Impact of Natriuretic Peptide and Prior Hospitalization in Patients With Severe Mitral Regurgitation: COAPT Trial

BACKGROUND: The clinical significance of elevated baseline natriuretic peptide level and prior heart failure hospitalization (HFH) within the prior year in mitral transcatheter edge-to-edge repair outcomes is unclear. This analysis examined the impact of BNP (B-type natriuretic peptide) or NT-proBNP (N-terminal pro-B-type natriuretic peptide) and prior HFH on outcomes in patients with severe secondary mitral regurgitation. METHODS: The COAPT trial (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation) was a randomized controlled trial of subjects assigned to mitral valve transcatheter edge-to-edge repair with the MitraClip device versus guideline-directed medical therapy alone. COAPT patients were grouped by BNP/NT-proBNP levels and prior HFH within 1 year: (1) Mild heart failure (HF): no prior HFH with BNP/NT-proBNP<median; (2) Moderate HF: prior HFH with BNP/NT-proBNP<median or no prior HFH with BNP/NT-proBNP≥median; and (3) Severe HF: prior HFH and BNP/NT-proBNP≥median. The primary measures were 2-year rates of death or HFH. RESULTS: Of 572 patients, mild, moderate, and severe HF were present in 125 (21.9%), 288 (50.3%), and 159 (27.8%) patients, respectively. With guideline-directed medical therapy alone, the 2-year rates of death or HFH in mild, moderate, and severe HF were 56.4%, 60.5%, and 84.1%, respectively (Ptrend=0.001). These rates were 48.7% and 73.4% among patients with moderate HF and a prior HFH only versus elevated BNP/NT-proBNP≥median only (P=0.003). Mitral transcatheter edge-to-edge repair reduced death/HFH compared with guideline-directed medical therapy alone regardless of HF severity (Pinteraction=0.50). CONCLUSIONS: In patients with HF with severe secondary mitral regurgitation enrolled in the COAPT trial, 2-year rates of death/HFH were increased with an elevated baseline BNP/NT-proBNP≥median, and more so if HFH within 1 year prior had occurred. Treatment with mitral transcatheter edge-to-edge repair reduced all-cause mortality and HFH consistently in mild, moderate, and severe HF. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01626079.