Carpentier Type IIIb Research Articles

Atrial Functional Mitral Regurgitation Subtypes Undergoing Transcatheter Edge-to-Edge Repair: Suboptimal Outcomes in Atriogenic Hamstringing.

Two subtypes of atrial functional mitral regurgitation (AFMR) have been described, one is characterized by Carpentier type I and the other by Carpentier type IIIb leaflet motion. The authors sought to analyze echocardiographic characteristics and outcomes of AFMR subtypes undergoing mitral valve transcatheter edge-to-edge repair (M-TEER). Of 1,047 consecutive patients who underwent M-TEER, the authors identified those with isolated mitral annulus dilation (Carpentier I), termed AFMR-IAD, and those with atriogenic hamstringing characterized by restricted posterior mitral leaflet motion (Carpentier IIIb), termed AFMR-AH. Echocardiographic baseline characteristics and outcomes up to 1-year were analyzed. A total of 128 patients (12.2%) met AFMR criteria; 75 (58.6%) were identified as AFMR-IAD and 53 (41.4%) as AFMR-AH. AFMR-AH displayed greater left atrial and left ventricular volumes, greater mitral annulus, shorter and steeper posterior mitral leaflet, and more pronounced MR (all P< 0.05). Technical success was achieved in 98.7% (AFMR-IAD) and 86.8% (AFMR-AH) of patients (P = 0.009). At discharge, device detachments were exclusively observed in AFMR-AH (10.0%). MR≤II was achieved in 95.6% and 78.6% at 30days (P=0.009) and in 93.0% and 74.1% at 1 year (P = 0.038) in patients with AFMR-IAD and AFMR-AH, respectively. AFMR-AH was associated with procedural failure (OR: 1.17 [95%CI: 1.00-1.38]; P = 0.045) at 30days (43.4% vs 24.0%; P = 0.023) and all-cause mortality (HR: 2.54 [95%CI: 1.09-5.91]; P = 0.031) at 1 year (77% vs 92%, Kaplan-Meier estimated 1-year survival; P = 0.017). AFMR-AH shows worse procedural and clinical outcomes following M-TEER than AFMR-IAD. Thus, vigilance regarding this pathology is warranted and alternative mitral valve therapies might need to be considered.

Echocardiographic quantification of mitral apparatus morphology and dynamics in patients with dilated cardiomyopathy.

Mitral regurgitation is among the most common valvular heart diseases. Mitral regurgitation in patients with dilated cardiomyopathy is a complex pathology involving annular dilatation, papillary muscle displacement, systolic leaflet tethering, and left ventricular remodeling. Quantification of mitral apparatus damage in these patients is essential for successful interventional and surgical therapy. Mitral regurgitation in the presence of dilated cardiomyopathy is classified as Carpentier type IIIB, with restricted leaflet mobility as a standard feature. Echocardiography allows accurate evaluation of the complex anatomy and function of the mitral apparatus. Updated guidelines recommend two-dimensional followed by systematic three-dimensional echocardiographic evaluation in patients with mitral regurgitation. New three-dimensional echocardiographic software packages provide many parameters that help identify the precise morphology and function of the various components of the mitral apparatus, helping to determine the etiology of mitral regurgitation and evaluate disease severity. This review provides the first point-by-point approach to the assessment of all old and new echocardiographic methods, from the simplest to the most complex, used to examine the components of the mitral valve apparatus in patients with dilated cardiomyopathy. Although these parameters are still under research, this information will be helpful for establishing therapeutic procedures in a disease with a poor prognosis.

Subannular repair in secondary mitral regurgitation with restricted leaflet motion during systole

ObjectiveVentricular secondary mitral regurgitation (SMR) (Carpentier type IIIb) results from left ventricular (LV) remodelling, displacement of papillary muscles and tethering of mitral leaflets. The most appropriate treatment approach remains controversial....

Atrial functional mitral regurgitation: The concept has evolved, but inconsistencies still remain.

In our commentary we elucidated the fact that functional mitral regurgitation (FMR) is divided into two morphological subtypes: annular dilation with normal leaflet motion (Carpentier type I) and restricted systolic motion with left ventricular remodeling or dysfunction (Carpentier type IIIb). However, these phenotypes show some degree of overlap and there are currently no distinctive diagnostic cut-off values, therefore they may represent a continuum of the same disease. Moreover, correct left chambers quantification is critical for differentiating between atrial FMR and ventricular FMR. Three-dimensional echocardiography can quantify better leaflet areas, lengths, and closing angles, as well as the coaptation index, by eliminating geometric assumptions and integrating tethering of all leaflet surface and annular area enlargement. Also, It is expected that the use of artificial intelligence solutions and the deployment of automated onboard software that requires no or limited human input will stimulate wider clinical use of three-dimensional echocardiography in left chambers quantification.

Percutaneous mitral valve repair in recurrent severe mitral valve regurgitation after mitral annuloplasty : MitraClip-in-the-ring as acomplementary strategy.

Patients with reduced left ventricular (LV) function undergoing coronary artery bypass graft surgery or/and aortic valve replacement occasionally show severe mitral valve (MV) regurgitation and thus also undergo surgical mitral annuloplasty. Over time, further deterioration of LV function and additional ischemic events cause recurrence of severe MV regurgitation due to the Carpentier IIIb morphology of the MV that is not adequately addressed by the previously implanted annuloplasty ring. Seven patients (Society of Thoracic Surgeons score: 7.5 ± 1.5%) with Carpentier type-IIIb recurrent severe MV regurgitation, having undergone prior cardiothoracic surgery (median: 40months) including mitral annuloplasty, were treated with the MitraClip device. MitraClip implantation resulted in significantly reduced MV regurgitation and improved New York Heart Association functional state, translating into an increased exercise capability and improved cardiac biomarkers. The morphology of the MV was adequately addressed without causing relevant MV stenosis, while the MV annulus area remained unaltered. The procedure was safe with a 30-day mortality rate of 0%. MitraClip-in-the-ring is feasible and in principle safe for treating Carpentier type IIIb severe MV regurgitation after surgical MV repair using mitral annuloplasty. MitraClip-in-the-ring resulted in immediate amelioration of clinical symptoms and increased physical exercise capacity.

Functional mitral regurgitation, updated: ventricular or atrial?

Lone atrial fibrillation (AF) can cause functional mitral regurgitation (MR), commonly referred to as "atrial functional MR (AFMR)." This type of MR has recently received much attention as an important cause of heart failure, and it represents a considerable therapeutic target in heart failure patients with AF. Mitral annular dilatation due to left atrial (LA) dilatation can be recognized as an original cause of AFMR, whereas the exact cascade of AFMR etiologies has not been established. AFMR is typically classified as Carpentier type I, and is likely to have a central jet. In contrast, a proportion of AFMR is classified as a combination of Carpentier type I for a flattened anterior mitral leaflet and Carpentier type IIIb for a tethered posterior mitral leaflet and is likely to have an eccentric jet directed toward the LA posterior wall. The traditional functional MR occurring in patients with left ventricular (LV) dilatation and/or systolic dysfunction, which is classified as Carpentier type IIIb, has since been designated "ventricular functional MR (VFMR)" to distinguish it from AFMR. Traditional VFMR, newly recognized AFMR, and their etiologic relations to LV/LA size and function are discussed in this review article.

Reparación de la insuficiencia mitral funcional mediante abordaje del aparato subvalvular. Resultados a medio plazo

Introduction and objectivesSurgical treatment of functional mitral regurgitation still remains an issue widely debated due to its high morbidity and mortality and the absence of consensus about the best therapeutic option (repair vs replacement). We present our mid-term experience in its treatment with a repair approaching de subvalvular apparatus. MethodsBetween 2012 and 2016, 16 patients were operated on in our hospital with a moderate to severe mitral regurgitation due to a Carpentier's type IIIb mechanism. The mean logistic EuroSCORE was 10.81%. In all of them a restrictive ring annuloplasty was carried out, along with the relocation of the posteromedial papillary muscle in 14 patients and the approximation of the papillary muscles in 2 patients. Other procedures were carried out in 12 of these 16 patients. ResultsThe mean follow up period was 29.5 months. There were 2 perioperative deaths. There were no more deaths during the follow up. The recurrence of mitral regurgitation > 2 was 12.5% (2 patients). Only these 2 patients with a mitral regurgitation > 2 in the follow up echocardiograms needed hospital readmission at some point due to decompensated heart failure, remaining the rest of them in NYHA class i-ii/iv. ConclusionsApproaching the subvalvular apparatus in the repair of functional mitral regurgitation seems to be a valuable option in the treatment of this kind of regurgitation, offering optimal results in terms of survival at discharge and in recurrence at mid-term follow up.

Surgical Management of Ischemic Mitral Regurgitation

Case presentation: A 62-year-old man visited his cardiologist describing a 6-month history of increasing fatigue and shortness of breath on exertion. His medical history included an inferoposterior myocardial infarction (MI) 3 years previously that was treated with drug-eluting stents to his left circumflex and right coronary arteries. The result of physical examination was remarkable for crackles audible throughout the lower half of both lung fields, an elevated jugular venous pulse to the angle of the jaw, and a grade 3/6 holosystolic murmur loudest at the apex with radiation to the left axilla. An echocardiogram revealed a left ventricular ejection fraction (LVEF) of 15% to 20%, severe mitral regurgitation (MR), and a left ventricular end systolic dimension of 70 mm. The patient underwent a repeat cardiac angiogram that revealed patent stents in the circumflex and right coronary arteries and no other significant stenoses. The decision was made to surgically correct the patient’s MR with a mitral valve operation. He was brought to the operating room, where he was given general anesthesia, and a transesophageal echocardiogram was performed. Examination of the mitral valve revealed poor leaflet coaptation with a degree of leaflet tethering that resulted in severe MR. Inasmuch as the valve leaflets appeared structurally normal, a mitral valve repair procedure using a complete rigid annuloplasty ring was performed. A postoperative echocardiogram revealed trace MR, and the patient experienced no postoperative complications. This patient is a typical example of a growing problem in our aging population, namely, ischemic mitral regurgitation (IMR). IMR clearly has a negative impact on survival in patients with coronary artery disease, even in patients with mild to moderate MR; greater degrees of MR portend an even worse prognosis.1 With almost a fifth of patients who experience an MI followed by the development of IMR,2,3 and over …

Initial Results of Posterior Leaflet Extension for Severe Type IIIb Ischemic Mitral Regurgitation

Management of severe ischemic mitral regurgitation remains difficult with disappointing early and intermediate-term surgical results of valve repair. Forty-four patients with severe (4+) Carpentier type IIIb ischemic mitral regurgitation underwent mitral valve repair, with or without surgical revascularization, by posterior leaflet extension with a patch of bovine pericardium and a remodeling annuloplasty. Serial echocardiography was performed preoperatively, intraoperatively, and postoperatively to assess mitral valve competence. The postoperative functional status of patients was assessed. The average Parsonnet score was 38+/-13. Thirty-day mortality was 11%, and late mortality was 14%. Mean follow-up was 38 months. The actuarial freedom from moderate or severe recurrent mitral regurgitation was 90% at 2 years, whereas 90% of patients were in New York Heart Association class I at 2 years. Posterior leaflet extension with annuloplasty of the mitral valve for severe type IIIb ischemic regurgitation is a safe, effective method that provides good early and intermediate-term competence of the mitral valve and therefore good functional status.

Have We Found the Surgical Solution for Ischemic Mitral Regurgitation?

The article by deVarennes et al in the current issue of Circulation details the outcomes in 44 patients with severe (4+) Carpentier type IIIb ischemic mitral regurgitation undergoing mitral valve repair consisting of posterior leaflet extension with bovine pericardium, coupled with remodeling annuloplasty, with or without coronary revascularization.1 Dissatisfied with the long-term results of annuloplasty alone, this group added posterior leaflet extension in an attempt to improve long-term mitral valve competency in this complex group of patients. Chronic ischemic mitral regurgitation (IMR), also referred to as functional mitral regurgitation (MR) is present in 10% to 20% of patients with coronary artery disease.2 It is associated with a markedly worse prognosis and is a common cause of congestive heart failure in this patient grouping. Critical in the discussion of this topic is a definition of the entity at hand. Borger et al put forth a concise definition of chronic IMR as follows: “Chronic IMR should be defined as mitral regurgitation occurring more than one week after MI with (1) one or more left ventricular segmental wall motion abnormalities; (2) significant coronary artery disease in the territory supplying the wall motion abnormality; and (3) structurally normal mitral valve leaflets and chordae tendineae.”3 Article see p 2837 Myocardial infarction sets in motion a cascade of events that can lead to mitral insufficiency. Among these are distortion and remodeling of the left ventricle, which displace the papillary muscles away from the mitral annulus. This phenomenon places excessive tension on the chordae, with the result being apical mitral leaflet tethering. The resultant restriction in leaflet motion …

Evolving Concepts and Technologies in Mitral Valve Repair

Over the past few decades, it has become apparent that mitral valve repair is preferable to mitral valve replacement for the majority of patients undergoing surgery for mitral regurgitation (MR). The advantages of mitral valve repair include low rates of thromboembolism, resistance to endocarditis, excellent late durability reported for as long as 25 years, and no need for anticoagulation in the majority of patients.1–5 Because of these advantages of repair over replacement, the threshold for performing mitral valve repair has been lowered to include patients with MR who have early symptoms or even those who are asymptomatic, assuming that the chance of successful repair is ≥90% according to the latest American College of Cardiology/American Heart Association guidelines.6,7 Recently, surgeons have evaluated new techniques to further improve mitral valve repair, and cardiologists and surgeons are increasingly interested in the potential for percutaneous approaches to mitral valve repair.8 Myxomatous MR affects 1% to 2% of the population and therefore is a common pathology for mitral valve surgery, but the complexity of the operation may be difficult, which leads to generally low rates of repair. In a recent review, only 44.3% of patients in the United States who required mitral valve surgery for MR received a mitral valve repair,9 and in the Euro Heart Survey, repair rates were similarly low (46.5%).10 The goals of mitral repair are to maintain leaflet mobility, remodel the annulus, and allow normal coaptation of the anterior and posterior leaflets. Recent advances in techniques and new concepts for mitral repair are important to cardiologists and other clinicians interested in the management of patients with mitral valve disease. Accordingly, an improved understanding of these concepts will aid in the development of innovative techniques to create safe, durable, reliable, and reproducible mitral valve repair techniques, both …

Remodeling Annuloplasty Using a Prosthetic Ring Designed for Correcting Type-IIIb Ischemic Mitral Regurgitation

The most common mechanism underlying ischemic mitral regurgitation is restricted leaflet motion during systole (Carpentier's type IIIb). Annuloplasty is the preferred technique for surgical repair. The new Carpentier-McCarthy-Adams IMR Etlogix prosthetic annuloplasty ring was designed specifically to address the particular peculiarities of this condition, principally asymmetric annular dilatation. The aims of this study were to review the rationale underlying the creation of the ring and to report our early clinical experience. The study included 40 patients with type-IIIb ischemic mitral regurgitation (grade 3+/4+) who underwent mitral value reconstruction using the new prosthetic ring between December 2003 and June 2005. Their mean age was 68+/-10 years. Concomitant procedures included coronary artery bypass grafting (n=27, 68%), tricuspid valvuloplasty (n=10, 25%), and a modified Maze procedure (n=9, 22%). The mean predicted EuroSCORE mortality for surgery was 17+/-11%. In-hospital mortality was 2.5% (n=1). Major postoperative morbidities included one case of stroke (2.5%), one renal failure (2.5%), and four respiratory failures (10%). Predischarge echocardiography revealed no mitral regurgitation in 36 patients (92%) and mild regurgitation in three (8%). Long-term follow-up echocardiography was carried out in 36 patients (92%) after 15-34 months, and showed that the rate of recurrence of (grade >/=2+) mitral regurgitation was 3% (n=1). The Carpentier-McCarthy-Adams IMR Etlogix(R) annuloplasty ring was effective in correcting type-IIIb ischemic mitral regurgitation. Its novel three-dimensional asymmetric shape is designed to deal with the anatomical and pathological characteristics of the condition and its use may, therefore, result in an excellent long-term outcome.

Posterior mitral leaflet extension: An adjunctive repair option for ischemic mitral regurgitation?

Residual or recurrent mitral regurgitation frequently occurs after mitral valve repair for ischemic mitral regurgitation with an annuloplasty ring. Because annuloplasty primarily addresses annular dilatation, we studied an adjunctive technique that might correct restricted leaflet (Carpentier type IIIb) systolic closing motion, which often accompanies annular dilatation in patients with ischemic mitral regurgitation. Six sheep had radiopaque markers placed on the left ventricle, mitral leaflets and annulus, and mitral subvalvular apparatus. A pericardial patch was sutured into the middle scallop of the posterior mitral valve leaflet and furled in with a reefing stitch placed in the radial axis. Posterolateral left ventricular myocardial ischemia was created by using proximal circumflex occlusion to induce acute ischemic mitral regurgitation. Under open-chest conditions, 3-dimensional marker coordinates were measured by using biplane videofluoroscopy at baseline and during acute ischemia both before and after release of the reefing stitch (leaflet extension); transesophageal echocardiography was used to grade ischemic mitral regurgitation. Leaflet apical systolic tethering was not improved by leaflet extension, but ischemic mitral regurgitation decreased (control, 0.9 +/- 0.3*; ischemia, 2.4 +/- 0.3; leaflet extension, 1.5 +/- 0.3; *P < 0.002). Posterior mitral valve leaflet midline length (control, 1.45 +/- 0.09*; ischemia, 1.53 +/- 0.10; leaflet extension, 1.83 +/- 0.13*; *P < 0.001) and posterior mitral valve leaflet middle scallop area (control, 1.66 +/- 0.20 cm2*; ischemia, 1.91 +/- 0.22 cm2; leaflet extension, 2.36 +/- 0.22 cm2*; *P < 0.006) increased with leaflet extension because of patch unfurling (mean +/- 1 standard error of the mean; repeated-measures analysis of variance, Dunnet post-hoc test vs ischemia). Posterior mitral valve leaflet extension ameliorated acute ischemic mitral regurgitation but did not correct the abnormal apically restricted systolic posterior mitral valve leaflet closing motion. This technique might be a useful adjunct repair in combination with ring annuloplasty for ischemic mitral regurgitation, but the clinical role of this adjunct remains to be defined in patients.

Anterior leaflet augmentation for ischemic mitral regurgitation

Background Mitral valve repair improves survival and quality of life in patients with ischemic mitral regurgitation (MR). Although many repair methods exist for this condition, the ideal approach remains unknown. The purpose of this study is to describe a simple technique for repair of ischemic MR that addresses the pathophysiology of tethered leaflets and to report its early results. Methods The technique consists of pericardial patch enlargement of the anterior mitral leaflet and placement of a flexible annuloplasty band. Candidates for the repair had ischemic cardiomyopathy and echocardiographic evidence of moderate or severe Carpentier type IIIb MR. Patients were followed with serial echocardiography. Results Between January 2002 and November 2003, 25 adult patients underwent anterior leaflet augmentation for ischemic MR. Mean age was 64.8 ± 10.6 years, and mean left ventricular ejection fraction was 0.36 ± 0.14. Preoperative MR by transesophageal echocardiography was severe in 84% of patients and moderate in 16%. Annuloplasty band sizes were 27 mm to 31 mm (mean, 28.4 ± 1.1 mm). Concomitant coronary artery bypass grafting was performed in all patients. Transesophageal echocardiography immediately after repair revealed MR to be none or trace in 80% of patients and mild in 20%. No intraoperative conversion to valve replacement was performed. In follow-up, 2 patients have experienced moderate MR and are being treated medically, and no patients have mitral stenosis. At 2 years, actuarial freedom from moderate or greater MR is 81%. Conclusions For patients with ischemic MR, anterior leaflet augmentation is a simple and reproducible method of valve repair that addresses the pathophysiology of tethered leaflets. Early results in a small number of patients have been encouraging.

Restrictive mitral annuloplasty in refractory cardiogenic shock with acute postinfarction mitral insufficiency and intact papillary muscle

Acute severe mitral insufficiency after myocardial infarction usually results from rupture of a papillary muscle, which should be treated on an emergency basis with mitral valve repair or replacement. In the case of acute postinfarction mitral regurgitation with intact papillary muscle, no consensus exists, even with regard to the indication for surgery. Restrictive mitral annuloplasty (RMA) has been applied in chronic ischemic mitral insufficiency, with encouraging midterm results. 1,2 In this report, we describe 2 patients in whom RMA was applied as a lifesaving procedure in the presence of refractory cardiogenic shock in postinfarction mitral insufficiency with intact papillary muscle. Clinical Summaries PATIENT 1. A 55-year-old woman had an acute inferior wall infarction with cardiogenic shock. She received an intra-aortic balloon pump (IABP) and inotropes and was intubated. Coronary angiography revealed occlusion of the right coronary and circumflex arteries. Transesophageal echocardiography (TEE) showed grade 4 mitral insufficiency resulting from systolic restrictive motion of both leaflets (Carpentier type IIIb; Figures 1 and 2). The regurgitation jet was slightly eccentric because of the more restrictive posterior leaflet. Because of further hemodynamic deterioration, we decided to attempt correction of the mitral regurgitation as a lifesaving procedure. During the operation, a fresh infarction of the posterolateral wall involving the posterior papillary muscle was observed. The subvalvular apparatus was intact, and there was no structural anomaly of the mitral valve leaflets. RMA was performed with a size 28 Carpentier-Edwards Physioring (Baxter Healthcare Corporation CardioVascular Group, Irvine, Calif), thereby downsizing the prosthetic ring by two sizes. Tentative revascularization of the circumflex and right coronary artery territory was performed with a sequential saphenous vein graft. The patient was weaned from extracorporeal circulation with inotropic support (epinephrine at 0.22 g/kg/min, dobutamine at 15 g/kg/min, dopamine at 8 g/kg/min, and enoximon at 4 g/kg/min). Intraoperative TEE showed trivial mitral regurgitation with a mean transvalvular mitral gradient of 3 mm Hg (mitral valve surface area 2c m 2 ) and

Ischemic mitral regurgitation redux—To repair or to replace?

Ischemic mitral regurgitation redux—To repair or to replace?