Cardiology · Medical Literature
Prognostic Value of the Meta-Analysis Global Group in Chronic Heart Failure Risk Score in Patients Undergoing Mitral Valve Transcatheter Edge-to-Edge Repair.
Abstract
The prognostic value of the Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) score in patients undergoing mitral valve transcatheter edge-to-edge repair (M-TEER) remains unclear. This study evaluated the MAGGIC score to predict outcomes after M-TEER in patients with functional (FMR) or degenerative mitral regurgitation (DMR) and compared its performance with conventional surgical and M-TEER-specific risk models. We analyzed 3609 patients (FMR, 71%; DMR, 29%) who underwent M-TEER in the OCEAN (Optimized Catheter Valvular Intervention)-Mitral registry. Patients were stratified into MAGGIC score tertiles. The primary outcome was all-cause death at 1 and 3 years. Secondary outcomes included cardiovascular death. Predictive performance was compared with Society of Thoracic Surgeons score, European System for Cardiac Operative Risk Evaluation II, MitraScore, and COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation) score. The median age was 81 years, 55.3% were men, and median MAGGIC score was 30. In the FMR cohort, patients in tertile 3 had higher risks of all-cause death (1 year: adjusted hazard ratio [HRadj], 4.15 [95% CI, 2.34-7.36]; 3 years: HRadj, 1.83 [95% CI, 1.22-2.77]) and cardiovascular death (1 year: HRadj, 2.31 [95% CI, 1.56-3.43]; 3 years: HRadj, 1.61 [95% CI, 1.13-2.31]). In the DMR cohort, tertile 3 was associated with higher all-cause death (1 year: HRadj, 2.84 [95% CI, 1.18-6.86]; 3 years: HRadj, 2.25 [95% CI, 1.07-4.73]) and cardiovascular death at 3 years (HRadj, 3.49 [95% CI, 1.23-9.84]). The MAGGIC score demonstrated comparable or superior discrimination on the basis of the concordance index. The MAGGIC score independently predicted 1- and 3-year all-cause death after M-TEER in both FMR and DMR cohorts and cardiovascular death in the FMR cohort and at 3 years in the DMR cohort. It demonstrated comparable or superior predictive performance to conventional surgical and M-TEER-specific risk models.
Clinical relevance
Does the Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) risk score independently predict all-cause and cardiovascular mortality at 1 and 3 years in patients with functional or degenerative mitral regurgitation undergoing mitral valve transcatheter edge-to-edge repair (M-TEER), and how does its discriminative performance compare to conventional surgical and M-TEER-specific risk models? __SNAPSHOT__ {"studyDesign":"Prospective multicenter registry-based cohort study (OCEAN-Mitral registry) with post-hoc risk stratification analysis","setting":"Japan; 21 participating institutions; Japanese multicenter investigator-initiated registry (OCEAN [Optimized Catheter Valvular Intervention]-Mitral)","sampleSize":"n=3,609 (FMR cohort: ~2,562 [71%]; DMR cohort: ~1,047 [29%])","population":"Consecutive symptomatic patients with significant mitral regurgitation (functional [FMR] or degenerative [DMR]) undergoing M-TEER; median age 81 years, 55.3% male, median MAGGIC score 30; predominantly elderly, high-risk surgical candidates","intervention":"Stratification by MAGGIC score tertiles applied to patients undergoing M-TEER (MitraClip device)","comparator":"Lower MAGGIC score tertiles (tertile 1 and tertile 2) served as reference groups within each MR etiology cohort; predictive performance of MAGGIC score was also benchmarked against STS score, EuroSCORE II, MitraScore, and COAPT score","primaryOutcome":"All-cause death at 1 year and 3 years","followUp":"Up to 3 years (both 1-year and 3-year timepoints reported)","fundingSource":"The OCEAN-Mitral registry is supported by Edwards Lifesciences, Medtronic Japan, Boston Scientific, Abbott Medical Japan, and Daiichi-Sankyo Company (industry-supported registry); multiple investigators have disclosed consultant, speaker, proctor, and lecture fees from Abbott Medical"}
Key findings
In the FMR cohort, patients in MAGGIC score tertile 3 (highest risk) demonstrated significantly higher risk of all-cause death at both 1 year (adjusted HR 4.15, 95% CI 2.34–7.36) and 3 years (adjusted HR 1.83, 95% CI 1.22–2.77), as well as higher cardiovascular death at 1 year (adjusted HR 2.31, 95% CI 1.56–3.43) and 3 years (adjusted HR 1.61, 95% CI 1.13–2.31) compared to lower tertiles. In the DMR cohort, tertile 3 was associated with higher all-cause death at 1 year (adjusted HR 2.84, 95% CI 1.18–6.86) and 3 years (adjusted HR 2.25, 95% CI 1.07–4.73), and higher cardiovascular death at 3 years (adjusted HR 3.49, 95% CI 1.23–9.84); cardiovascular death at 1 year in the DMR cohort was not reported as statistically significant. Absolute event rates, NNT/NNH, and p-values for the individual comparisons were not reported in the abstract. The MAGGIC score demonstrated comparable or superior discrimination to STS score, EuroSCORE II, MitraScore, and COAPT score based on concordance (C) index, though specific C-index values and confidence intervals were not provided in the abstract. No specific safety or adverse event data were reported in the abstract.
Practice implications
This study establishes that the MAGGIC score — a freely available, clinically practical heart failure risk tool incorporating age, sex, ejection fraction, NYHA class, creatinine, BMI, blood pressure, diabetes, COPD, and heart failure duration — independently predicts medium-term mortality after M-TEER in both FMR and DMR patient populations. The effect magnitudes are clinically meaningful, particularly the 4-fold increase in 1-year all-cause mortality risk in the highest FMR tertile. Critically, this tool performed at least as well as M-TEER-specific scores (MitraScore, COAPT score) and conventional surgical scores (STS, EuroSCORE II) in this population, suggesting it may be a practical adjunct for pre-procedural risk stratification in structural heart disease programs. However, several important caveats apply: (1) The study does not establish whether MAGGIC score should guide decisions to offer or withhold M-TEER, as this was a prognostic — not a decision-analytic — study. (2) The cohort is exclusively Japanese, and given known anatomical and procedural differences in Asian M-TEER populations (e.g., smaller heart and valve dimensions), generalizability to Western populations requires validation. (3) The effect sizes in the DMR cohort are notably wide (e.g., HR 2.84, 95% CI 1.18–6.86 at 1 year), suggesting limited precision, possibly due to the smaller DMR subgroup (~1,047 patients). (4) Only the abstract is available for review; full covariate adjustment methodology, absolute event rates, model calibration statistics, and subgroup analyses cannot be independently evaluated. (5) The registry is supported by device manufacturers, and several investigators have disclosed financial relationships with Abbott Medical, introducing potential for industry-related bias. __LIMITATIONS__ Registry-based observational design with risk of unmeasured confounding; causal inference is not supported,Exclusively Japanese population enrolled at 21 institutions — generalizability to ethnically and anatomically diverse Western populations is uncertain and requires external validation,Smaller DMR subgroup (~1,047 patients) results in wide confidence intervals, reducing precision of DMR-specific estimates,Industry-supported registry (Abbott Medical, Edwards Lifesciences, Medtronic Japan, Boston Scientific, Daiichi-Sankyo) with multiple investigator financial conflicts of interest,Specific C-index values, calibration statistics, absolute event rates, and p-values not reported in abstract, limiting full critical appraisal,MAGGIC score was originally derived in chronic heart failure patients — its calibration (not just discrimination) in the M-TEER population is not fully characterizable from the abstract alone,No prospective validation of MAGGIC-guided decision-making for M-TEER candidacy; this study establishes association, not clinical utility,Only abstract available for review; full covariate adjustment models, missing data handling, and sensitivity analyses cannot be assessed,Post-hoc tertile-based stratification may introduce analytical flexibility concerns __BOTTOM_LINE_CATEGORY__ potentially_practice_informing __BOTTOM_LINE__ The MAGGIC score — a simple, widely available heart failure risk tool — independently predicts 1- and 3-year all-cause and cardiovascular mortality after M-TEER in both functional and degenerative mitral regurgitation, with discriminative performance at least comparable to established surgical and M-TEER-specific risk scores. These findings support its potential utility in pre-procedural risk stratification at structural heart disease programs without requiring specialized scoring tools. External validation in non-Japanese populations and prospective evaluation of MAGGIC-guided patient selection are needed before practice adoption.