Correspondence High sensitive Troponin T useful in clinical decision making for MitraClip implantation J.F. Velu, B.J. Bouma, K.T. Koch, M.M. Vis, J. Baan Jr ⁎ ,1 Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands article info Article history: Received 26 April 2016 Accepted 28 June 2016 Available online 29 June 2016 Keywords: Mitral regurgitation Percutaneous mitral valve repair MitraClip High sensitive Troponin T To the Editor, Mitral Regurgitation (MR) may be treated by a percutaneous mitral valve repair with the MitraClip in high-risk patients with acceptable long-term safety and efficacy [1]. In current practice, clinical decision making can be difficult because current risk assessment for survival and clinical improvement is often insufficient, mostly due to the scarce data available. Biomarkers, i.e. estimated glomerular filtration rate (eGFR), N-terminal B-type natriuretic peptide (NT-proBNP) and high sensitive Troponin T (hsTnT), are commonly used for decision making and available in daily clinical practice. Decreased eGFR is associated with decreased survival in patients with severe MR after MitraClip implanta- tion [2]. High NT-proBNP levels are associated with heart failure (HF) severity and decreased survival after MitraClip implantation in several studies [3]. Increased wall stress in dilated or hypertrophic cardiomyop- athy can induce increased myocardial oxygen demand and release of troponins. One study with only 34 patients, and without clinical data, found that hsTnT predicted cardiovascular mortality in patients undergoing a MitraClip implantation [4]. We investigated which biomarker (eGFR, NT-proBNP and hsTnT) can be of help to identify patients with a limited mid-term survival and without clinical improvement. Biomarkers were measured pre- procedural in consecutive patients who underwent a MitraClip implan- tation. Outcome was defined as mid-term survival (Cox model) and clinical improvement in terms of New York Heart Association (NYHA) class (Chi squared test) six months after implantation. All 140 patients who received a MitraClip between May 2009 and November 2015 in the Academic Medical Center Amsterdam (AMC), the Netherlands, were enrolled in the study. Informed consent was obtained from each patient and the study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki. Baseline characteristics are presented in Table 1. The mean age was 75 years, 54% of the patients were male, 81% of the patients were classified in NHYA class N III/IV and 96% had MR grade ≥ 3. Mean eGFR was 57 ± 23 mL/min/1.73 m 2 , median NT-proBNP was 2167 ng/L (interquartile range: 1011 to 4173) and median hsTnT was 0.028 μg/L (interquartile range: 0.016 to 0.036). Optimal cut-off values of the biomarkers were determined using ROC analysis for mortality at 6 months and clinical in- terpretation and set to eGFR ≤ 30 mL/min/1.73 m 2 (Area Under the Curve (AUC): 0.45), NT-proBNP ≥ 5000 ng/L (AUC: 0.56) and hsTnT ≥ 0.05 μg/L (AUC:0.65). Sixteen patients had a pre-procedural hsTnT level of ≥ 0.05 μg/L, of which 12/16 had a functional MR, 8/16 suffer from coronary artery disease (CAD), 16/16 had symptoms of dyspnoe, 0/16 had symptoms of angina pectoris and 11/16 had a MR reduction after the MitraClip implantation. All biomarkers were univariately associated with mid-term survival after MitraClip im- plantation; eGFR (hazard ratio (HR): 2.6; 95% confidence interval (CI): 1.3 to 5.3), NT-proBNP (HR: 2.8; 95% CI: 1.4 to 5.3) and hsTnT (HR: 5.2; 95% CI: 2.4 to 11.2). Multivariate analysis revealed only hsTnT as determinant for mid-term survival after MitraClip implan- tation (HR: 4.0; 95% CI: 1.7 to 9.0). The survival with hsTnT as predic- tor is visualized in Fig. 1. HsTnT b 0.05 μg/L (OR: 11.4; p b 0.001) was associated with clinical improvement when defined as NYHA ≤ II at 6 months; eGFR (odds ratio (OR): 1.3; p = 0.678), NT-proBNP (OR: 1.6; p = 0.333). The current findings may improve daily clinical decision making in deciding whether to advice treatment with a MitraClip. Our study dem- onstrated that hsTnT ≥ 0.05 μg/L was the strongest biomarker predicting a poor prognosis. The median survival of the 16 patients with a hsTnT ≥ 0.05 μg/L was 250 days, compared to the median survival of 1526 days for patients with a hsTnT b 0.05 μg/L. Our study is of help to identify patients with an impaired prognosis as the ESC guidelines have set a minimum life expectancy. The ESC guidelines state that the MitraClip procedure may be considered in patients with a life International Journal of Cardiology 220 (2016) 614–615 ⁎ Corresponding author at: Academic Medical Center, Department of Cardiology Room B2-252, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands. E-mail address: j.baan@amc.nl (J. Baan). 1 J. Baan receives an unrestricted research grant from Abbott. http://dx.doi.org/10.1016/j.ijcard.2016.06.285 0167-5273/© 2016 Elsevier Ireland Ltd. All rights reserved. Contents lists available at ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard