Mitral transcatheter edge-to-edge repair: patient selection, current devices, and clinical outcomes

BackgroundTranscatheter mitral valve replacement (TMVR) has emerged as an alternative therapeutic option for the treatment of severe mitral regurgitation in patients with prohibitive or high surgical risk. The aim of this systematic review is to evaluate the clinical procedural characteristics and outcomes associated with the early TMVR experience.Methods and ResultsPublished studies and international conference presentations reporting data on TMVR systems were identified. Only records including clinical characteristics, procedural results, and 30‐day and midterm outcomes were analyzed. A total of 16 publications describing 308 patients were analyzed. Most patients (65.9%) were men, with a mean age of 75 years (range: 69–81 years) and Society for Thoracic Surgery Predicted Risk of Mortality score of 7.7% (range: 6.1–8.6%). The etiology of mitral regurgitation was predominantly secondary or mixed (87.1%), and 81.5% of the patients were in New York Heart Association class III or IV. A transapical approach was used in 81.5% of patients, and overall technical success was high (91.7%). Postprocedural mean transmitral gradient was 3.5 mm Hg (range: 3–5.5 mm Hg), and only 4 cases (1.5%) presented residual moderate to severe mitral regurgitation. Procedural and all‐cause 30‐day mortality were 4.6% and 13.6%, respectively. Left ventricular outflow obstruction and conversion to open heart surgery were reported in 0.3% and 4% of patients, respectively. All‐cause and cardiovascular‐related mortality rates were 27.6% and 23.3%, respectively, after a mean follow‐up of 10 (range: 3 to 24) months.ConclusionsTMVR was a feasible, less invasive alternative for treating severe mitral regurgitation in patients with high or prohibitive surgical risk. TMVR was associated with a high rate of successful valve implantation and excellent hemodynamic results. However, periprocedural complications and all‐cause mortality were relatively high.

Background: Coronary heart disease (CHD) remains the most prevalent pathology within the circulatory system. Among its chronic complications, ischemic mitral valve regurgitation (IMR) is observed in approximately 15% of patients with sustained myocardial ischemia. The presence of this complex valvular defect significantly increases both overall mortality and the incidence of adverse cardiovascular events. Notably, the presence of moderate to severe mitral regurgitation in patients undergoing surgical revascularization has been shown to double the risk of death. Despite the well-established etiology of IMR, data regarding the efficacy of surgical interventions and the determinants of postoperative outcomes remain inconclusive. Methods: The objective of the present study was to evaluate both early and long-term outcomes of surgical treatment of mitral regurgitation in patients undergoing coronary artery bypass grafting (CABG) due to ischemic heart disease. Particular attention was given to the influence of the severity of regurgitation, left ventricular ejection fraction (LVEF), and the dimensions of the left atrium (LA) and left ventricle (LV) on the postoperative prognosis. An additional aim was to identify preoperative risk factors associated with increased postoperative mortality and morbidity. A retrospective analysis was conducted on 421 patients diagnosed with ischemic mitral regurgitation who underwent concomitant mitral valve surgery and CABG. Exclusion criteria included emergent and urgent procedures as well as non-ischemic etiologies of mitral valve dysfunction. Results: The study cohort comprised 34.9% women and 65.1% men, with the mean age of 65.7 years (±7.57). A substantial proportion (76.7%) of patients were aged over 60 years. More than half (51.5%) presented with severe heart failure symptoms, classified as NYHA class III or IV, while over 70% were categorized as CCS class II or III. Among the surgical procedures performed, 344 patients underwent mitral valve repair, and 77 patients required mitral valve replacement. Additionally, 119 individuals underwent concomitant tricuspid valve repair. Short-term survival was significantly affected by the presence of hypertension, prior cerebrovascular events, and chronic kidney disease. In contrast, hypertension and chronic obstructive pulmonary disease were identified as significant predictors of adverse late-term outcomes. Conclusions: Interestingly, neither the preoperative severity of mitral regurgitation nor the echocardiographic measurements of LA and LV dimensions were found to significantly influence surgical outcomes. The perioperative risk, as assessed by the EuroSCORE II (average score: 10.0%), corresponded closely with observed mortality rates following mitral valve repair (9.9%) and replacement (10.4%). Notably, the need for concomitant tricuspid valve surgery was associated with an elevated mortality rate (12.4%). Furthermore, the preoperative echocardiographic evaluation of LA regurgitation severity, as well as LA and LV dimensions, did not exhibit a statistically significant impact on either early or long-term surgical outcomes. However, a reduced LVEF was correlated with increased long-term mortality. The presence of advanced clinical symptoms and the necessity for tricuspid valve repair were independently associated with a poorer late-term prognosis. Importantly, the annual mortality rate observed in the late-term follow-up of patients who underwent surgical treatment of ischemic mitral regurgitation was lower than rates reported in the literature for patients managed conservatively. The EuroSCORE II scale proved to be a reliable and precise tool in predicting surgical risk and outcomes in this patient population.

Usefulness of peak mitral inflow velocity to predict severe mitral regurgitation in patients with normal or impaired left ventricular systolic function

BackgroundPatients with severe mitral regurgitation and cardiogenic shock demonstrate a poor prognosis. Mitral transcatheter edge‐to‐edge repair could alter patient management.Methods and ResultsWe systematically reviewed PubMed/Medline, Scopus, and Cochrane Library until January 2023, including studies assessing transcatheter edge‐to‐edge repair in patients with severe mitral regurgitation and cardiogenic shock. Studies with <5 patients were excluded. The primary outcome was device success and all‐cause death, while secondary outcomes included myocardial infarction, stroke, and heart failure hospitalization rates at 30‐day and intermediate‐term follow‐up. A fixed‐effects meta‐analysis was used to estimate pooled rates. Risk of bias was assessed with the Newcastle–Ottawa Scale. A total of 24 studies and 5428 patients were included, with a mean age of 71.2±3.3 years and a high mean Society of Thoracic Surgery score (15.2±8.9). Device success was achieved in 86% (95% CI, 85%–87%) and mitral regurgitation ≤2+ in 89% (95% CI: 88%–90%). The 30‐day all‐cause mortality rate was 14% (95% CI, 13%–15%). Stroke, myocardial infarction, and heart failure hospitalization rates were 2% (95% CI, 1%–2%), 15% (95% CI, 13%–18%), and 9% (95% CI, 8%–10%), respectively. Patients with acute myocardial infarction had similar device success (81% [95% CI, 74%–87%]), a 30‐day mortality rate of 20% (95% CI, 16%–25%), and intermediate‐term mortality rate of 14% (95% CI, 9%–19%). In non–myocardial infarction populations, the 30‐day mortality rate was 13% (95% CI, 13%–14%), and the intermediate‐term mortality rate was 35% (95% CI, 34%–36%).ConclusionsIn patients with mitral regurgitation and cardiogenic shock, transcatheter edge‐to‐edge repair is associated with favorable 30‐day and intermediate‐term outcomes. Limitations, including the observational design of included studies and considerable heterogeneity, necessitate further research in this setting.

Background: Transcatheter mitral valve repair (TMVr) is increasingly being used to treat severe mitral regurgitation in patients at high surgical risk. While cardiac rehabilitation (CR) improves outcomes in post-surgical cardiac populations, its benefit after TMVr remains poorly characterized. Hypothesis: We hypothesized that outpatient CR following TMVr is associated with improved clinical outcomes compared to no CR. Methods: This retrospective cohort study utilized the TriNetX Research Network to identify adult patients who underwent TMVr between January 2014 and December 2023. Patients were grouped by participation in outpatient CR within 30 days of discharge (n=570) versus no CR (n=6,906). Propensity score matching was performed using demographics, comorbidities, medications, and laboratory values, yielding 562 matched pairs. The primary outcomes were all-cause hospitalization, intravenous (IV) diuretic use (as a surrogate for acute heart failure decompensation), repeat TMVr, and all-cause mortality. Hazard ratios (HR) were estimated using Cox proportional hazards models. Results: After matching, groups were well balanced (mean age 76 ± 10 years; 44% female). Over a mean follow-up of 330 days, patients in the CR group had a significantly lower rate of IV diuretic use (16.7% vs. 22.2%; HR 0.69, 95% CI 0.53–0.90, p=0.006) and all-cause mortality (11.0% vs. 14.6%; HR 0.71, 95% CI 0.51–0.99, p=0.041). All-cause hospitalizations were numerically lower in the CR group (36.8% vs. 38.6%) but not statistically significant (HR 0.89, 95% CI 0.73–1.07, p=0.209). Repeat TMVr was rare in both groups (1.8% vs. 2.3%, p=0.228). Conclusion: Outpatient cardiac rehabilitation after TMVr was associated with a significant reduction in rate of IV diuretic use and mortality, suggesting improved heart failure management. These findings support routine referral to CR programs as part of post-TMVr care pathways.

BACKGROUND: Mechanical complications can occur after acute myocardial infarction. Most commonly mitral regurgitation (MR) occurs after infero-basal myocardial infarction (MI) due to papillary muscles dysfunction. MR may also develop with antero-apical MI. The objective of the study was to determine the frequency of mitral regurgitation in acute MI patients and to risk stratify the patients with MR for anterior and inferior wall MI. AIMS &amp; OBJECTIVE: To assess the frequency of mitral regurgitation in patients with acute myocardial infarction. MATERIAL &amp; METHODS: This was a descriptive case series carried out at the Cardiology department of Jinnah Hospital, Lahore from: 29-10-2013 to 29-04-2014. A total of 340 patients of MI were included. Echocardiography examination was carried out on all subjects on day 3-4 post MI. Frequency of mitral regurgitation in each group was measured by color flow Doppler technique. RESULTS: Out of study population, 153 (45%) were in between 30-50 years and 187 (55%) were in between 51-75 years. The mean of age was calculated as 55.09+11.81 years. In our data 181 (53.24%) were male and 159 (46.76%) were female. Frequency of MR in acute MI patients was recorded in 69 (20.29%) while 271 (79.71%) had no findings of MR. From the total of 69 cases, MR was recorded in 13 (18.84%) as anterior wall MI and 16 (23.19%) as inferior wall MI, p value was calculated as 0.532 which shows insignificant difference. There was a significant difference in hospital stay and mortality between both groups p-value 0.04. CONCLUSION: Mechanical complications develop after acute myocardial infarction and may be associated with serious outcomes. KEYWORDS: Acute MI, mitral regurgitation, anterior and inferior wall MI.

A cute severe valvular regurgitation is a surgical emer- gency, but accurate and timely diagnosis can be difficult.Although cardiovascular collapse is a common presentation, examination findings to suggest acute regurgitation may be subtle, and the clinical presentation may be nonspecific.Consequently, the presentation of acute valvular regurgitation may be mistaken for other acute conditions, such as sepsis, pneumonia, or nonvalvular heart failure.Although acute regurgitation may affect any valve, acute regurgitation of the left-sided valves is more common and has greater clinical impact than acute regurgitation of right-sided valves.Data to guide appropriate management of patients with acute regurgitation are sparse; there are no randomized trials, and much of the literature describes either small series or the experiences of specific centers.Despite these limitations, the available data are sufficient to allow identification of general principles as well as development of applicable guidelines from both the American College of Cardiology/American Heart Association and European Society of Cardiology.2][3] The data and guidelines emphasize overarching clinical principles, including the need for a high clinical suspicion of acute regurgitation, timely use of echocardiography, and, in the majority of patients, rapid progression to surgery. CausesCauses of acute regurgitation overlap with causes of chronic regurgitation and vary depending on the valve affected (Table 1).Endocarditis may affect either the aortic or mitral valve, whereas other causes are unique to the specific valve involved.The majority of causes of acute regurgitation present as an acute or subacute event.However, acute regurgitation can occur in patients with chronic regurgitation, when regurgitant severity is exacerbated by factors such as coronary ischemia, chordal rupture, or leaflet perforation from endocarditis.Acute regurgitation of either the aortic or mitral valve may result from procedural complications of percutaneous valve procedures.In addition, acute prosthetic valve regurgitation is seen more frequently as more patients undergo valve surgery.Acute prosthetic valve regurgitation is usually due to a tear of a bioprosthetic leaflet 4 or thrombosis of a mechanical valve, although perivalvular regurgitation can occur, particularly in prosthetic valve endocarditis.Acute aortic regurgitation is most commonly due to endocarditis, but there are a variety of less common causes as well.Aortic dissection, whether due to Marfan syndrome, bicuspid aortic valve, or atherosclerotic disease, may present with aortic regurgitation.Blunt trauma may result in leaflet rupture. 5Another less common cause is rupture of a fenestration in the aortic leaflet. 6cute mitral regurgitation may result from either "organic" or "functional" causes.Organic causes are those that result in permanent structural disruption of the valve, such as leaflet perforation from endocarditis, chordal rupture in myxomatous valve disease, or papillary muscle rupture due to myocardial infarction.Functional mitral regurgitation results from abnormalities of the left ventricle, such as cardiomyopathies in which the papillary muscles are laterally displaced, or acute ischemia, in which an akinetic wall segment and papillary muscle impair mitral valve closure.The distinction between organic and functional causes is an important one because treatment of organic causes requires surgical repair, whereas functional causes may improve with treatment of the underlying myocardial ischemia, infarction, or cardiomyopathy.Functional mitral regurgitation is more often chronic than acute.However, processes that result in rapid decline of ventricular function may cause acute functional mitral regurgitation as part of the presentation of acute heart failure.8][9] Emphasizing the variability in pathological process, a study demonstrated that mitral regurgitation in Takotsubo cardiomyopathy can result from outflow tract obstruction and systolic anterior mitral leaflet motion due to apical ballooning with preserved basal ventricular function. 9Rheumatic carditis can cause acute mitral regurgitation through a combination of leaflet inflammation and myocardial dysfunction, with some data suggesting that the degree of valve dysfunction drives outcomes. 10Although uncommon in industrialized nations, acute rheumatic carditis remains a significant issue in developing countries.

Background Many patients undergoing Trancatheter aortic valve replacement (TAVR) for aortic stenosis also have significant mitral regurgitation (MR). We sought to understand the association of concomitant MR with TAVR clinical outcomes, as well changes in MR after TAVR. Methods Patients who underwent TAVR at our center, between April 2008 to December 2017, were studied, with longer-term clinical outcomes. Results Of 667patients, 92 (13.8%) had moderate MR, and 47 (2.1%) had severe MR. At 3.2±2.2 years, mortality was 39.4%, 46.1%, 39.1%, 57.6% and 50% and heart failure (HF) rehospitalization was 7%, 7.9%, 17.6%, 21.9% and 46.2% (p&lt;0.001) in the no, mild, moderate, moderate-severe and severe MR patients, respectively. After procedure, 64 patients (9.9%) had moderate MR and 24 patients (3.7%) had severe MR. At follow-up, the mortality was 35.9%, 46.5%, 48.4%, 52.9% and 85.7%, p&lt;0.001 and HF rehospitalization 9.1%, 5.5%, 23.4%, 35.3% and 40% in the no, mild, moderate, moderate-severe and severe MR patients, respectively. MR improved early after TAVI grade in 88 patients (13.2%). Baseline MR is not associated with mortality (HR= 0.883 [95 CI 0.708–1.102], p=0.114), but MR post-TAVR was associated with increase risk of mortality (HR= 1.539 [95 CI 1.187–1.996], p=0.001. In 7 patients with persistent MR received percutaneous mitral repair with MitraClip®. Conclusions In our series, Moderate or severe MR after TAVR is associated with increased mortality or HF rehospitalization, this increased risk may be attributable to the minority of patients whose MR does not improve and could benefit from percutaneous mitral procedures (Mitraclip®).

There is currently little evidence for transcatheter edge-to-edge mitral valve repair (TEER) for mitral regurgitation (MR) in patients with cardiogenic shock (CS). Therefore, this study investigated the characteristics and outcomes of CS patients who underwent TEER for MR. PubMed, EMBASE were searched in July 2023. Case series and observational studies reporting clinical characteristics and outcomes in CS patients with MR who underwent TEER were included. We performed a one-group meta-analysis using a random effects model. A total of 4060 patients from 7 case series and 5 observational studies were included. The mean age was 68.2 (95% confidence interval [CI]: 64.1-72.2) years, and 41.4% of patients (95% CI: 39.1%-43.7%) were female. Pre-TEER, severe MR was present in 85.3% (95% CI: 76.1%-91.3%) of patients. Mean left ventricular ejection fraction was 36.7% (95% CI: 29.2%-44.2%), and 54.6% (95% CI: 36.9%-71.2%) of patients received mechanical circulatory support. The severity of MR post-TEER was less than 2+ in 88% (95% CI: 87%-89%) of patients. In-hospital mortality was 11% (95% CI: 10%-13%), whereas 30-day and 1-year mortality rates were 15% (95% CI: 13%-16%), and 36% (95% CI: 21%-54%), respectively. This systematic review and meta-analysis assessed the clinical characteristics and outcomes of TEER in CS patients with MR. TEER for MR in patients with CS has been successful in reducing MR in most of the patients, but with a high mortality rate. Randomized controlled trials of TEER for MR and CS are needed.

Temporal resolution of mitral regurgitation in patients with mitral valve prolapse: A phonocardiographic and doppler echocardiographic study

Objective: To evaluate LV papillary muscles (PM) function using transesophageal echocardiography (TEE), and to determine the relationship between PM function and mitral regurgitation in patients with normal left ventricular sys-tolic function. Design: TEE examinations were prospectively performed. End diastolic and end systolic PM lengths were obtained from the transgastric long axis views and fractional systolic shortening (FS) was calculated. LV ejection fraction was determined using modified Simpson rule and mitral regurgitation was determined using regurgitant jet area by color flow. Setting: Tertiary Center. Patients: 85 consecutive adult patients (51 with mitral regurgitation and 34 without) with normal LV chamber dimensions and LV systolic function, meeting enrollment criteria. Results: The % FS in patients with mitral regurgitation was 21.7 ± 3.6% for anterior PM (APM) and 18.7 ± 4.6% for posterior PM (PPM). In those without mitral regurgitation, the values were as follows; 22.6 ± 5.4% (APM) and 19.5 ± 3.8% (PPM). In a subgroup of patients with severe mitral regurgitation (n = 23), the values for PM FS were 20.3 ± 6.8 (APM) and 18.4 ± 6.9 % (PPM). There was no statistically significant difference in PM fractional shortening between the groups. Anterior papillary muscle length was longer in those patients with mitral regurgitation compared to those without [(End-diastolic length (cm): 3.38 ± 0.61 v 2.88 ± 0.47(p: 0.008) and end-systolic length of 2.46 ± 0.51 v 2.17 ± 0.33 (p: 0.04)]. These differences are more pronounced in those with severe mitral regurgitation (p: 0.002 and 0.004 for EDL and ESL respectively. Conclusion: In patients with normal LVEF, PM contraction is similar in those with and without MR. In patients with MR however, anterior PM length (ED & ES) is significantly increased. Our data suggests that in patients with normal LVEF, PM dysfunction appears to play no significant role in the causation of MR. Anterior papillary muscle length however, appears to be a major determinant of mitral regurgitation in such patients.

Patients with heart failure (HF) and severe mitral regurgitation (MR) have poor outcomes. Early identification could allow physicians to consider interventions that may improve outcomes. We identified factors associated with progression to severe MR in patients with HF. A total of 11 521 patients with HF and MR were screened, out of which we identified 7391 patients with a clinical diagnosis of HF and at least two echocardiograms at least 6 months apart. We excluded patients without a documented severity of MR at initial (n=1840) or follow-up (n=960) echocardiogram and those with severe MR at initial echocardiogram (n=450). We evaluated factors associated with the development of either moderate to severe or severe MR using multivariable logistic regression analysis. A total of 7391 patients were included in the study, 4173 (56.5%) male, and median age 75 (IQR (IQR) 64-83). In total, 357 (4.8%) patients developed severe MR on the follow-up echocardiogram at a median of 1.4 years (IQR 0.9-2.4). In addition to baseline MR severity, atrial fibrillation (adjusted OR (aOR)1.52), ischaemic heart disease (aOR 1.44), hypertension (aOR 1.35) and higher left ventricular end-diastolic dimension (aOR 1.36 per 1 cm) were associated with increased progression to severe MR. Beta-blocker prescription was associated with reduced progression to severe MR (aOR 0.74). We identified several factors associated with the progression to severe MR in patients with HF. This information could be used by clinicians to identify patients who require closer echocardiographic follow-up and access to appropriate early interventions.

Ventricular dyssynchrony; it is a dynamic phenomenon

The impact of mitral regurgitation (MR) in patients hospitalized for acute heart failure (AHF) is not well established. We assessed the role of MR in patients enrolled in the Relaxin in Acute Heart Failure 2 (RELAX-AHF-2) trial. Patients enrolled in RELAX-AHF-2 with available data regarding MR status were included in this analysis. Baseline characteristics, in-hospital data, and clinical outcomes through 180-day follow-up were evaluated. The impact of moderate/severe MR was assessed. Among 6420 AHF patients with known MR status, 1810 patients (28.2%) had moderate/severe MR. Compared to patients with no/mild MR, those with moderate/severe MR were more likely to have history of heart failure (HF), prior HF hospitalization, more comorbidities, symptoms/signs of HF, lower left ventricular ejection fraction and higher N-terminal pro-B-type natriuretic peptide levels. Moderate/severe MR was associated with longer length of hospital stay, higher rates of residual dyspnoea, increased jugular venous pressure through the index hospitalization and a higher unadjusted risk of the composite of cardiovascular (CV) death or rehospitalization for HF/renal failure (RF) through 180 days (crude hazard ratio [HR] 1.15, 95% confidence interval [CI] 1.03-1.27, p=0.01). The association between moderate/severe MR and poorer outcomes was not maintained in a multivariable model including several covariates of interest (adjusted HR 1.03, 95% CI 0.91-1.17, p=0.65). Similar findings were observed for HF/RF rehospitalization alone. In patients with AHF, moderate/severe MR was associated with a worse clinical profile but did not have an independent prognostic impact on clinical outcomes.

Incidental Moderate Mitral Regurgitation in Patients Undergoing Coronary Artery Bypass Grafting: Update on Guidelines and Key Randomized Trials