Asymptomatic Severe Mitral Regurgitation Research Articles

Gender and Sex Differences in the Management, Intervention, and Outcomes of Patients With Severe Primary Mitral Regurgitation.

Gender- and sex-based disparities in mitral valve disease exist; however the factors associated with these differences are unknown. Identifying these differences is essential in devising mitigating strategies. We evaluated gender and sex differences among patients with severe primary mitral regurgitation (MR) across treatment phases. We conducted a retrospective cohort study of patients with new diagnoses of severe primary MR between 2016 and 2020. We compared multidisciplinary evaluation incidence and 2-year survival between men and women. We analyzed a subgroup meeting class 1 indications for intervention, which includes severe symptomatic MR or severe asymptomatic MR with ejection fraction <60% or left ventricular end-systolic diameter >40 mm. Logistic regression models identified predictors associated with the likelihood of multidisciplinary evaluation. Among 330 patients meeting class 1 indications, women were older (79 versus 76 years, P=0.01) and had higher Society of Thoracic Surgeons risk scores for mitral valve repair than men (2.5% versus 1.4%, P=0.003). Women were less likely to undergo multidisciplinary evaluation (57% versus 84%, P<0.001) and intervention (47% versus 69%, P<0.001) than men. Median days to intervention for women and men were 77 and 43, respectively. Women had a higher 2-year mortality rate than men (31% versus 21%, P=0.035). On a multivariable model, female sex and older age were associated with lower odds of undergoing multidisciplinary evaluation (odds ratio, 0.26; P<0.001; odds ratio, 0.95; P<0.001, respectively). Women with severe primary MR with class 1 indication for intervention were less likely to undergo multidisciplinary evaluation and intervention and had a longer interval to intervention than men. Survival was comparable after accounting for age and comorbidity differences.

Early mitral valve repair surgery versus active surveillance in patients with asymptomatic severe primary mitral regurgitation; insights from the Dutch AMR registry

Abstract Background Management of asymptomatic patients with severe mitral regurgitation (MR) and preserved left ventricular function is still a challenging clinical entity. According to international guidelines, early mitral valve repair (MVR) surgery and active surveillance with facilitated surgery are both possible treatment strategies. Conflicting evidence is available on the number of patients that reach an indication for facilitated surgery during follow-up in the active surveillance strategy group [1, 2]. In the multicenter Dutch AMR registry, asymptomatic MR patients were allocated to either strategy according to the heart team decision [3]. In this registry there was a low threshold to perform additional testing (i.e. cardiac magnetic resonance imaging, holter monitoring and/or cardiopulmonary exercise testing). Purpose To prospectively assess the percentage of MR patients undergoing facilitated surgery during a long-term active surveillance strategy. Methods Since 2013, 99 patients with severe primary MR were included in the Dutch AMR Registry in 5 medical centers. Enrollment for early surgery or active surveillance was based on ESC guidelines and heart team decision. During long term follow-up, we assessed primary endpoints for both groups; occurrence of atrial fibrillation, cerebrovascular accident, heart failure, MVR surgery and cardiovascular/non-cardiovascular death. In particular, we assessed the number and timing of patients that underwent facilitated surgery in the active surveillance group. Results In total, 71 patients were allocated to the active surveillance and 28 to the early surgery group. 39 Patients in the active surveillance group reached a primary endpoint including 3 deaths (2 cardiovascular and 1 non-cardiovascular) (Figure 1). In the early surgery group, 4 patients reached a primary endpoint including 2 cardiovascular deaths. Over a mean follow-up time of 4.4 years, 36 patients (51%) of the active surveillance population underwent facilitated surgery due to either symptomatic or asymptomatic triggers (Table 1). Conclusions In the Dutch AMR registry, 51% of MR patients under active surveillance needed facilitated surgery within 4.4 years. Approximately half of these patients were still asymptomatic when developing an indication for surgery. Cardiovascular mortality rates were similar between the two treatment strategies. This result shows that active surveillance can be safely accomplished in asymptomatic severe MR patients. The Dutch AMR registry will further elucidate 1) whether MR patients can be stratified at baseline to either strategy based on additional testing and 2) whether facilitated surgery is non-inferior to early surgery in terms of surgical outcome, quality of life and long-term survival. For now, the current results support an active surveillance strategy in selected asymptomatic MR patients based on guidelines since half of patients are still free of symptoms without guideline indications for surgery.Figure 1Table 1

Cardiopulmonary exercise testing augments watchful waiting in asymptomatic severe primary mitral regurgitation.

Our aim is to describe the use of cardiopulmonary exercise testing in watchful waiting for asymptomatic severe primary mitral regurgitation. Between October 2016 and October 2017, ten patients with asymptomatic severe primary mitral regurgitation underwent watchful waiting in a single centre. Baseline assessment included history, physical examination, transthoracic echocardiogram and cardiopulmonary exercise testing. Patients were re-evaluated every 6months with history, physical examination and transthoracic echocardiogram; and at 12months with cardiopulmonary exercise testing. At 1year follow up, five patients remained asymptomatic with no significant change in left ventricular ejection fraction (p = 0.18). This was associated with no significant change in cardiopulmonary exercise testing parameters. However, five patients developed early new symptoms or changes in echocardiographic parameters with a significant fall in left ventricular ejection fraction (p < 0.01). This was associated with a significant fall in anaerobic threshold (p = 0.04) and four of the five patients having an abnormal percentage predicted peak VO2 at 1year follow up. Changes in symptomatic status or echocardiographic parameters during a watchful waiting approach for asymptomatic severe primary mitral regurgitation is associated with a significant reduction in cardiopulmonary exercise testing parameters.

Clinical and Prognostic Implications of Cardiopulmonary Exercise Stress Echocardiography in Asymptomatic Degenerative Mitral Regurgitation

The current guidelines recommend intervention in severe degenerative mitral regurgitation (MR) in symptomatic patients or asymptomatic patients with left ventricular dilatation or dysfunction. The insidious onset of symptoms may mean that patients do not report their symptoms. The role of systematic exercise testing for symptoms in MR is not clearly defined. A total of 97 patients with moderate to severe asymptomatic MR underwent exercise echocardiography combined with cardiopulmonary exercise testing. The predictors of exercise-induced dyspnea, symptom-free survival, and mitral valve intervention were identified. A total of 18 patients (19%) developed limiting dyspnea on exercise. Spontaneous symptom-free survival at 24months was significantly higher in those without exercise-induced symptoms than those with exercise-induced symptoms, p <0.0001. The only independent predictors of spontaneous symptoms at 2years were effective regurgitant orifice area (odds ratio 27.45, 95% confidence interval [CI] 1.43 to 528.40, p=0.03) and exercise-induced symptoms (odds ratio 11.56, 95% CI 1.71 to 78.09, p=0.01). The only independent predictor of surgery was indexed left ventricular systolic volumes (odds ratio 1.17, 95% CI 1.04 to 1.30, p=0.006). Where only the patients who underwent surgery due to symptoms were included, the only independent predictor was exercise-induced symptoms (odds ratio 13.94, 95% CI 1.39 to 140.27, p=0.025). In conclusion, in patients with primary asymptomatic degenerative MR, 1/5 develop revealed symptoms during exercise. This predicts a subsequent development of spontaneous symptoms and mitral valve intervention due to symptoms.

Cardiac Damage Staging Classification in Asymptomatic Moderate or Severe Primary Mitral Regurgitation

BackgroundOptimal timing for intervention remains uncertain in asymptomatic patients with primary mitral regurgitation (MR). We aimed to assess the prognostic value of a new cardiac damage staging classification in patients with asymptomatic moderate or severe primary MR. MethodsClinical, Doppler-echocardiographic, and outcome data prospectively collected in 338 asymptomatic patients (64 ± 15 years, 68% men) with at least moderate primary MR were retrospectively analyzed. Patients were hierarchically classified as per the following staging classification: no cardiac damage (stage 0), mild left ventricular or left atrial damage (stage 1), moderate or severe left ventricular or left atrial damage (stage 2), pulmonary vasculature or tricuspid valve damage (stage 3), or right ventricular damage (stage 4). ResultsThere was a stepwise increase in 10-year mortality rates as per cardiac damage stage: 20.0% in stage 0, 25.6% in stage 1, 31.5% in stage 2, and 61.3% in stage 3-4 (p < 0.001). The staging classification was significantly associated with increased risk of mortality (hazard ratio = 1.41 per one-stage increase, 95% confidence interval: 1.07-1.85, p = 0.015) and the composite of cardiovascular mortality or hospitalization (hazard ratio = 1.51 per one-stage increase, 95% confidence interval: 1.07-2.15, p = 0.020) in multivariable analysis adjusted for EuroSCORE II, mitral valve intervention as a time-dependent variable, and other risk factors. The proposed scheme showed incremental value over several clinical variables (net reclassification index = 0.40, p = 0.03). ConclusionsThe new staging classification provides independent and incremental prognostic value in patients with asymptomatic moderate or severe MR.

Profile of adult patients presenting for rheumatic mitral valve surgery at a tertiary academic hospital.

Peri-operative morbidity and mortality are increased in patients with rheumatic heart disease. Pre-operative risk stratification is imperative for optimisation and a better outcome. This was a descriptive, retrospective, contextual study. A consecutive convenience sampling method was used. Eighty-nine patients who underwent mitral valve surgery at Charlotte Maxeke Johannesburg Academic Hospital between January 2014 and December 2015 were enrolled. The objectives of the study were to describe the demographic profile of the patients presenting for rheumatic mitral valve surgery, describe their peri-operative cardiovascular and echocardiographic parameters, and risk stratify according to their clinical and echocardiographic parameters. Demographic, echocardiographic and laboratory data as well as the cardiovascular examination were analysed. Descriptive statistics using proportions (percentages), means (standard deviations) or medians (interquartile ranges) were used where appropriate. A total of 102 patients were reviewed. Thirteen were excluded due to significant missing data. Of the 89 analysed, all had demographic data, 81 had cardiovascular clinical examination data, 82 had echocardiographic data and 52 had laboratory data. Forty-seven patients presented with mitral regurgitation (MR) and 35 had mitral stenosis (MS). Data included two mixed mitral valve disease patients with predominant regurgitation who were classified under the MR group. In total, 45% (39 patients) had arrhythmias and 49% (42 patients) had congestive cardiac failure at presentation for surgery. The overall mean (SD) pulmonary artery systolic pressure was 57 (20) mmHg and mean (SD) left atrial size was 53 (11) mm. Those with MS presented with mean (SD) mitral valve area of 0.9 (0.2) cm2. Of the analysed MR patients, 51% presented with left ventricular ejection fraction < 60% and 55% with left ventricular end-systolic diameter > 40 mm. Among the analysed MS patients, 59% had mitral valve area < 1 cm2. A substantial number (49% MR and 54% MS) of collected records were not eligible for analysis and stratification using the American Heart Association/American College of Cardiology (ACC/AHA) guidelines for valvular heart disease due to missing vital information. Of the 24 MR patients analysed utilising the 2014/2017 AHA/ACC guidelines, 13 had asymptomatic severe MR (stage C) and 11 had symptomatic severe MR (stage D). One patient had progressive MS (stage B), eight had asymptomatic severe MS (stage C) and seven had symptomatic severe MS (stage D). The majority of those who could be stratified presented in stages C and D of disease progression; however, they also presented with concomitant clinical and echocardiographic features that placed them at high risk of perioperative morbidity.

Minimally invasive and robotic approaches to mitral valve surgery: Transthoracic aortic crossclamping is optimal

Minimally invasive and robotic approaches to mitral valve surgery: Transthoracic aortic crossclamping is optimal

Relation of Guideline Adherence to Outcomes in Patients With Asymptomatic Severe Primary Mitral Regurgitation

Current guidelines empirically recommend serial clinical evaluations for asymptomatic patients with severe mitral regurgitation (MR). However, there is a paucity of data on the effectiveness of such monitoring. This study sought to examine the potential benefit of guideline adherence among asymptomatic patients with severe primary MR. Asymptomatic patients with severe primary MR who had been evaluated in the Allina Health system between January 1, 2012 and May 30, 2018 were examined. The medical records were manually reviewed for demographics, comorbidities, echocardiographic data, subsequent interventions, and clinical outcomes. Patients were grouped according to occurrence of guideline adherence, which was defined as a serial clinical evaluation with echocardiography every 12 ± 1 month until mitral valve surgery, or death. Over the study period, 246 patients (67.3 ± 15.5 years, 61.4% men) with severe, asymptomatic primary MR were identified, including 154 patients (62.6%) with and 92 patients (37.4%) without guideline adherence. Overall, there were no differences in demographics, morbidities, MR severity, or left ventricular function between patient adherence groups. During follow-up (40.9; 21.2, 58.3 months), patients with adherence more frequently had surgery or transcatheter therapy performed (64.3% vs 18.5%; p <0.001) and the time to intervention was earlier (13.6 [3.9-22.7] vs 44.2[25.6-57.3] months; p <0.001). Compared to non-adherent patients, those with guideline adherence had a significantly higher five-year survival free from all-cause mortality (92.0% vs 74.3%, p=0.002), and freedom from death or hospitalization for heart failure (90.1% vs 69.3%, p=0.001). Adherent patients also had a significantly better survival free from combined endpoint of death, re-hospitalization for heart failure, myocardial infarction, and stroke (84.5% vs 63.2%, p=0.002). In patients with asymptomatic severe primary MR, guideline adherence with serial evaluations every 12 months or less is associated with earlier therapy and improved long-term outcomes. These data support educational efforts to promote guideline adherence.

Disparate impact of severe aortic and mitral regurgitation on left ventricular dilation.

In asymptomatic severe aortic (AR) and mitral regurgitation (MR), left ventricular (LV) dimension criteria were established to guide timing of valve replacement to prevent irreversible LV dysfunction. Given both lesions are primary LV volume overload ''leaks'', it might be expected that both lesions would induce similar impact on the LV and result in equivalent dimension criteria for intervention. However, the dimension-based intervention criteria for AR versus MR (developed through natural history studies), differ markedly. The pathophysiological foundations for such discordance have neither been fully elucidated nor emphasized. This case-based treatise compares the two regurgitant lesions with respect to: (a) ''total regurgitant circuits''; (b) ''driving pressures'' resulting in LV volume overload from each respective ''leak''; and (c) volume and afterload wall stresses imposed on the LV.Key points The ''total circuits'' of volume overload differ: The AR circuit includes the LV and systemic vasculature, whereas MR includes the LV ejecting into the left atrium/pulmonary veins and systemic circulation. The ''driving pressure'' of regurgitation and afterload are high with AR and low with MR. Differing ''total circuits'' and ''driving pressures'' impose disparate wall stresses upon the LV. Parallel and serial sarcomere replication occurs in AR, while only serial replication occurs in MR. It therefore follows that for regurgitation of similar severities, AR results in greater LV dilation at the point of irreversible myocardial dysfunction compared to MR. These considerations may explain, at least in part, the disparate dimension criteria employed for valve intervention for severe AR vs MR.

Takotsubo syndrome after mitral valve surgery: a case report.

BackgroundTakotsubo syndrome is a frequent entity; however, it has never been described after a mitral valve surgery.Case summary We present the case of a 79-year-old woman, with background of atrial fibrillation and a left atrial appendage closure device, who was admitted for elective mitral valve replacement, because of asymptomatic severe primary mitral regurgitation. Biologic mitral valve was implanted without incidences, but in the postoperative, she developed cardiogenic shock. Electrocardiogram (ECG) showed inverted T waves in precordial leads and an echocardiography showed severe left ventricular (LV) dysfunction with mid to distal diffuse hypokinesis, and better contractility in basal segments. Troponin levels were mildly elevated. With the suspicion of a postoperative acute coronary syndrome, a coronary angiography was performed and showed no significant coronary lesions. The haemodynamic situation was compromised for the next 48 h, in which vasoactive support and intra-aortic balloon counterpulsation were implemented. After 48 h, the haemodynamic situation suddenly improved. The ECG was normalized, and a control echocardiogram showed partial recovery of the LV function with resolution of regional wall motion abnormalities. The patient could be discharged at 1 week. The clinical picture was interpreted as a stress cardiomyopathy after mitral valve surgery.Discussion Takotsubo syndrome is a threatening condition; complications in acute phase could lead to a fatal outcome. Mitral valve surgery has to be considered as a trigger for this entity, after excluding coronary involvement, specially of left circumflex artery.

Predictive Value of Pre-Operative 2D and 3D Transthoracic Echocardiography in Patients Undergoing Mitral Valve Repair: Long Term Follow Up of Mitral Valve Regurgitation Recurrence and Heart Chamber Remodeling.

The “ideal” management of asymptomatic severe mitral regurgitation (MR) in valve prolapse (MVP) is still debated. The aims of this study were to identify pre-operatory parameters predictive of residual MR and of early and long-term favorable remodeling after MVP repair. We included 295 patients who underwent MV repair for MVP with pre-operatory two- and three-dimensional transthoracic echocardiography (2DTTE and 3DTTE) and 6-months (6M) and 3-years (3Y) follow-up 2DTTE. MVP was classified by 3DTTE as simple or complex and surgical procedures as simple or complex. Pre-operative echo parameters were compared to post-operative values at 6M and 3Y. Patients were divided into Group 1 (6M-MR < 2) and Group 2 (6M-MR ≥ 2), and predictors of MR ≥ 2 were investigated. MVP was simple in 178/295 pts, and 94% underwent simple procedures, while in only 42/117 (36%) of complex MVP a simple procedure was performed. A significant relation among prolapse anatomy, surgical procedures and residual MR was found. Post-operative MR ≥ 2 was present in 9.8%: complex MVP undergoing complex procedures had twice the percentage of MR ≥ 2 vs. simple MVP and simple procedures. MVP complexity resulted independent predictor of 6M-MR ≥ 2. Favorable cardiac remodeling, initially found in all cases, was maintained only in MR < 2 at 3Y. Pre-operative 3DTTE MVP morphology identifies pts undergoing simple or complex procedures predicting MR recurrence and favorable cardiac remodeling.

P763 Asymptomatic severe organic mitral regurgitation: Does the anatomic substrate affect the functional response to supine ergometry?

Abstract Asymptomatic severe mitral regurgitation (MR) remains a grey zone in decision making for intervention. The predictive role of left ventricular (LV) functional reserve remains uncertain and the potential role of the anatomical substrate has not been elucidated. Aim of the study was to compare the LV function and hemodynamic changes during supine ergometry (Ex) in asymptomatic severe MR between myxomatous (Myx) and degenerative (Deg) substrate. Methods 32 patients with Deg (male M/female F = 15/17) and 19 with MyxS (M/F = 7/12) were studied at rest (R) and Ex. We estimated heart rate (HR), rate-pressure product (HRxBP), LV endsystolic (LVESV)- enddiastolic volume (LVEDV), ejection fraction (EF), LV longitudinal strain (GLS), transmitral E wave (E), ratio E/e, peak tricuspid gradient (TrPG). To adjust for a potential volume effect on GLS, GLS was normalized to volumes and respective ratios were considered (GLS/LVESV, GLS/LVEDV). Parameters were measured at R and Ex and % changes were calculated : %d (Ex-R). Results Myx and Deg had similar chronotropic reserve and HR-BP. Myx were younger, and during Ex they had a greater LVEDV, a greater EF. a smaller E/e, and a smaller TrPG compared with Deg. Myx group, despite having a better GLS both at R and Ex, revealed a smaller % GLS improvement from R to Ex (15% vs 32%). The normalized GLS/LVESV and GLS/LVEDV were similar at R between Myx and Deg, but they showed a smaller improvement during Ex in Myx. (table-results) Conclusion Despite similar severity of MR, asymptomatic patients with MyxS revealed a different dynamic profile during Ex compared with Deg. The underlying MV substrate in organic MR might be related with a different LV adaptation to volume loading combined with subsequent uneven stress induced hemodynamic response. The disparities found might have implications both in the nature history of MR as well as in the decision making for intervention. RESULTS Parameter DegS MyxS p Age(years) 65 ± 11 44 ± 12 &amp;lt;0. 001 LVEDV Ex (ml) 85 + 32 117 ± 41 =0. 007 EF Ex(%) 65 + 7 69 ± 8 =0. 05 GLS R(%) -17.6 ± 6.8 -22.2 ± 4.3 =0. 04 GLS Ex(%) -22 ± 4 -25.0 ± 5.7 =0. 05 % d (Ex-R) LV strain/endsystolic volume 0.84 ± 0.4 -0.54 ± 0.5 =0. 05 E/e" Ex 16.7 ± 8.8 9.7 ± 2.2 =0. 004 TrPG Ex(mmHg) 59 ± 11 44 ± 11 =0. 0001

559 An analysis of myocardial efficiency in patients with severe asymptomatic mitral regurgitation

Abstract Funding Acknowledgements None declared. Background and Aims It is difficult to determine left ventricular systolic performance in patients with severe mitral regurgitation (MR) since left ventricular ejection fraction (EF) could be preserved until the end stages of the disease. Myocardial efficiency describes the amount of external work (EW) done by the left ventricle per unit of oxygen consumed (mVO2). In the present study, we aimed to investigate MEf in patients with asymptomatic severe MR using a novel echocardiographic method. Methods: A total of 27 patients with severe asymptomatic MR and 26 healthy volunteers were included in this cross-sectional study. EW was measured using stroke volume and blood pressure, while mVO2 was estimated using double product and LV mass. Results: There were no differences between the groups with regards to EF (66%±5% vs. 69%±7%), while MEf was significantly reduced in patients with severe MR (25%±11% vs. 44%±12%, p &amp;lt; 0.001) (Table 1). This difference was maintained even after adjustment for age, gender and body surface area (adjusted :0.44, 95%CI: 0.39–0.49 for controls and adjusted :0.24, 95%CI: 0.19–0.29 for patients with severe MR). Further analysis showed that this reduction was due to an increase in total mVO2 in the severe MR group (Figure 1). Conclusions: Myocardial efficiency was significantly lower in patients with asymptomatic severe MR and preserved EF. Table 1 Parameter Control Group (n = 26) Severe Mitral Regurgitation (n = 27) P Value Age (y) 36.5 ± 8.9 41.3 ± 14.2 0.23 Gender (%Male) 9 (35%) 10 (37%) 1.0 BSA (m2) 1.82 ± 0.20 1.76 ± 0.18 0.64 LV End-Diastolic Volume (ml) 83.13 ± 18.88 121.91 ± 37.63 &amp;lt;0.001 LV End-Systolic Volume (ml) 28.07 ± 9.57 45.30 ± 17.42 &amp;lt;0.001 Left Ventricular Ejection Fraction (%) 0.69 ± 0.07 0.66 ± 0.05 0.29 Systolic Mitral Velocity (cm/s) 7.88 ± 1.14 8.07 ± 1.81 0.66 Stroke Work (j) 1.14 ± 0.21 1.15 ± 0.36 0.91 Minute External Work (j) 65.96 ± 14.71 70.17 ± 23.15 0.85 mVO2 (ml.min-1.100g-1) 6.79 ± 1.93 9.48 ± 4.71 0.02 Total mVO2 (j) 166.58 ± 77.14 346.46 ± 202.71 &amp;lt;0.001 Myocardial Efficiency (%) 44 ± 12 25 ± 11 &amp;lt;0.001 Table 1. Demographic, anthropometric, echocardiographic and mechanoenergetic data for study groups. BSA, body surface area; LV, left ventricle; mVO2, myocardial oxygen consumption. Abstract 559 Figure 1

An Analysis of Myocardial Efficiency in Patients with Severe Asymptomatic Mitral Regurgitation

BACKGROUNDIt is difficult to determine left ventricular systolic performance in patients with severe mitral regurgitation (MR) since left ventricular ejection fraction (EF) could be preserved until the end stages of the disease. Myocardial efficiency (MEf) describes the amount of external work (EW) done by the left ventricle per unit of oxygen consumed (mVO2). In the present study, we aimed to investigate MEf in patients with asymptomatic severe MR using a novel echocardiographic method.METHODSA total of 27 patients with severe asymptomatic MR and 26 healthy volunteers were included in this cross-sectional study. EW was measured using stroke volume and blood pressure, while mVO2 was estimated using double product and left ventricular mass.RESULTSThere were no differences between the groups with regards to EF (66% ± 5% vs. 69% ± 7%), while MEf was significantly reduced in patients with severe MR (25% ± 11% vs. 44% ± 12%, p < 0.001). This difference was maintained even after adjustment for age, gender and body surface area (adjusted : 0.44, 95% CI: 0.39–0.49 for controls and adjusted : 0.24, 95% CI: 0.19–0.29 for patients with severe MR). Further analysis showed that this reduction was due to an increase in total mVO2 in the severe MR group. MEf of thepatients who were both on β-blockers and angiotensin converting enzyme inhibitors/angiotensin receptor blockers were higher than those who were not on any drugs, but this difference was not statistically significant (32% ± 15% vs. 23% ± 9%, p = 0.41).CONCLUSIONSMEf was significantly lower in patients with asymptomatic severe MR and preserved EF.

P1424 Long-term follow-up in patients undergoing early surgery (repair) for severe degenerative mitral regurgitation

Abstract Discordance between studies drives debate regarding the "ideal" (early surgery vs watchful waiting) management of asymptomatic severe mitral regurgitation (MR) in valve prolapse (MVP). Independently on disagreement between studies, strategies are mainly oriented towards early surgery in centers that can achieve &amp;lt;1% mortality rates and &amp;gt;95% repair rates. Data on a detailed evaluation of outcomes in terms of left ventricular ejection fraction (LV EF) in the early repair strategy are lacking. Aims of this study in a large population undergoing early MVP repair are: a) to assess LV function comparing EF and volumes in the follow-up (FU) at 6 month (6ms) and 3 year (3ys) b) to verify whether pre-op volumes and EF may predict functional results c) to compare these findings to the surgical procedure (simple or complex) and to the residual MR. Between 2008 and 2018, 1000 cases underwent early MV repair in our Center. We retrospectively selected 300 pts with pre-op 2D and 3DTTE, 6 ms and 3ys 2DTTE FU. Results: 286 pts (200 males; 61 ± 12 ys; 222 Barlow, 78 fibroelastic deficiency at 3DTTE examination) had MV surgery (96% reparability; 14 MV replacement after a first attempt of repair). 87 had complex MVP and in 56 the surgical procedure was complex. MR at 6ms &amp;lt;1+ (262 pts) predicted stability of MR at 3ys, while in the 38 cases with MR &amp;gt;1+, MR increased at 3ys (2,6±.6+). Complexity of pre-op 3D morphology predicted complexity of MV repair and identified pts with higher risk of MR recurrence. Table summarizes functional results showing that early restoration of MR, causes significant morphological and haemodynamic improvements at 6 ms without significant additional changes at 3ys. Pre-op systolic LV volume and EF significantly correlated with LV remodelling. In conclusions a) early MV repair is associated with favourable LV remodelling and stable systolic function at FU; b) 2DTTE predicts in an early surgical strategy favourable LV remodelling c) pre-operative 3DTTE morphology (simple vs complex MVP) predicts repair procedure (simple vs complex) that in the large majority (91%) is associated with freedom from MR recurrence. Table Pre-op 6-month FU 3-years FU Left ventricular end diastolic volume (ml) 140 ± 41 104 ± 30 * 103 ± 35 Left ventricular end systolic volume (ml) 49 ± 19 45 ± 19* 43 ± 22 Left ventricular ejection fraction (%) 65 ± 7 58 ± 8* 59 ± 7§ Mitral regurgitation (+) 3.9 ± 0.2 0.6±.6* 0.9±.9§ Left atrial volume (ml) 123 ± 48 91 ± 35* 87 ± 45 *= p &amp;lt; 0.01 6 ms vs pre-op; §=p &amp;lt; 0.01 3ys vs 6 ms

Minimally invasive mitral valve repair

### Learning objectives Modified cardiopulmonary bypass techniques, including vacuum-assisted venous drainage, were introduced in 1995 and enabled safe and effective minimally invasive mitral valve (MV) surgery. Approaches have evolved since...

Impact of Beta-Blockade on Cardiac Events in Patients with Chronic Severe Nonischemic Mitral Regurgitation

Objectives: The aim of this study was to examine the impact of beta-blockade on cardiac events among patients with initially asymptomatic chronic severe nonischemic mitral valve regurgitation (MR). Methods: Data from 52 consecutive patients in our prospective natural history study of isolated chronic severe nonischemic MR were assessed post hoc over 19 years to examine the relation of chronic beta-blockade use to subsequent cardiac events (death or indications for mitral valve surgery, MVS). At entry, all patients were free of surgical indications; 9 received beta-blockers. Cardiac event rate differences were analyzed by Kaplan-Meier log rank comparison. Results: During follow-up, cardiac events included sudden death (1), heart failure (8), atrial fibrillation (6), left ventricular dimensions at systole ≥4.5 cm (11), left ventricular ejection fraction <60% (6), right ventricular ejection fraction <35% (2), and a combination of cardiac events (7). The cardiac event risk was 4-fold higher among patients receiving beta-blockers (average annual risk = 60.6%) versus those not receiving beta-blockers (average annual risk = 15.2%; p = 0.001). These effects remained statistically significant (p = 0.005) when analysis was adjusted for other baseline covariates. Conclusions: Beta-blockade appears to confer an increased risk of sudden cardiac death or indications for MVS among patients with chronic severe nonischemic MR. Randomized trials are needed to confirm these findings.

Markers of increased risk in primary mitral regurgitation.

Myxomatous degaeneration is the most common etiology of primary mitral regurgitation (MR) in the developed world (1). Severe MR can impose significant hemodynamic stress on the left ventricle (LV). However, LV can remain in a compensated asymptomatic stage for long time with preserved ejection fraction (EF). After long period of time, EF drops and overt heart failure ensues (2). Mitral surgery is the cornerstone in management of severe MR to halt this process. Nonetheless, LV sustains subclinical structural and microscopic damage early before traditional indications for MV surgery is met (3). Current class I indications for MV surgery are development of symptoms or abnormal ejection fraction (4), and both of these conditions are associated with non-optimal postoperative outcomes. There is a growing concern that EF does not reflect true LV systolic function and it merely reflects ventricular ejection which is a fraction derived from end diastolic volume (EDV) (5). In conditions with supra-physiological EDV and reduced afterload such as severe MR, EF is doomed to be normal even in suboptimal LV performance. LV global longitudinal strain (LV-GLS), which measures myocardial systolic deformation, has been proposed to be more reflective of true LV systolic function (6). As a result to the aforementioned factors, timing of surgery in asymptomatic severe MR patients with preserved EF remains a challenging and a controversial decision (7). With the new advances in cardiac surgery and improvements in perioperative care, postoperative mortality in patients undergoing MV surgery in the last few years is less than 0.1%, with hospital stay as short as 5 days and more than 97% success rate in achieving trivial MR with MV repair (8), which argues for earlier intervention in patients with severe MR before it is too late.

Standards defining a 'Heart Valve Centre': ESC Working Group on Valvular Heart Disease and European Association for Cardiothoracic Surgery Viewpoint.

The increasing number of patients with heart valve disease and the wider range of therapeutic options now available, demands the standardization of organizational structures. The ‘heart valve clinic’ is already established as a specialist outpatient clinic linked with multidisciplinary inpatient care as well as education and training. Recent international guidelines extend this specialist concept to a ‘Heart Valve Centre of Excellence’ or ‘Heart Valve Centre’. These centres were proposed in order that durable mitral valve repair could be virtually guaranteed at close to zero risk in patients with asymptomatic severe mitral regurgitation caused by prolapse. The intention was that invasive valve interventions should not occur outside Heart Valve Centres. The standards defining such a centre have not previously been described and this is the purpose of this document. A Heart Valve Centre includes a heart valve clinic, but also multidisciplinary heart teams for the care of patients with mitral valve disease, tricuspid valve disease, diseases of the aorta and aortic valve and infective endocarditis (Table 1). [...]

Standards defining a 'Heart Valve Centre': ESC Working Group on Valvular Heart Disease and European Association for Cardiothoracic Surgery Viewpoint.

The increasing number of patients with heart valve disease and the wider range of therapeutic options now available, demands the standardization of organizational structures. The ‘heart valve clinic’ is already established as a specialist outpatient clinic linked with multidisciplinary inpatient care as well as education and training. Recent international guidelines extend this specialist concept to a ‘Heart Valve Centre of Excellence’ or ‘Heart Valve Centre’. These centres were proposed in order that durable mitral valve repair could be virtually guaranteed at close to zero risk in patients with asymptomatic severe mitral regurgitation caused by prolapse. The intention was that invasive valve interventions should not occur outside Heart Valve Centres. The standards defining such a centre have not previously been described and this is the purpose of this document. A Heart Valve Centre includes a heart valve clinic, but also multidisciplinary heart teams for the care of patients with mitral valve disease, tricuspid valve disease, diseases of the aorta and aortic valve and infective endocarditis (Table 1). [...]