Changes In Mitral Regurgitation Research Articles

Impact on Outcome of Different Mechanisms, Baseline Degree and Changes of Mitral Regurgitation in Patients With Aortic Stenosis Who Underwent Transcatheter Aortic Valve Replacement.

Mitral regurgitation (MR) is frequent in patients with aortic stenosis (AS). Although primary MR is an established negative prognostic factor, whether different mechanisms of MR have different effects on outcome is currently unknown. The aim of this study was to evaluate the impact of the MR mechanism in patients undergoing transcatheter aortic valve replacement (TAVR). This is a retrospective observational study of patients who underwent TAVR for severe aortic stenosis in a high-volume tertiary care center. Echocardiographic comprehensive MR assessment was performed at baseline and within 3 months post TAVR. The study population was divided into 4 groups according to MR mechanism: Group I: fibro-calcific leaflet degeneration; Group II: prolapse/flail; Group III: ventricular secondary MR (functional MR); and Group IV: atrial functional MR. The study end point was a combination of death from cardiovascular cause and heart failure-related hospitalization. The study population included 427 patients (mean age 81.7±6.5 years; 71% primary MR; 62% ≥moderate MR). At 3-year follow-up, survival free from the composite end point significantly differs according to MR mechanism: it was higher in group IV (atrial functional MR, 96.6%) compared with group I (80.4%, P=0.002) and group II patients (60.7%, P=0.001), and group III (84.8%, P=0.037); patients with MR due to leaflet prolapse showed poorer prognosis compared with patients with functional MR (group III, P=0.023 and group IV, P=0.001) and with group I (P=0.040). Overall, severe MR after TAVR identified patients with poorer prognosis and was significantly more frequent in group II (46.4%, P=0.001). In patients undergoing TAVR, preprocedural identification of MR mechanism and mechanism provides prognostic insights.

Evaluation of the Effect of Conversion of Nonvalvular Atrial Fibrillation to Sinus Rhythm on Cardiac Remodeling.

Atrial fibrillation (AF)represents the most prevalent cardiac arrhythmia globally, with a significant burden on mortality and morbidity. While rhythm control strategies, particularly electrical cardioversion (EC), have gained traction in recent years, the precise impact of sinus rhythm (SR) restoration on cardiac reverse remodeling remains a subject of debate. In this study, 23 AF patients underwent elective EC. AF diagnosis was made via ECG by a cardiologist, and candidates for cardioversion were selected by an electrophysiologist. Transthoracic echocardiography (TTE) by utilizing two-dimensional, three-dimensional, and tissue Doppler imaging modalities was performed before cardioversion. Patients who maintained SR after six months underwent a second TTE evaluation. SR was restored successfully in all 23 patients and 15 patients (65.2%) maintained SR after six months. SR group had significantly lower baseline cardiac output (CO)and indexed left ventricular end-systolic volume (LVESVi), and better European Heart Rhythm Association (EHRA) scores after six months. Within the SR group, patients exhibited significant changes in mitral regurgitation, tricuspid regurgitation, EHRA score, LVESVi, stroke volume, left ventricle ejection fraction, left ventricle global longitudinal strain, indexed minimum left atrial volume, left atrial emptying fraction, and left and right atrial diameters. Reduced CO was associated with AF recurrence. Receiver operating curve analysis revealed that CO value can predict six-month AF recurrence with a cut-off point of 2.3. Our study underscores the beneficial effects of SR restoration on cardiac parameters in AF patients post EC. Notably, CO value emerged as a predictor of AF recurrence, emphasizing the importance of comprehensive assessments for predicting long-term outcomes.

Hemodynamic and Echocardiographic Assessment of Left Ventricle Recovery with Left Ventricular Assist Devices: Do We Explant?

<h3>Introduction</h3> Explantation of left ventricular assist devices (LVAD) after left ventricular (LV) recovery is estimated to occur in 1-2% of cases. Herein, we present a case of hemodynamic and echocardiographic assessment of LV recovery during outflow graft balloon occlusion leading to LVAD explantation. <h3>Case Report</h3> A 56-year-old female with medical history of systolic heart failure due to non-ischemic cardiomyopathy with LVEF 25%. She underwent an urgent HeartMate 3 LVAD implant after an admission for cardiogenic shock. Post LVAD course was complicated by driveline infection. History was notable for admissions due to low-flow alarms in the setting of dehydration. On echocardiogram, progressive LVEF improvement was noted although with suboptimal images. CT angiography did not demonstrate any occlusion of the cannulas. Right heart catheterization showed stable cardiac index despite minimal flow on LVAD. Cardiopulmonary testing was favorable. After multi-disciplinary discussion, patient underwent LVAD wean study in the cath lab under hemodynamic and transesophageal echo (TEE) guidance with therapeutic anticoagulation. LVAD was turned off for 10 minutes with outflow graft occluded by Armada 14 mm x 20 cm peripheral balloon. Wiring of the outflow graft from aorta and balloon occlusion were visualized by TEE (Figure). The left and right ventricular function were similar to baseline with no change in mitral regurgitation. Cardiac index was normal (Figure). Patient subsequently underwent successful LVAD explant. She is doing well with NYHA class I symptoms and LVEF 45-50% noted upon 3-months follow-up <h3>Summary</h3> LVAD explantation is a feasible option in LV recovery after appropriate hemodynamic and echocardiographic assessment. TEE is an essential tool, especially in patients with suboptimal windows. Outflow graft balloon occlusion can be used if there is concern about falsely poor results related to backflow or ongoing LVAD support at low speed leading to falsely improved results

Clinical impact of changes in mitral regurgitation severity after medical therapy optimization in heart failure

BackgroundFew data are available regarding changes in mitral regurgitation (MR) severity with guideline-recommended medical therapy (GRMT) in heart failure (HF). Our aim was to evaluate the evolution and impact of MR after GRMT in the Biology study to Tailored treatment in chronic heart failure (BIOSTAT-CHF).MethodsA retrospective post-hoc analysis was performed on HF patients from BIOSTAT-CHF with available data on MR status at baseline and at 9-month follow-up after GRMT optimization. The primary endpoint was a composite of all-cause death or HF hospitalization.ResultsAmong 1022 patients with data at both time-points, 462 (45.2%) had moderate-severe MR at baseline and 360 (35.2%) had it at 9-month follow-up. Regression of moderate-severe MR from baseline to 9 months occurred in 192/462 patients (41.6%) and worsening from baseline to moderate-severe MR at 9 months occurred in 90/560 patients (16.1%). The presence of moderate-severe MR at 9 months, independent from baseline severity, was associated with an increased risk of the primary endpoint (unadjusted hazard ratio [HR], 2.03; 95% confidence interval [CI], 1.57–2.63; p < 0.001), also after adjusting for the BIOSTAT-CHF risk-prediction model (adjusted HR, 1.85; 95% CI 1.43–2.39; p < 0.001). Younger age, LVEF ≥ 50% and treatment with higher ACEi/ARB doses were associated with a lower likelihood of persistence of moderate-severe MR at 9 months, whereas older age was the only predictor of worsening MR.ConclusionsAmong patients with HF undergoing GRMT optimization, ACEi/ARB up-titration and HFpEF were associated with MR improvement, and the presence of moderate-severe MR after GRMT was associated with worse outcome.Graphical abstract

Hemodynamics in mitral regurgitation – before and after correction with MitraClip

Haemodynamic changes in mitral regurgitation underlie triggering of patient&amp;rsquo;s symptoms and development of heart failure. A number of endovascular methods for the correction of mitral regurgitation successfully counteract pathological hemodynamics and thus manage to improve both the manifestations of heart failure and the patient&amp;#39;s symptoms. This article is a review of the physiology of the mitral valve and the changes that occur in the presence of mitral regurgitation. The peculiarities of the hemodynamics of the left atrium in the conditions of mitral regurgitation and after some types of transcatheter treatment &amp;ndash; edge-to-edge correction of the valve with Mitraclip and the implantation of an occluder in paraprosthetic mitral regurgitation are considered. The change in left atrial parameters immediately after correction of the defect is of value both for the assessment of immediate procedural success and for the patient&amp;#39;s prognosis.

128 Clinical impact of changes in mitral regurgitation severity after optimization of medical therapy in heart failure: insights from BIOSTAT-CHF

Abstract Aims Few data are available regarding changes in mitral regurgitation (MR) severity with guideline-directed medical therapy (GDMT) in heart failure (HF). We evaluated the evolution and impact of MR after GDMT in the BIOlogy Study to TAilored Treatment in Chronic Heart Failure (BIOSTAT-CHF). Methods and results A retrospective post hoc analysis was performed on HF patients from BIOSTAT-CHF with available data on MR status at baseline and at 9-month follow-up after GRMT optimization. The primary endpoint was a composite of all-cause death or HF hospitalization. Among 1022 patients with data at both time-points, 462 (45.2%) had moderate-severe MR at baseline and 360 (35.2%) had it at 9-month follow-up. Regression of moderate–severe MR from baseline to 9 months occurred in 192/462 patients (41.6%) and worsening from baseline to moderate–severe MR at 9 months occurred in 90/560 patients (16.1%). The presence of moderate-severe MR at 9 months, independent from baseline severity, was associated with an increased risk of the primary endpoint [unadjusted hazard ratio (HR), 2.03; 95% confidence interval (CI): 1.57–2.63; P &amp;lt; 0.001], also after adjusting for the BIOSTAT-CHF risk-prediction model (adjusted HR: 1.85; 95% CI: 1.43–2.39; P &amp;lt; 0.001). Younger age, LVEF ≥50% and treatment with higher ACEi/ARB doses were associated with a lower likelihood of moderate–severe MR at 9 months, whereas older age was the only predictor of worsening MR. Conclusions Among patients with HF undergoing GDMT optimization, ACEi/ARB up-titration and HFpEF were associated with MR improvement, and the presence of moderate–severe MR after GRMT was associated with worse outcome.

127 SARS-CoV-2 pandemic: post-lockdown subclinic cardiovascular events detected by 12-leads electrocardiogram at Emergency Department

AimsFew data are available regarding changes in mitral regurgitation (MR) severity with guideline-directed medical therapy (GDMT) in heart failure (HF). We evaluated the evolution and impact of MR after GDMT in the BIOlogy Study to TAilored Treatment in Chronic Heart Failure (BIOSTAT-CHF).Methods and resultsA retrospective post hoc analysis was performed on HF patients from BIOSTAT-CHF with available data on MR status at baseline and at 9-month follow-up after GRMT optimization. The primary endpoint was a composite of all-cause death or HF hospitalization. Among 1022 patients with data at both time-points, 462 (45.2%) had moderate-severe MR at baseline and 360 (35.2%) had it at 9-month follow-up. Regression of moderate–severe MR from baseline to 9 months occurred in 192/462 patients (41.6%) and worsening from baseline to moderate–severe MR at 9 months occurred in 90/560 patients (16.1%). The presence of moderate–severe MR at 9 months, independent from baseline severity, was associated with an increased risk of the primary endpoint [unadjusted hazard ratio (HR), 2.03; 95% confidence interval (CI), 1.57–2.63; P < 0.001], also after adjusting for the BIOSTAT-CHF risk-prediction model (adjusted HR, 1.85; 95% CI, 1.43–2.39; P < 0.001). Younger age, LVEF ≥50% and treatment with higher ACEi/ARB doses were associated with a lower likelihood of moderate–severe MR at 9 months, whereas older age was the only predictor of worsening MR.ConclusionsAmong patients with HF undergoing GDMT optimization, ACEi/ARB up-titration and HFpEF were associated with MR improvement, and the presence of moderate–severe MR after GRMT was associated with worse outcome.127 Figure 1

Abstract 11458: Temporal Changes in Mitral Regurgitation After Percutaneous Mitral Valve Repair with MitraClip for Functional Mitral Regurgitation in Patients with Atrial Fibrillation

Background: Recently, percutaneous mitral valve (MV) repair has been increasingly performed for functional mitral regurgitation (FMR). However, few studies have examined the effectiveness of percutaneous MV repair for atrial FMR (AFMR). The aim of this study is to compare the effectiveness of MitraClip implantation between patients with AFMR and ventricular FMR (VFMR). Methods: We retrospectively reviewed 113 grade 3 to 4+ FMR patients with persistent atrial fibrillation or atrial flutter who underwent MitraClip implantation. We classified the patients into 2 groups; 43 patients with preserved left ventricular (LV) ejection fraction (LVEF) ≥ 50% and normal LV wall motion were defined as AFMR. 70 patients with LV dysfunction (LVEF &lt; 50 %) or LV wall motion abnormality were defined as VFMR. Transthoracic echocardiography (TTE) follow-up was performed at approximately 1-day, 1-month and 1-year after the procedure. Results: The percentage of grade 4+ mitral regurgitation (MR) was 53% in AFMR and 49% in VFMR at baseline (P=0.61). Acute procedural success rate was similar between AFMR and VFMR (95.3% vs. 97.1%, P=0.49). The median period of 1-month and 1-year follow-up TTE were 33 [interquartile range (IQR): 28-36] days and 356 (IQR: 248-399) days in AFMR, and 34 (IQR: 30-38) days and 366 (IQR: 336-415) days in VFMR, respectively. The percentage of grade 3 or 4+ MR at 1-day, 1-month, and 1-year after the procedure were 4.7% (2/43), 10% (3/30), and 5.6% (1/18) in AFMR, and 2.9% (2/70), 7.3% (4/55), and 2.9% (1/35) in VFMR (P=0.49, 0.48, and 0.57, respectively, AFMR vs. VFMR at the same follow-up point). The rates of redo MitraClip or MV surgery for recurrent MR within 1-month and between 1-month/1-year were 0% and 9.3% in AFMR, and 1.4% and 1.4% in VFMR. The percentage of New York Heart Association functional class III or IV at baseline, 1-month, and 1-year after the procedure were 90.7% (39/43), 23.3% (7/30), and 33.3% (6/18) in AFMR and 97.1% (68/70), 27.3% (15/55), and 22.9% (8/35) in VFMR (P=0.15, 0.69, and 0.41, respectively, AFMR vs. VFMR at the same follow-up point). Conclusions: In our series, MitraClip implantation had comparable therapeutic effect on both MR severity and heart failure symptoms between patients with AFMR and VFMR.

Changes in mitral regurgitation following acute myocardial infarction: early and long-term follow-up

Abstract Background Mitral regurgitation (MR) is commonly observed following acute myocardial infarction (MI). Localised left ventricular (LV) remodelling in the region of papillary muscles together with impaired myocardial contractility promote MR. There is a paucity of long-term follow-up studies to determine whether the severity of MR observed post-MI, changes with time. Purpose This study retrospectively followed up patients with MR detected following acute MI (AMI) to investigate changes in MR severity with time and assess for pre-discharge predictors of MR regression or progression. Methods Clinical records of 1000 patients admitted with AMI between 2016 and 2017 to a single centre were retrospectively interrogated. One hundred and nine patients met the inclusion criteria of MR on pre-discharge transthoracic echocardiography (TTE) and follow-up TTE scans. Echocardiographic parameters were investigated to determine predictors of progression or regression at follow-up. Patients were divided according to those who had early follow-up TTE (within 1-year) and late follow-up TTE (beyond 1-year). Results Early follow-up TTE was performed in 73 patients at a median of 6 (IQR 3–9) months. Patients had a mean age of 69±13 years and were predominantly male 50/73 (68%). At baseline, relative MR severities were: 49/73 (67%) mild MR, 23/73 (32%) moderate MR and 1 (1%) severe MR. At follow-up, MR had completely resolved in 18/73 (23%) patients, while 39/73 (53%) had mild MR, 15/73 (21%) moderate MR and 1 (1%) severe MR. Compared to patients with no resolution of MR, those with completel resolution were younger (mean age 62±16 vs 72±11 years; p=0.015) but there were no other significant differences between the groups. Resolution at early follow-up did not significantly influence long-term mortality rates. Late follow-up TTE was performed in 69 patients at a median 2.4 (IQR 2–3.2) years. Pre-discharge, 49/69 (71%) patients had mild MR and 20/69 (29%) moderate MR. At follow-up, MR had completely resolved in 18/69 (26%), and amongst patients with persistent MR, proportion of severities were: 37/69 (54%) mild MR, 11/69 (16%) moderate MR and 3/69 (4%) severe MR. Patients with progression of mild MR were more likely to have lower left ventricular ejection fraction (LVEF: 47±15 vs 57±12%; p=0.010) and greater indexed left ventricular end-systolic volume (LVESVi: 37±23 vs 25±14 ml/m2; p&amp;lt;0.001) on pre-discharge TTE. Resolution of MR at late follow-up was associated with a reduction in long-term mortality [deaths: 2/55 (3%) vs 3/14 (21%); p=0.022] at a mean follow-up of 4.2 years from MI. Conclusion MR observed following AMI completely resolved in approximately one-quarter of patients at 6-month and 2-year follow-up. Progression of mild MR at long-term follow-up appears to be associated with increased mortality and is predicted by lower LVEF and greater LVESVi pre-discharge. Funding Acknowledgement Type of funding sources: None.

Mitral valve asymmetry in healthy, pathological, and repaired cases

The entry of blood into the left ventricle is regulated by the two valve leaflets. Mitral valve prolapse is the primary cause of mitral regurgitation. Mitral valve repair is the gold standard therapeutic procedure for patients with degenerative mitral valve regurgitation and follows two fundamental principles: restoring a good coaptation surface of the flap and correcting annular dilation. This study presents a first step in the direction of addressing the influence of valve geometry on valve fluid dynamics and mitral regurgitation. To this end, it develops a systematic analysis to identify how the level of regurgitation and the efficiency of flow transit in the left ventricle depend on the degree of asymmetry of the leaflets. The analysis is performed starting from a mathematically designed mitral valve and then extended to the actual valves extracted from medical imaging. The specific objective is to evaluate the changes in mitral regurgitation associated with the symmetrical properties of the mitral valve. The broader aim is to begin building physics-based means for evaluating repair options and prosthetic design. Results showed that valve shape does not affect flow; sub-volumes are similar to inflow and vary to outflow due to the presence of false regurgitation under healthy/repaired conditions and regurgitation under pathological conditions affecting the amount of direct flow, delayed and finally the Stroke volume. The best valve asymmetry point was found to be 0.25, while the optimal range was between 0.4 and 0.2, giving an important suggestion to valve surgery.

Higher preoperative left atrial volume index predicts lack of mitral regurgitation improvement after transcatheter aortic valve replacement.

Moderate-to-severe mitral regurgitation is present in 20-35% of patients undergoing transcatheter aortic valve replacement (TAVR) and the current literature lacks simple echocardiographic parameters, which can predict post-TAVR changes in mitral regurgitation. The aim of this study is to investigate the echocardiographic predictors of improvement or worsening of mitral regurgitation in patients undergoing TAVR with moderate-to-severe mitral regurgitation. This retrospective study included 113 patients who underwent TAVR with preoperative mitral regurgitation grade at least 2. Patients with concomitant coronary artery disease requiring treatment were excluded. Mitral regurgitation was related to the annular dilatation or tethering mechanism in all patients. Preoperative and postoperative echocardiographies were compared in terms of mitral regurgitation and other commonly measured parameters. After TAVR, a reduction in mitral regurgitation was observed in 62.8% of cases. On the basis of the difference between postoperative and preoperative echocardiograms, 71 patients had improved mitral regurgitation, whereas 42 patients had stable or worsened mitral regurgitation. After analyzing preoperative echocardiographic parameters with regard to this group difference, left atrial volume index (LAVI) was the only variable that was different between groups (33.4 ± 4.8 ml/m in improved mitral regurgitation vs. 39.8 ± 3.0 ml/m in not improved mitral regurgitation, P < 0.001). In a multivariable logistic regression model, a LAVI increase was associated with lack of an acute reduction in mitral regurgitation (odds ratio = 1.41, P < 0.001) after adjustment for age and preoperative serum creatinine. Higher preoperative LAVI is a determinant predictor of lack of an acute reduction in mitral regurgitation after TAVR, and LAVI could be used as a stratifying tool to tailor the treatment strategy and the timing of the procedures. However, validation of these results and long-term outcomes are warranted to support those conclusions.

Total Intravenous Anesthesia Maintained the Degree of Pre-Existing Mitral Regurgitation Better than Isoflurane Anesthesia in Cardiac Surgery: A Randomized Controlled Trial.

Accurate assessment of mitral regurgitation (MR) is critical during mitral valve repair surgery. However, anesthesia may influence the degree of mitral regurgitation by changing pre- and after-load or cardiac contractility. Therefore, we compared changes in mitral regurgitation by total intravenous anesthesia (TIVA) and inhalation anesthesia in patients with pre-existing mitral regurgitation. This was a double-blind randomized controlled study conducted at a tertiary care center in 2018. Fifty-four mitral regurgitation patents undergoing elective cardiac surgery were randomly assigned to receive TIVA or isoflurane. Primary endpoint was change of regurgitation volume by anesthesia. The reduction of regurgitation volume by anesthesia was greater in the isoflurane group than in the TIVA group (mean (95% confidence interval CI): −0.20 (−6.15, 5.75) vs. −9.66 (−15.77, −3.56), mL·beat−1, p = 0.0266) and this phenomenon was more prominent with severe mitral regurgitation (grade 3 or 4) (mean (95% CI): −0.33 (−9.10, 8.44) vs. −16.20 (−24.22, −8.18), mL·beat−1, p = 0.0079). Among patients with MR grade 3 or 4, 94% remained the same with TIVA during anesthesia compared to 56% with isoflurane. In conclusion, TIVA maintained the pre-anesthetic state of mitral regurgitation relatively well, while the severity of mitral regurgitation tended to decrease with isoflurane anesthesia.

Change in mitral regurgitation severity impacts survival after transcatheter aortic valve replacement

BackgroundThe impact of a change in mitral regurgitation (MR) following TAVR is unknown. We studied the impact of baseline MR and early post-procedural change in MR on survival following TAVR. MethodsThe SWEDEHEART registry included all TAVRs performed in Sweden. Patients were dichotomized into no/mild and moderate/severe MR groups. Vital status, echocardiographic data at baseline and within 7 days after TAVR were analyzed. Results1712 patients were included. 1404 (82%) had no/mild MR and 308 (18%) had moderate/severe MR. Baseline moderate/severe MR conferred a higher mortality rate at 5-year follow-up (adjusted HR 1.29, CI 1.01–1.65, p = 0.04). Using persistent ≤mild MR as the reference, when moderate/severe MR persisted or if MR worsened from ≤mild at baseline to moderate/severe after TAVR, higher 5-year mortality rates were seen (adjusted HR 1.66, CI 1.17–2.34, p = 0.04; adjusted HR 1.97, CI 1.29–3.00, p = 0.002, respectively). If baseline moderate/severe MR improved to ≤mild after TAVR no excess mortality was seen (HR 1.09, CI 0.75–1.58, p = 0.67). Paravalvular aortic regurgitation (PVL) was inversely associated with MR improvement after TAVR (OR 0.4, 95%: CI 0.17–0.94; p = 0.034). Atrial fibrillation (OR 2.1, 95% CI: 1.27–3.39, p = 0.004), self-expanding valve (OR 3.8, 95% CI: 2.08–7.14, p < 0.0001), and PVL (4.3, 95% CI 2.32–7.78. p < 0.0001) were associated with MR worsening. ConclusionsModerate/severe baseline MR in patients undergoing TAVR is associated with a mortality increase during 5 years of follow-up. This risk is offset if MR improves to ≤mild, whereas worsening of MR after TAVR is associated with a 2-fold mortality increase.

CMR quantitation of change in mitral regurgitation following transcatheter aortic valve replacement (TAVR): impact on left ventricular reverse remodeling and outcome

Current echocardiographic data reporting the impact of concomitant mitral regurgitation (MR) on outcome in patients who undergo transcatheter aortic valve replacement (TAVR) are conflicting. Using cardiovascular magnetic resonance (CMR) imaging, this study aimed to assess the impact of MR severity on cardiac reverse remodeling and patient outcome. 85 patients undergoing TAVR with CMR pre- and 6 m post-TAVR were evaluated. The CMR protocol included cines for left (LV) and right ventricular (RV) volumes, flow assessment, and myocardial scar assessment by late gadolinium enhancement (LGE). Patients were dichotomised according to CMR severity of MR fraction at baseline (‘non-significant’ vs ‘significant’) and followed up for a median duration of 3 years. Forty-two (49%) patients had ‘significant MR’ at baseline; they had similar LV and RV size and function compared to the ‘non-significant MR’ group but had greater LV mass at baseline. In those with significant MR at baseline, 77% (n = 32) had a reduction in MR post-TAVR, moving them into the ‘non-significant’ category at 6-months, with an overall reduction in MR fraction from 34 to 17% (p < 0.001). Improvement in MR was not associated with more favourable cardiac reverse remodeling when compared with the ‘non-improvers’. Significant MR at baseline was not associated with increased mortality at follow-up. Significant MR is common in patients undergoing TAVR and improves in the majority post-procedure. Improvement in MR was not associated with more favourable LV reverse remodeling and baseline MR severity was not associated with mortality.

Surgical treatment of functional mitral regurgitation involving the subvalvular apparatus.

We retrospectively studied outcomes after mitral annuloplasty (MAP) combined with subvalvular procedures for patients with functional mitral regurgitation and ischemic dilated cardiomyopathy. We focused on changes in mitral regurgitation (MR) grade, mitral valve tethering, and left ventricular (LV) volume before and after surgery. Thirty-one patients underwent MAP combined with subvalvular procedures including papillary muscle (PM) approximation, PM relocation, and chordal cutting. Fifteen patients underwent left ventriculoplasty. Twenty patients underwent PM approximation, and 11 patients underwent PM relocation. Two patients underwent chordal cutting in addition to PM approximation or relocation. In 25 patients, echocardiographic measurements of MR grade, mitral valve tethering, and LV volume were compared among three time points: before, immediately after, and one year after surgery. There were no in-hospital deaths. LV volume as well as both tenting height and area were significantly reduced immediately after and at one year after surgery. Five patients developed recurrent MR at one year after surgery. In comparison with the other 20 patients, the preoperative MR grade was significantly higher (p = 0.018). The postoperative reduction of LV volume was significant in patients without recurrent MR. Both tenting height and area could be significantly reduced and maintained after MAP combined with subvalvular procedures. The preoperative MR grade and the presence of a large postoperative LV volume were more likely to result in recurrent MR. However, among patients with recurrent MR, the MR grade does not increase during mid-term follow-up.

Impact of TAVI on Mitral Regurgitation: A Prospective Echocardiographic Study

This study aims to assess changes in mitral regurgitation (MR) severity after transcatheter aortic valve implantation (TAVI). Existing data on MR after TAVI are contradictory. Thirty-five patients with MR graded≥2+ were followed after undergoing TAVI with either the Edwards Sapien or CoreValve device. Echocardiography was performed the week before and 3months after the procedure. MR was graded on a scale of 0 to 4+, classified as organic or functional, and the effective regurgitant orifice area (EROA) and MR index were calculated. At baseline, MR was graded 4+ in 4 (11.4%) patients, 3+ in 10 (28.6%), and 2+ in 21 (60%). At follow-up, MR was graded at 3+ in 4 (11.4%) patients, 2+ in 8 (22.9%), and 1+ in 19 (54.3%); 4 (11.4%) exhibited no MR. EROA (24.4±11.5mm(2) pre-TAVI vs. 11.2±10.3mm(2) post-TAVI, P<0.001) and MR index (1.9±0.3 pre-TAVI vs. 1.3±0.7 post-TAVI, P<0.001) were reduced with TAVI, independent of the etiology. MR decreased by at least 1 grade in 28 (80%) patients, with a reduction ≥2 grades in 10 (28.6%) patients; no patient showed a worsened condition. Subgroup analyses showed that the reduction in MR was significant in patients treated with the Edwards Sapien device but not in patients treated with the CoreValve device. This multiparametric echocardiographic evaluation showed that MR improved significantly after TAVI and that this result may be related to the type of valve implanted.

Improvement of mitral regurgitation after transcatheter aortic valve implantation (TAVI)

Objectives To assess the change in mitral regurgitation (MR) severity after transcatheter aortic valve implantation (TAVI). Background Mitral regurgitation (MR) is frequently present in patients with calcific aortic stenosis (AS). Following surgical aortic valve replacement, improvement in MR is reported in 27–82% of the patients. The changes in MR severity following TAVI are unknown. Methods From April 2009 to January 2011, 57 patients with severe symptomatic aortic stenosis underwent TAVI [40 cases Edwards Sapien valve (Edwards Lifesciences Inc, Irvine CA), and 17 cases the CoreValve ReValving System]. Transthoracic echocardiography was performed before and 3 months after successful TAVI procedure. MR was assessed by expert readers and by color flow mapping and was graded as none (grade 0), mild (grade 1), moderate (grade 2), moderately severe (grade 3) or severe (grade 4). Results The mean MR grade was 1.7 ± 1.0 and 0.9 ± 0.7 pre- and post-TAVI respectively ( p value Conclusions MR improved significantly after TAVI for severe AS. Further study with careful echocardiographic evaluation of the mitral valve prior to TAVI may help to predict which patients should experience an improvement in their MR.

756 Acute Outcomes of MitraClip Therapy for Mitral Regurgitation in High Risk Surgical Patients

756 Acute Outcomes of MitraClip Therapy for Mitral Regurgitation in High Risk Surgical Patients

Percutaneous Transluminal Mitral Commissurotomy for Rheumatic Mitral Stenosis in a 5-Year-Old Child

We report a 5-year-old boy weighing 11 kg, with severe mitral valve stenosis of rheumatic aetiology, who underwent successful percutaneous transluminal mitral commissurotomy (PTMC) with valvuloplasty balloon. Postprocedural mean pressure gradient across the mitral valve decreased to 6 mmHg from an initially recorded value of 22 mmHg. In addition to symptomatic improvement, the mitral valvular area increased from 0.4 to 0.8 cm(2) without significant change in mitral regurgitation. At 1- and 3-month follow up, transthoracic echocardiography revealed further improvement with an increase in mitral valve area to 1.0 cm(2), a decrease in pulmonary arterial pressure, and a mean mitral valve pressure gradient of 8 mmHg with trivial mitral regurgitation. To best of our knowledge, this is the first successful PTMC procedure performed in the youngest and smallest ever reported child with rheumatic mitral stenosis (MS). We conclude that PTMC with valvuloplasty balloon could be a logical alternative to surgery in young patients with rheumatic MS.

Changes in mitral regurgitation and left ventricular geometry during exercise affect exercise capacity in patients with systolic heart failure

Changes in mitral regurgitation and left ventricular geometry during exercise affect exercise capacity in patients with systolic heart failure