Chronic Severe Mitral Regurgitation Research Articles

TCT-752 Combined Valvular and Subvalvular Intervention With Innovalve TMVR Facilitates Reverse Remodeling and Improves Left Ventricular Ejection Fraction in Patients With Severe Chronic Mitral Regurgitation (TWIST-EFS and FIH Studies)

TCT-752 Combined Valvular and Subvalvular Intervention With Innovalve TMVR Facilitates Reverse Remodeling and Improves Left Ventricular Ejection Fraction in Patients With Severe Chronic Mitral Regurgitation (TWIST-EFS and FIH Studies)

An experimental model of chronic severe mitral regurgitation.

To develop a minimally invasive, reproducible model of chronic severe mitral regurgitation (MR) that replicates the clinical phenotype of left atrial (LA) and left ventricular dilation and susceptibility to atrial fibrillation. Under transesophageal echocardiographic guidance, chordae tendinae were avulsed using endovascular forceps until the ratio of regurgitant jet area to LA area was ≥70%. Animals survived for an average of 8.6±1.6months (standard deviation) and imaged with monthly transthoracic echocardiography (TTE). Animals underwent baseline and preterminal magnetic resonance imaging. Terminal studies included TTE, transesophageal echocardiography, and rapid atrial pacing to test inducibility of atrial tachyarrhythmias. Eight dogs underwent creation of severe MR and interval monitoring. Two were excluded-one died from acute heart failure, and the other had resolution of MR. Six dogs underwent the full experimental protocol; only one required medical management of clinical heart failure. MR remained severe over time, with a mean terminal regurgitant jet area to LA area of 71±14% (standard deviation) and regurgitant fraction of 52±11%. Mean LA volume increased over 130% (TTE: 163±147%, P=.039; magnetic resonance imaging: 132±54%, P=.011). Mean left ventricular end-diastolic volume increased by 38±21% (P=.008). Inducible atrial tachyarrhythmias were seen in 4 of 6 animals at terminal surgery, and none at baseline. Within the 6 dogs that successfully completed the full experimental protocol, this model replicated the clinical phenotype of severe MR, which led to marked structural and electrophysiologic cardiac remodeling. This model allowed for precise measurements at repeated time points and will facilitate future studies to elucidate the mechanisms of atrial and ventricular remodeling secondary to MR and the pathophysiology of valvular atrial fibrillation.

Left atrial remodeling and right ventricular-pulmonary arterial coupling after MitraClip implantation

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Transcatheter edge-to-edge mitral valve repair (TEER) with the MitraClip system has emerged as a therapeutic alternative to surgical solutions in high risk patients with severe mitral regurgitation (MR). MR is characterized by left ventricular volume overload, which leads to left ventricular dilatation. Furthermore, MR is a common cause of pulmonary hypertension. Right ventricular (RV) intrinsic contractility and its response to afterload is referred to as RV-pulmonary arterial (PA) coupling. Effect of TEER in patients with MR on left atrial (LA) function and RV-PA coupling is less investigated. Purpose The aim of our study was to assess clinical characteristics of patients undergoing MitraClip implantation including LA function and RV-PA coupling. Methods Eighty-eight consecutive patients with chronic severe MR were enrolled in the single-center observational study (mean age 71.5±7.9 years, male 54.5%, ischemic cardiomyopathy 54.5%). Primary MR (PMR) was present in 22.7%, secondary MR (SMR) in 73.9 % and mixed (MxMR) etiology in 3.4%. Conventional and advanced echocardiography examination was performed using speckle tracking echocardiography before TEER and at 6 month post-TEER follow-up. Left atrial maximal (LAV max) and minimal (LAV min) volumes were measured indexed for body surface area. Furthermore, we analysed left atrial functional parameters, such as reservoir strain, conduit strain and contraction strain. Results The technical success of MitraClip implantation was 95,5%. Mortality rate at 6 month follow-up time was 10.8% (1/88 PMR, 7/88 SMR, 1/88 MxMR). Severe residual MR developed during follow-up in 4.2% and New York Heart Association class III-IV functional status was concluded in 6.8% at 6 month post-TEER. Significant decrease in left ventricular end-diastolic median diameter (mm) was observed at follow-up compared to pre-TEER: 57.5 (IQR: 51.25 – 63.75) vs 60.5 (IQR: 52.5 – 66.75), respectively, p = 0.01. Similarly, the median value of pulmonary artery systolic pressure (PASP) substantially decreased (mmHg) after TEER: 42 (IQR: 32 – 52) vs 49.5 (IQR: 41 – 57), respectively, p = 0.003. Tricuspid annulus systolic excursion/PASP median value, representing RV-PA coupling, improved remarkably: 0.45 (IQR: 0.31 – 0.69) vs 0.38 (IQR: 0.29 – 0.52), respectively, p = 0.02. Compared to pre-TEER, median LA volumes and strain parameters did not change significantly at 6 month post-TEER: reservoir strain (%) 12.88 (IQR: 8.18–18.78) vs 11.74 (IQR: 7.48–20.36), p = 0.41; LAV max (ml) 48.70 (IQR: 39.81–62.29) vs 48.17 (IQR: 42.08–58.7), p = 0.31; LAV min (ml) 34.33 (IQR: 24.5–46.32) vs 33.89 (IQR: 26.02–44.53), p = 0.69. Conclusions The function of the enlarged LA was severely reduced, which did not change after MitraClip implantation in our population. However, positive left ventricular remodeling and improvement in RV-PA coupling was observed 6 month after MitraClip procedure.

Association between early changes of left atrial volume and right ventricular function after transcatheter edge-to-edge repair for mitral regurgitation

Abstract Funding Acknowledgements Type of funding sources: None. Background Transcatheter edge-to-edge repair (TEER) has recently become a therapeutic option for patients with severe mitral regurgitation (MR) who are unsuitable for surgery, in order to improve clinical outcomes. MR is a determinant of structural and functional changes of all cardiac chambers. The left atrium (LA) and the right ventricle (RV) play an important role in the pathogenesis of symptoms in patients affected by severe MR. Recent data suggests that reverse changes of left ventricle (LV), as well as LA and RV, are associated to reduced morbidity and mortality. Purpose The aim of the study is to test the association between changes of LAV and RV function early after TEER. Methods This is a retrospective study that enrolled patients with chronic functional severe MR, at high surgical risk, who underwent TEER between February 2015 and July 2022. We evaluated the changes of LA and RV function between baseline and before discharge and their relation with symptoms. Results A total of 52 patients were included (mean age 65.2 ± 10.2 years; 69% males, mean left ventricular ejection fraction [LVEF] 28.8 ± 5.7%). No differences of baseline clinical and echocardiographic characteristics were detected between the groups of patients who had LA volume (LAV) reduction (n = 31) and those who did not (n = 21), including symptoms assessed with New York Heart Association (NYHA) classification. However, the former group had a significant higher LA size (LAVI 76.6 ± 18.2 vs. 61.2 ± 17.6 mL/m2, p = 0.004). In the overall population, we observed a significant increase in tricuspid annular plane systolic excursion (TAPSE), S’ wave at Tissue Doppler and ratio between TAPSE and pulmonary artery systolic pressure (TAPSE/PASP), as well as a decrease of PASP (respectively, p = 0.034, p = 0.003, p < 0.001 and p < 0.001). Compared to patients who did not have LAV reduction, those who had showed a significant increase of TAPSE/PASP (from 0.40 ± 0.17 to 0.52 ± 0.21 mm/mmHg, p = 0.002), S’ wave (from 8.7 ± 1.6 to 9.4 ± 1.7 cm/s, p = 0.005) and a decrease of PASP (from 50.3 ± 14.3 to 38.9 ± 11.5 mmHg, p < 0.001). The absolute change of LAV from baseline to discharge was associated with the change of PASP (b coefficient 0.55, 95% confidence interval 0.09, 1.02, p = 0.022) and TAPSE/PASP (b coefficient −4.06, 95% confidence interval −7.78, −0.33, p = 0.033), even after adjustment for covariates (respectively, b coefficient 0.61, 95% confidence interval 0.07, 1.14, p = 0.027 and b coefficient −4.82, 95% confidence interval −9.43, −0.23, p = 0.040). Finally, NYHA class significantly improved in the group of patients whose LAV reduced (p = 0.011). Conclusion In this retrospective study, an association between early changes of LA structure and RV functional parameters has been described. After TEER, RV function improved, especially in patients who had LAV reduction. In the latter, we observed an improvement of NYHA functional class.

Successful management of the leaflet perforation after the transcatheter edge-to-edge repair procedure using transcatheter occlusion.

A 57-year-old female was diagnosed with chronic heart failure and severe functional mitral regurgitation (FMR) despite guideline-directed medical therapy. An echocardiogram revealed severe mitral regurgitation (MR) (4+) vena contracta width 8 mm with ejection fraction (21%), and no calcification on the annulus and leaflets was noted. Mitral transcatheter edge-to-edge repair (TEER) was attempted for this patient. Transcatheter edge-to-edge repair was done under general anaesthesia with transoesophageal echocardiography (TEE) guidance using a novel designed SQ-Krin TEER system (Shenqi Medical). After transseptal puncture was achieved, a 24F guiding sheath was placed in the left atrium (LA). Then, one LW-size clip (6 mm width with 12 mm arm length) was placed in the A2/P2 region (Panel A). Mitral regurgitation severity was reduced to none (Panel A). However, 20 min after release, TEE revealed a large regurgitant gap (7–8 mm) between the anterior mitral leaflet (AML) and the clip arm with torrential MR (Panels B–D), and clip-induced leaflet perforation was confirmed. Considering the high risk of open-heart surgery, transcatheter occlusion was attempted. A 14F steerable catheter was placed in the LA through the previous puncture site, and the guide wire was placed into the left ventricle (LV) through the tear hole, and then a 14 mm Amplatzer Vascular Plug II (St Jude Medical, Abbott) was implanted through the delivery system to occlude the hole (Panels E and F). Mitral regurgitation was reduced to a mild degree after the procedure (Panels G and H). Post-operative recovery was uneventful and no sign of haemolysis. In the 1-year follow-up, the patient presented good condition with mild MR, and both the clip and the plug were in a stable position (Panel I). Leaflet perforation after the TEER procedure is a rare complication with a poor prognosis, especially for an FMR patient. Other than open-heart surgery, transcatheter occlusion may provide a reliable salvage management option.

Beating Heart Mitral Valve Replacement in Secondary Mitral Regurgitation with Poor Left Ventricular Function Literature Review

The poor early and mid-term prognosis of secondary mitral regurgitation (MR) with impaired left ventricular function after restrictive annuloplasty with cardioplegic arrest has opened the way for transcatheter repair. The indication for surgery is only incontestable when concomitant coronary revascularization is required. Beating heart mitral valve surgery without aortic clamping has been promoted as an alternative to the technique of cardioplegic arrest. Its potential advantage is the elimination of ischemic reperfusion injury and its impact on myocardial function. On the other hand a randomized study confirmed that for ischemic MR, mitral valve replacement (MVR) reduces the rate of MR recurrence and re-hospitalization compared to restrictive annuloplasty. We performed a review of the literature to assess the strength of the evidence supporting the efficacy of beating heart MVR without aortic clamping compared to the conventional technique for secondary MR with poor left ventricular function. In a randomized study of patients with chronic severe mitral regurgitation and left ventricular dysfunction, beating heart MVR was associated with better LV function, reduction of cardiac enzymes early postoperatively, reduced duration of mechanical ventilation, and ICU than MVR using warm blood cardioplegic arrest. This together with the absence of related perioperative mortality and the major complications suggests that this technique is safe and beneficial to LV function. This finding has been verified by a multitude of other observational studies which have shown that the benefit of this technique is more palpable in cases of redo mitral surgery or in cases of MR with poor left ventricular function.

Percutaneous Transcatheter Edge-to-Edge Mitral Valve Repair With MitraClip System in the Era of G4

The use of transcatheter edge-to-edge mitral valve repair (TEER) in symptomatic patients with severe mitral regurgitation (MR) has dramatically increased over the last few years. Current guidelines consider TEER as a reasonable option in symptomatic patients with primary or chronic secondary severe MR with high or prohibitive surgical risk and favorable anatomy. However, several anatomical and morphological mitral features have restricted the use of this mini-invasive technique in its early experience. The latest fourth generation (G4) of the MitraClip system has been recently introduced and includes the possibility of independent leaflet grasping and 4 different sizes. This technical update offers the possibility of selecting and combining multiple devices for complex mitral valve anatomies and challenging procedures, which helps expand the applications of TEER. The present review describes the potential advantages and the help of the MitraClip G4 devices to overcome various anatomic and morphologic issues in challenging cases with complex primary and secondary MR procedures.

Transoesophageal echocardiography findings in young patients with cryptogenic ischemic stroke

Abstract Background and purpose The cause of ischemic stroke (IS) remains often unclear in young patients. Relevant structural heart abnormities with known embolic potential may represent cause of IS also in young population. The use of transoesophageal echocardiography (TEE) allows reliable detection of most relevant structural pathologies. The aim was to assess frequency and spectrum of relevant cardiac abnormities in young IS patients. Subjects and methods The study set consisted of young acute IS patients <50 years enrolled in the prospective HISTORY (Heart and Ischemic STrOke Relationship studY) study, registered on ClinicalTrials.gov NCT01541163). In all patients, the brain ischemia was confirmed on CT or MRI. Admission ECG, serum specific cardiac markers, TEE, 24-hour and 3-week ECG-Holter were performed in all patients. Results Out of 1284 patients enrolled in the HISTORY study, 135 (73 males, mean age 40.2±8.1 years) were <40 years. In total, the relevant TEE abnormities were present in 47 (35%) of these patients. Patent foramen ovale (PFO) with evident left to right shunt was detected in 38 (28%) patients, with significant right to left shunt in 25 (19%) patients, and other atrial septal defect with clinically significant bidirectional flow in 4 (3%) patients. Significant valvular heart disease was present in 2 (1%) patients (1 bicuspid aortic valve with moderate aortic regurgitation, 1 chronic severe mitral regurgitation), and 4 (3%) patients severe left ventricular systolic dysfunction (left ventricular ejection fraction ≤35%) due to idiopathic dilated cardiomyopathy. Left atrial myxoma was detected in one patient. Conclusion The relevant structural abnormities with embolic potential were detected using TEE in 35% of young IS patients. Routine use of TEE to elucidate the causes of stroke, has a role especially in young patients who present with cryptogenic stroke and no cardiovascular risk factors, as well as in the setting of a PFO associated with a deep venous thrombosis. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): IGA LF UP, MH CZ - DRO

Impact of atrial fibrillation on outcome of percutaneous mitral valve repair (PMVR) procedure

Abstract Background Limited evidence exists regarding the impact of atrial fibrillation (AF) on outcomes after percutaneous mitral valve repair (PMVR). The aim of the present study was to compare 1-year clinical outcomes following PMVR in patients with and without AF. Methods 426 patients with PMVR for severe MR were included in the COburg MItraclip (COMI) registry between 2016 and 2021. Patients were divided into an AF group (group A, n=284) and a non-AF group (group B, n=142). Clinical profiles, PMVR procedure characteristics and the clinical follow-up were compared between the two groups. Results Patients with AF were older (79.3±6.3 [AF] vs. 77.8±8 years [non-AF], p=0.03), had higher N-terminal B-type natriuretic peptide levels (NT-pro BNP: 5675±5544.2 vs 8516±11184.5, p=0.004), more often a coronary artery disease (62% vs 38%, p=0.03) and had a lower stroke risk (CHA2DS2-VASc score: 4.6±1.2 vs 4.9±1.3, p=0.01). There were no significant differences between groups with regard to the gender, logistic Euroscore or prevalence of chronic heart failure, hypertension, diabetes mellitus or severe mitral regurgitation. Acute procedural success (post-procedural 2. MR, 95.1% vs. 94.4%; p=0.76) and procedure-related major complications were similar. There were no significant differences in 1-year MACCE (death, MI, stroke, bleeding), health-related quality of life or clinical improvement. Conclusion In patients with mitral regurgitation who underwent PMVR, AF is common and appears not to have a relevant negative impact on the clinical outcome at 1 year compared to patients with sinus rhythm. Funding Acknowledgement Type of funding sources: None.

444 Favorable Cardiac Remodeling After Tendyne Transcatheter Mitral Valve Replacement: A Cardiac Computed Tomographic Evaluation

Introduction: Transcatheter mitral valve replacement (TMVR) with the transapically delivered Tendyne bioprosthesis is a less invasive therapeutic alternative for patients with severe mitral regurgitation (MR) and high or prohibitive surgical risk. Initial studies have shown favorable left ventricular (LV) remodeling after Tendyne TMVR. Though it is known that chronic severe MR leads to left atrial (LA) remodeling, pulmonary hypertension and right ventricular (RV) dysfunction, limited data exists on changes in RV function and morphology after Tendyne TMVR.

Why are left ventricular linear internal diameters still so important for clinical decision-making to undergo surgery in asymptomatic patients with chronic severe aortic or primary mitral regurgitation?

Division of Cardiology, A.R.C., Policlinico San Giorgio, Via Gemelli 10, Pordenone, Italy Correspondence to Gian Luigi Nicolosi, MD, FESC, FACC, Division of Cardiology, A.R.C., Policlinico San Giorgio, Via Gemelli 10, Pordenone, Italy e-mail: [email protected] Received 24 September, 2021 Revised 21 November, 2021 Accepted 26 December, 2021

Prognostic Impact of Left Atrial Strain After Mitral Valve Repair Surgery in Patients With Severe Mitral Regurgitation.

The prognostic value of left atrial (LA) function in terms of long-term clinical outcomes after mitral regurgitation (MR) surgery remains unclear. Therefore, we investigated the impact of preoperative LA global longitudinal strain (LAGLS) on the long-term postoperative clinical outcomes in chronic severe MR patients who underwent mitral valve (MV) repair surgery. From January 2012 to December 2017, we analyzed 338 patients (mean age, 51.9±12.5 years; 218 males [64.5%]) treated with MV repair surgery for severe MR. The primary outcome was cardiovascular events, defined as the composite of all-cause death, newly developed atrial fibrillation (AF), and re-hospitalization for cardiovascular causes. During a median follow-up of 45 months (interquartile range, 26-65), 30 (8.9%) cardiovascular events, 5 (1.5%) all-cause death, 8 (2.4%) newly developed AF, and 26 (7.7%) re-hospitalizations occurred. On multivariable analysis, baseline LAGLS was an independent predictor of cardiovascular events (adjusted hazard ratio [HR], 0.91; 95% confidential interval [CI], 0.85-0.97; p=0.004) and re-hospitalization (adjusted HR, 0.93; 95% CI, 0.86-1.00; p=0.037). According to the optimal cutoff value of LAGLS, patients with low LAGLS (<23.6%) had a significantly higher risk of cardiovascular events (adjusted HR, 2.70; 95% CI, 1.04-7.00; p=0.041) than those with high LAGLS (≥23.6%). In a subgroup analysis, patients with high LAGLS had better clinical outcomes regardless of whether the patient had a LA volume index <60 mL/m². In patients with chronic severe MR who received successful MV repair surgery, preoperative LAGLS is an independent predictor of long-term postoperative outcomes.

Abstract 13766: The Use of Echocardiography to Assess Regional Strain Abnormalities in Patients With Chronic Mitral Regurgitation

Background: Patients with primary mitral regurgitation (MR) secondary to mitral valve prolapse (MVP) have regional LV fibrosis in myocardial segments adjacent to the posterior papillary muscle detected by MRI not seen in other patients with MR.. Echocardiographically determined strain is associated with LV fibrosis. Patients with chronic MR are generally followed by echocardiography, however no study has utilized echocardiography to examine regional strain variations in these patients. The object of this study was to examine regional myocardial strain in patients with chronic MR with and without MVP. Methods: Patients undergoing routine transthoracic echocardiography for the assessment of chronic severe MR were included. Patients with secondary MR, ejection fraction &lt; 50%, other significant primary valve disease, history of cardiomyopathy, ischemic heart disease, previous cardiac surgery or pacemaker implantation were excluded. The primary MR subjects were be divided into MVP or non-MVP cohorts. MVP was defined as displacement of 1 or both mitral leaflets by at least 2 mm below the mitral annulus in parasternal long-axis view. Global and segmental strain analysis in 17 left ventricular segments was performed offline and results of the MVP and non-MVP groups compared. Results: 28 patients (mean age 63 ±14 yrs ; 23F/5M) of whom 11 had MVP and 17 had non-MVP disease were included in the study. Patients in the MVP group were significantly younger (59.2 ± 16 vs 69 ± 11 p = 0.05) then in the non-MVP group. Standard echocardiographic measurements including ejection fraction were similar except for estimated PA pressure which was lower in the MVP group, (31.3 ± 6.9 vs 42.6 ± 11.9 mmHg p-value = 0.008).Global strain was normal and similar in the two groups (-21.3 ± 4.4% vs -19.9 ± 2.9%; p = 0.30). (Patients with MVP had significantly reduced segmental strain in the inferior basal segment ( -11.2 ± 9.7 in the MVP group, -18 ± 2.6 in the non-MVP group, p-value 0.037). No other segments showed significant differences between the MVP and non-MVP groups Conclusions: Our findings suggest that patients with chronic MR and MVP have significantly reduced echocardiographic strain in the inferior base when compared to patients with MR secondary to other causes.

Prognostic utility of global longitudinal strain (GLS) in patients with severe primary mitral regurgitation undergoing mitral valve surgery: a systematic review and meta-analysis

Abstract Background Mitral valve (MV) surgery is recommended for the treatment of chronic severe mitral regurgitation (MR). However, the optimal timing of surgery in patients with asymptomatic severe primary MR remains elusive. Global longitudinal strain (GLS) may provide additional prognostic value in predicting postoperative outcomes in patients with chronic severe primary mitral regurgitation (MR) undergoing MV surgery. Purpose We aimed to determine the prognostic value of GLS in predicting postoperative mortality and LV dysfunction among patients with chronic severe primary MR. Methods Systematic search of Pubmed, Cochrane library, Clinicaltrials.gov, and Herdin.ph from inception to July 2019, using the terms “mitral insufficiency”, “mitral regurgitation”, “mitral valve surgery”, and “global longitudinal strain” was done without language restriction. We included and extracted data from cohort studies of patients with chronic severe primary MR who underwent MV surgery and which GLS, mortality and ejection fraction. We used the Newcastle Ottawa Scale to assess the quality of included studies. Review Manager 5.3 was used to perform analysis. Forest plots with summary hazard ratios (HR) and odds ratios (OR) with 95% confidence intervals (CI), I2 test for heterogeneity, and funnel plots were reported. Results Our search yielded 12 cohort studies with 2,843 patients; 7 prospective and 5 retrospective studies were included in the qualitative synthesis with 11 good quality studies. Cut-off GLS values ranged from −21.7% to −18.1%. In terms of postoperative all-cause mortality, the summary HR for worse versus better preoperative GLS is 1.22 (95% CI 1.04–1.44, p value &amp;lt;0.ehab724.16031, I2 95%). In terms of postoperative LV dysfunction, the summary OR is 1.74 (95% CI 1.14–2.66, p value 0.01, I2 94%) with significant heterogeneity. Conclusion Left ventricular GLS has prognostic value in terms of predicting postoperative mortality and LV dysfunction. However, significant heterogeneity exists between studies. Larger studies with well-defined inclusion criteria need to be performed and standardized GLS cut-offs need to be determined. Funding Acknowledgement Type of funding sources: None. GLS in Predicting All-Cause MortalityGLS in Predicting Post-op Dysfunction

Stroke volume but not ejection fraction predicts prognosis in acute heart failure

Abstract Background Heart failure (HF) patients are categorized according to left ventricular ejection fraction (LVEF), being such index both easily feasible and prognostic. However, the risk stratification of patients hospitalized for acute decompensated heart failure (ADHF) according to the absolute value of LVEF at presentation is unexplored and its prognostic significance has not been tested against stroke volume indexed (SVi). Purpose To examine the prognostic impact of SVi versus LVEF in patients hospitalized for ADHF (wet and warm phenotype). Methods Eighty-five ADHF patients (mean age 75.6±10.4 years, 59% males) were prospectively enrolled within 24–48 hours from admission to the emergency department. In the acute phase all patients underwent a complete transthoracic echocardiography (TTE) and lung ultrasonography (LUS) associated with blood sample and a thorough clinical examination. Patients were then stratified into two groups according to the presence or the absence of a preserved SVi at admission (SVi ≥35 ml/m2). Results During a median follow-up (FU) time of 12 months (IQR months 8–15 months) we observed a CV event rate of 28.2%. During the FU period 14 patients (16.5%) were re-hospitalized for ADHF, 7 patients died for CV reason (8.2%), 1 patient underwent mitral valve replacement for severe chronic mitral regurgitation, 1 patient was re-hospitalized for cardiac resynchronization therapy and 1 subject was re-hospitalized for acute coronary syndrome. Interestingly, patients that had a preserved TTE-derived SVi at admission (SVi ≥35 ml/m2) exhibited a significantly higher survival, when compared to subjects that showed an impairment of cardiac output at rest (SVi &amp;lt;35 ml/m2) (log-rank: HR 5.5 CI 95% 2.1–14.3; p=0.04) (Figure 1). On the other hand, LVEF was not independently associated with the endpoint and HFrEF, HFmrEF and HFpEF patients showed a comparable median survival (Figure 2). Conclusions Although the categorization of LVEF in CHF patients bears a pivotal classificatory and prognostic role, its assessment in ADHF, may lack of prognostic value especially when compared to SVi which represents a better parameter to define high-risk subjects who benefit from closer monitoring. Funding Acknowledgement Type of funding sources: None.

Reverse Myocardial Remodeling Following Valve Repair in Patients With Chronic Severe Primary Degenerative Mitral Regurgitation

ObjectivesThe aims of this study were to quantify preoperative myocardial fibrosis using late gadolinium enhancement (LGE), extracellular volume fraction (ECV%), and indexed extracellular volume (iECV) on cardiac magnetic resonance; determine whether this varies following surgery; and examine the impact on postoperative outcomes. BackgroundMyocardial fibrosis complicates chronic severe primary mitral regurgitation and is associated with left ventricular dilatation and dysfunction. It is not known if this nonischemic fibrosis is reversible following surgery or if it affects ventricular remodeling and patient outcomes. MethodsA multicenter prospective study was conducted among 104 subjects with primary mitral regurgitation undergoing mitral valve repair. Cardiac magnetic resonance and cardiopulmonary exercise stress testing were performed preoperatively and ≥6 months after surgery. Symptoms were assessed using the Minnesota Living With Heart Failure Questionnaire. ResultsMitral valve repair was performed for Class 2a indications in 65 patients and Class 1 indications in 39 patients. Ninety-three patients were followed up at 8.8 months (IQR: 7.4 months-10.6 months). Following surgery, there were significant reductions in both ECV% (from 27.4% to 26.6%; P = 0.027) and iECV (from 17.9 to 15.4 mL/m2; P < 0.001), but the incidence of LGE was unchanged. Neither preoperative ECV% nor LGE affected postoperative function, but iECV predicted left ventricular end-systolic volume index (β = 1.04; 95% CI: 0.49 to 1.58; P < 0.001) and left ventricular ejection fraction (β = −0.61; 95% CI: −1.05 to −0.18; P = 0.006). Patients with above-median iECV of ≥17.6 mL/m2 had significantly larger postoperative values of left ventricular end-systolic volume index (30.5 ± 12.7 mL/m2 vs 23.9 ± 8.0 mL/m2; P = 0.003), an association that remained significant in subcohort analyses of patients in New York Heart Association functional class I. ConclusionsMitral valve surgery results in reductions in ECV% and iECV, which are surrogates of diffuse myocardial fibrosis, and preoperative iECV predicts the degree of postoperative remodeling irrespective of symptoms. (The Role of Myocardial Fibrosis in Degenerative Mitral Regurgitation; NCT02355418)

Mitral valve repair in chronic severe mitral regurgitation: short-term results and analysis of mortality predictors.

Mitral valve repair is the accepted treatment for mitral regurgitation (MR) but lack of resources and socioeconomic concerns delay surgical referral and intervention in developing countries. We evaluated immediate and short-term results of mitral valve repair for non-ischemic MR at our centre and aimed to identify the predictors of in-hospital and follow-up mortality. The study was conducted at a tertiary-level hospital in South India. All patients >18years with severe non-ischemic MR who underwent mitral valve repair over a period of 6years were included. Perioperative data was collected from hospital records and follow-up data was obtained by prospective methods. There were 244 patients (170 males). Most of the patients were in the age group 31-60years (76.6%). Aetiology of MR was degenerative (n= 159; 65.2%), rheumatic (n= 34; 13.9%), structural (n= 42; 17.2%), or miscellaneous (n= 9; 3.7%). All patients underwent ring annuloplasty with various valve repair techniques. One hundred patients (44.7%) underwent additional cardiac procedures. At discharge, MR was moderate in 4 patients; the rest had no or mild MR. The mean hospital stay of survivors was 7.1days (SD 2.52, range 5-25days). There were 9 in-hospital deaths (3.68%) and 10 deaths during follow-up (4.2%). The mean follow-up period was 1.39years, complete for 87.6%. Pre-operativeleft ventricle ejection fraction(LVEF) <60% (p= 0.04) was found to be significantly associated with immediate mortality. Logistic regression analysis detected age (p= 0.019), female sex (p= 0.015), and left ventricular (LV) dysfunction at discharge (p= 0.025) to be significantly associated with follow-up mortality. Pre-operative LV dysfunction was identified as a significant risk factor for in-hospital mortality. Female sex, age greater than 45years, and LV dysfunction at discharge were found to be significantly associated with follow-up mortality. Hence, it is important to perform mitral valve repair in severe regurgitation patients before significant LV dysfunction sets in for a better outcome.

Ventricular stroke work indices to predict mortality after successful percutaneous edge-to-edge-repair for severe mitral valve regurgitation

Abstract Background Several studies identified predictors of worse clinical outcome despite successful transcatheter mitral valve repair (TMVR). The capability of invasively measured left and right ventricular stroke work indices (LVSWi, RVSWi) to predict mortality after successful TMVR is unclear. Purpose To assess the impact of LVSWi and RVSWi on mortality in patients with chronic heart failure (CHF) and severe mitral regurgitation (MR) undergoing TMVR. Methods Consecutive patients (pts.) with CHF (LV ejection fraction ≤50% from any cause) and severe MR who underwent successful TMVR (MR≤2+ at discharge) were included and followed prospectively. Primary endpoint was defined as all-cause mortality during a median follow-up period of 16±9 months. LVSWi was calculated as: Stroke volume index × (mean arterial pressure − postcapillary wedge pressure) × 0.0136 = g/m–1/m2. RVSWi was calculated as: Stroke volume index × (mean pulmonary artery pressure − right atrial pressure) × 0.0136 = g/m–1/m2. Receiver operator characteristic (ROC) analysis was used to determine discriminative capacity of LVSWi and RVSWi. Kaplan-Meier estimate was used for survival analysis. A multivariable Cox proportional-hazards regression analysis was performed to identify independent risk factors for all-cause mortality. Results 140 patients (median age 74±9.9 years, 67.9% male) at high operative risk (LogEuro-SCORE 34.6±14.1%) were enrolled. Mean LVSWi and RVSWi were 22.3±10.7 g/m–1/m2 and 8.9±4.1 g/m–1/m2, respectively. 46 pts. died (33.1%). Pts. who died presented higher LogEuro-SCORE (27.8±16.6% vs. 20.1±13.7%; p=0.001), higher levels of NT-proBNP (12121±10602 ng/l vs. 6745±10820 ng/l; p=0.001), higher levels of creatinine (1.8±0.8 mg/dl vs. 1.4±0.8 mg/dl; p&amp;lt;0.001), lower LVSWi (18.9±8.1 g/m–1/m2 vs. 24.0±11.4 g/m–1/m2; p=0.01) and RVSWi (7.8±3.2 g/m–1/m2 vs. 9.4±4.4 g/m–1/m2; p=0.037), respectively. ROC curve analysis revealed that optimal sensitivity and specificity were achieved using a threshold of 24.8 g/m–1/m2 for LVSWi (sensitivity 80.4%, specificity 40.2%, area under the curve (AUC) 0.71 [0.60–0.81]; p=0.001) and 8.3 g/m–1/m2 for RVSWi (sensitivity 67.4%, specificity 57.0%, AUC 0.67 [0.56–0.78]; p=0.006), respectively. At long-term follow-up, a significantly lower survival rate was observed in pts. with LVSWi ≤24.8 g/m–1/m2 (20.0% vs. 39.4%; log-rank p=0.038) and in pts. with RVSWi ≤8.3 g/m–1/m2 (22.1% vs. 43.7%; log-rank p=0.026), respectively. In Cox regression analysis a LVSWi of ≤24.8 g/m–1/m2 and a RVSWi of ≤8.3 g/m–1/m2 were independent predictors for all-cause mortality (hazard ratio (HR) 2.83; 95% confidence interval (CI) 1.1 to 7.6; p=0.04; HR 2.52; 95% CI 1.04 to 6.1; p=0.041). Conclusions LVSWi and RVSWi are associated with mortality among pts. with CHF undergoing successful TMVR for severe MR. A LVSWi cut-off value of &amp;gt;24g/m–1/m2 and a RVSWi cut-off value of &amp;lt;8g/m–1/m2 seem to predict mortality independent of other clinical and echocardiographic factors. Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): Hospital Links der Weser, Bremen, Germany

Workup and Management of Primary Mitral Regurgitation

We summarize the current concepts and methods for diagnosis and management of primary mitral regurgitation due to leaflet prolapse or flail. Current practice guidelines emphasize accurate diagnosis of chronic primary severe MR, differentiating between symptomatic and asymptomatic states, and assessing both hemodynamic and functional impact, thereby ensuring timely surgical or transcatheter intervention for those who stand to benefit from it. No effective medical therapy for chronic severe mitral regurgitation has been found to date. Surgical repair has significant advantages over valve replacement in primary MR patients with favorable anatomy. Transcatheter interventions may be an option in selected patients who are at prohibitive surgical risk. Successful management of chronic severe primary MR relies on accurate diagnosis and careful timing of intervention. Care should be individualized and rely on input from a heart valve team that includes expert imagers, surgeons, and interventional cardiologists.

Prognostic Impact of the Pulmonary Artery Pulsatility Index in Patients with Chronic Heart Failure and Severe Mitral Regurgitation Undergoing Percutaneous Edge-to-Edge Repair

Background: Pulmonary artery (PA) pulsatility index (PAPi), calculated as (PA systolic pressure – PA diastolic pressure)/right atrial pressure, emerged as a novel predictor of right ventricular failure in patients with acute inferior myocardial infarction, advanced heart failure, and severe pulmonary hypertension. However, the prognostic utility of PAPi in transcatheter mitral valve repair (TMVR) using the MitraClip® system has never been tested. Objective: To assess the prognostic impact of PAPi in patients with severe functional mitral regurgitation (MR) and chronic heart failure (CHF) undergoing TMVR. Methods: Consecutive patients with severe functional MR (grade 3+ or 4+) and CHF who underwent successful TMVR (MR ≤2+ at discharge) were enrolled and divided into 3 groups according to PAPi (A: low PAPi ≤2.2; B: intermediate PAPi 2.21–3.99; C: high PAPi ≥4.0). The primary endpoint was a composite of all-cause mortality and rehospitalization due to CHF during a mean follow-up period of 16 ± 4 months. The impact of PAPi on prognosis was assessed by a receiver-operating characteristic (ROC) analysis and a multivariable Cox proportional hazard regression analysis investigating independent predictors for outcome. Results: 78 patients (A: n = 27, B: n = 28, C: n = 23) at high operative risk (logistic EuroSCORE [European System for Cardiac Operative Risk Evaluation] 18.8 vs. 21.5 vs. 20.6%; nonsignificant) were enrolled. Mean PAPi was 1.6 ± 0.41 vs. 2.9 ± 0.53 vs. 6.8 ± 3.5; p < 0.001). Patients with low PAPi showed significantly higher rates of early rehospitalization for heart failure at the 30-day follow-up (14.9 vs. 7.1 vs. 4.3%; p = 0.04). In the long term, a significantly lower event-free survival for the combined primary endpoint was observed in the low PAPi group (44.4 vs. 25.0 vs. 20.3%; log-rank p = 0.016). ROC curve analysis revealed that optimal sensitivity and specificity were achieved using a PAPi cutoff of 2.46 (sensitivity 83%, specificity 78.3%, area under the curve 0.82 [0.64–0.99]; p = 0.01). In Cox regression analysis, PAPi ≤2.46 was an independent predictor for the combined primary endpoint (hazard ratio 2.85; 95% confidence interval 1.15–7.04; p = 0.023). Conclusions: PAPi is strongly associated with clinical outcome among patients with CHF and functional MR undergoing TMVR. A PAPi value ≤2.46 predicts a worse prognosis independent of other important clinical, echocardiographic, and hemodynamic factors. Therefore, PAPi may serve as a new parameter to improve patient selection for TMVR.