Kaplan Meier curves confirmed considerable heterogeneity among patients randomized in MITRA HF and COAPT trial.


      The present meta-analysis confirms the beneficial role of percutaneous mitral valve repair in patients with secondary MR. However, all the results were associated with considerable heterogeneity.
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        • Nkomo V.T.
        • Gardin J.M.
        • Skelton T.N.
        • Gottdiener J.S.
        • Scott C.G.
        • Enriquez-Sarano M
        Burden of valvular heart diseases: a population-based study.
        Lancet. 2006; 368: 1005-1011
        • Asgar A.W.
        • Mack M.J.
        • Stone G.W.
        Secondary mitral regurgitation in heart failure: pathophysiology, prognosis, and therapeutic considerations.
        J Am Coll Cardiol. 2015; 65: 1231-1248
        • Francesco G.
        • Maurice E.-.S.
        • J Z.K.
        • R B.K.
        • Jamil T.A
        Ischemic mitral regurgitation.
        Circulation. 2001; 103: 1759-1764
        • Goel S.S.
        • Bajaj N.
        • Aggarwal B.
        • Gupta S.
        • Poddar K.L.
        • Ige M.
        • et al.
        Prevalence and outcomes of unoperated patients with severe symptomatic mitral regurgitation and heart failure: comprehensive analysis to determine the potential role of mitraclip for this unmet need.
        J Am Coll Cardiol. 2014; 63: 185-186
        • Michler R.E.
        • Smith P.K.
        • Parides M.K.
        • Ailawadi G.
        • Thourani V.
        • Moskowitz A.J.
        • et al.
        Two-Year outcomes of surgical treatment of moderate ischemic mitral regurgitation.
        N Engl J Med. 2016; 374: 1932-1941
        • De Bonis M.
        • Al-Attar N.
        • Antunes M.
        • Borger M.
        • Casselman F.
        • Falk V.
        • et al.
        Surgical and interventional management of mitral valve regurgitation: a position statement from the European Society of Cardiology working groups on cardiovascular surgery and valvular heart disease.
        Eur Heart J. 2015; 37: 133-139
        • Doshi R.
        • Shlofmitz E.
        • Shah J.
        • Meraj P
        Comparison of transcatheter mitral valve repair versus surgical mitral valve repair in patients with advanced kidney disease (from the national inpatient sample).
        Am J Cardiol. 2018; 121: 762-767
        • Stone G.W.
        • Lindenfeld J.
        • Abraham W.T.
        • Kar S.
        • Lim D.S.
        • Mishell J.M.
        • et al.
        Transcatheter mitral-valve repair in patients with heart failure.
        N Engl J Med. 2018; 379: 2307-2318
        • Obadia J.-.F.
        • Messika-Zeitoun D.
        • Leurent G.
        • Iung B.
        • Bonnet G.
        • Piriou N.
        • et al.
        Percutaneous repair or medical treatment for secondary mitral regurgitation.
        N Engl J Med. 2018; 379: 2297-2306
        • Liberati A.
        • Altman D.G.
        • Tetzlaff J.
        • Mulrow C.
        • Gøtzsche P.C.
        • Ioannidis J.P.A.
        • et al.
        The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration.
        BMJ. 2009; 339: b2700
        • Goutham R.
        • Francisco L.-J.
        • Jack B.
        • Frank D.
        • H D.N.
        • A H.M.
        et al. methodological standards for meta-analyses and qualitative systematic reviews of cardiac prevention and treatment studies: a scientific statement from the American heart association.
        Circulation. 2017; 136: e172-e194
        • Hozo S.P.
        • Djulbegovic B.
        • Hozo I
        Estimating the mean and variance from the median, range, and the size of a sample.
        BMC Med Res Methodol. 2005; 5: 13
        • Guyot P.
        • Ades A.E.
        • Ouwens M.J.N.M.
        • Welton N.J
        Enhanced secondary analysis of survival data: reconstructing the data from published Kaplan-Meier survival curves.
        BMC Med Res Methodol. 2012; 12: 9
        • Giannini C.
        • Fiorelli F.
        • De Carlo M.
        • Guarracino F.
        • Faggioni M.
        • Giordano P.
        • et al.
        Comparison of percutaneous mitral valve repair versus conservative treatment in severe functional mitral regurgitation.
        Am J Cardiol. 2016; 117: 271-277
        • Asgar A.W.
        • Khairy P.
        • Guertin M.-.C.
        • Cournoyer D.
        • Ducharme A.
        • Bonan R.
        • et al.
        Clinical outcomes and economic impact of transcatheter mitral leaflet repair in heart failure patients.
        J Med Econ. 2017; 20: 82-90
        • Giannini C.
        • D'ascenzo F.
        • Fiorelli F.
        • Spontoni P.
        • Swaans M.J.
        • Velazquez E.J.
        • et al.
        A meta-analysis of Mitraclip combined with medical therapy vs. medical therapy alone for treatment of mitral regurgitation in heart failure patients.
        ESC Hear Fail. 2018; 5: 1150-1158
        • Arora G.
        • Patel N.
        • Arora P.
        Futile mitra-fr and a positive coapt trial: where does the evidence leave the clinicians?.
        Int J Cardiol Hear Vasc. 2018; 22: 18-19
        • Pibarot P.
        • Delgado V.
        • Bax J.J
        MITRA-FR vs. COAPT: lessons from two trials with diametrically opposed results.
        Eur Heart J Cardiovasc Imaging. 2019; 20: 620-624
        • S D.A.
        Are serial bnp measurements useful in heart failure management?.
        Circulation. 2013; 127: 509-516