Predictors of Left Atrial Compliance and V-Wave Response in Patients Undergoing Transcatheter Mitral Valve Therapy

BACKGROUND Large V waves on pulmonary capillary wedge pressure tracings are common in patients with severe mitral regurgitation (MR) and typically decrease after transcatheter mitral valve therapy (TMVT). A persistently elevated V wave despite MR resolution may reflect impaired left atrial (LA) compliance. OBJECTIVES The aim of this study was to identify noninvasive predictors of invasive LA compliance and V-wave response in patients undergoing TMVT. METHODS Patients who underwent transcatheter edge-to-edge repair or valve-in-valve transcatheter mitral valve replacement between 2019 and 2023 at the Cleveland Clinic were retrospectively analyzed. Patients were classified as having a compliant LA if their baseline LA mean pressure was ≤12 mm Hg with severe MR or if the V wave decreased by ≥50% after MR resolution following TMVT; all other patients were classified as noncompliant. RESULTS Two hundred fifty-five patients were included, of whom 107 (42%) had a compliant LA and 148 (58%) had a noncompliant LA. Noncompliant patients had more atrial fibrillation (AF) or atrial flutter, prior AF intervention or LA appendage (LAA) ligation, and prior cardiac surgery. They also had lower LA reservoir strain and worse left ventricular global longitudinal strain. On multivariable analysis, low LA reservoir strain (OR: 0.89; 95% CI: 0.83-0.95; P = 0.001) and prior AF intervention or LAA ligation (OR: 4.27; 95% CI: 1.43-12.72; P = 0.009) significantly predicted low invasive LA compliance. Low LA compliance was significantly associated with increased composite outcome of heart failure hospitalization and mortality at 1 year. CONCLUSIONS Low LA strain and prior AF intervention or LAA ligation may predict low invasive LA compliance and limited V-wave reduction after TMVT. LA compliance may explain hemodynamic and clinical responses to mitral valve therapies.