Reflections on percutaneous therapies for secondary mitral regurgitation

摘要

Great enthusiasm greeted the dramatic findings of the COAPT trial [1], which evaluated the role of MitraClip in the treatment of patients with symptomatic congestive heart failure and refractory secondary mitral regurgitation [2]. The results were certainly impressive, with marked reductions in mortality, heart failure hospitalizations, and patients' heart failure symptoms. The enthusiasm was so great that it was suggested that MitraClip for treatment of secondary mitral regurgitation perhaps should be considered to be given a Class I indication by guideline writing committees, in spite of being only a single trial. This would be unusual since the standard requirement for Class A level of significance for any recommendation is that the findings were found to be replicated in more than one randomized trial. The argument was made that the COAPT trial was so large, and the results so impressive, that no other trial could be done to replicate these observations. Perhaps that is justified, but it is reasonable at this time to carefully consider the available data, especially since there may be implications on other therapies which may show benefits, but which have not yet been tested with pivotal sized trials. These therapies might not only be considered competitive, but complementary to MitraClip, as they may not only overlap, but also treat patients not eligible for COAPT, or even work synergistically with MitraClip.