Concomitant Mitral Regurgitation Research Articles

Concomitant Mitral Regurgitation in Severe Aortic Stenosis - Insights From the CURRENT AS Registry-2.

Data on concomitant mitral regurgitation (MR) in patients with severe aortic stenosis (AS) are scarce.Methods and Results: We investigated the risk of concomitant MR in patients with severe AS in the CURRENT AS Registry-2 according to initial treatment strategy (transcatheter aortic valve implantation [TAVI], surgical aortic valve replacement [SAVR], or conservative). Among 3,365 patients with severe AS, 384 (11.4%) had moderate/severe MR (TAVI: n=126/1,148; SAVR: n=68/591; conservative: n=190/1,626). The cumulative 3-year incidence for death or heart failure (HF) hospitalization was significantly higher in the moderate/severe than no/mild MR group in the entire population (54.6% vs. 34.3%, respectively; P<0.001) and for each treatment strategy (TAVI: 45.0% vs. 31.8% [P=0.006]; SAVR: 31.9% vs. 18.7% [P<0.001]; conservative: 67.8% vs. 41.6% [P<0.001]). The higher adjusted risk of moderate/severe MR relative to no/mild MR for death or HF hospitalization was not significant in the entire population (hazard ratio [HR] 1.15; 95% confidence interval [CI] 0.95-1.39; P=0.15); however, the risk was significant in the SAVR (HR 1.92; 95% CI 1.04-3.56; P=0.04) and conservative (HR 1.30; 95% CI 1.02-1.67; P=0.04) groups, but not in the TAVI group (HR 1.03; 95% CI 0.70-1.52; P=0.86), despite no significant interaction (Pinteraction=0.37). Moderate/severe MR was associated with a higher risk for death or HF hospitalization in the initial SAVR and conservative strategies, while the association was less pronounced in the initial TAVI strategy.

The evaluation of simultaneous combined surgery of the heart and thyroid - own experience

Background: Patients referred for cardiac surgery usually also have other comorbidities. These include thyroid disease, which is relatively common in patients with heart problems. Objective: The aim of the study was to evaluate the feasibility of combined cardiac surgery and thyroidectomy. Material and methods: Six patients (age range: 54-74 years) qualified for elective, simultaneous surgeries on the heart and the thyroid were included in the study. In preparation for thyroidectomy, three patients were diagnosed with diseases requiring cardiac surgery. Two patients, initially referred for coronary artery bypass surgery in one case, and surgery for recurrent fluid in the pericardial sac with concomitant mitral and tricuspid valve regurgitation and atrial fibrillation in the other, were diagnosed in large hyperactive goitre. The last patient with a history of oncology (lung tumour), admitted to the Department of Cardiology due to a heart attack, had a CT scan of the chest, which revealed retrosternal goitre narrowing the lumen of the trachea to 9 mm. All patients underwent combined heart and thyroid operation and were discharged home 8-27 days after surgery. Conclusions: Although preoperative qualification requires a very cautious and individual approach, simultaneous surgeries in patients requiring thyroid and heart interventions are expedient and should be promoted.

Kiosk 6R-TB-06 - Total Regurgitant FBaction: A Novel CMR Parameter to Predict Outcomes in Patients with Concomitant Aortic and Mitral Regurgitation

Kiosk 6R-TB-06 - Total Regurgitant FBaction: A Novel CMR Parameter to Predict Outcomes in Patients with Concomitant Aortic and Mitral Regurgitation

The importance of concomitant mitral regurgitation for estimates of mitral valve area by pressure half time in patients with chronic rheumatic heart disease

AimsAim was to study how concomitant mitral regurgitation (MR) assessed by qualitative and quantitative methods influence mitral valve area (MVA) calculations by the pressure half time method (MVAPHT) compared to reference MVA (planimetry) in patients with rheumatic heart disease. Methods and resultsIn 72 patients with chronic rheumatic heart disease, MVAPHT was calculated as 220 divided by the pressure half time of the mitral early inflow Doppler spectrum. Direct measurement by planimetry was used as reference MVA and was mean (SD) 0.99 (0.69–1.99) cm2. Concomitant MR was present in 82%. MR severity was assessed qualitatively in all, semi-quantitatively by measuring the vena contracta width in 58 (81%), and quantitatively by calculation of the regurgitant volume in 28 (39%).MVA was significantly underestimated by MVAPHT, with increasing MR. In regression analyses MVAPHT underestimated MVA by 0.19 cm2 per higher grade of MR severity in qualitative assessment, and by 0.12–0.13 cm2 per mm larger vena contracta width and 10 ml larger regurgitant volume, respectively. The presented associations were more evident when i) MR severity was quantified compared to qualitative assessment and ii) reference measurements were made by three-dimensional transoesophageal recordings compared to transthoracic recordings. ConclusionMVAPHT underestimated mitral valve area compared to planimetry in patients with MS and concomitant MR. This study highlights the importance of taking the MR severity into account when evaluating MVA based on the PHT method. Direct measurements should be included in clinical decision making.

Morbidity and mortality of acute heart failure patients stratified by mitral regurgitation in the Arabian Gulf: Observations from the Gulf acute heart failure registry (Gulf CARE)

This study aimed to evaluate the clinical outcomes of patients with acute heart failure (AHF) stratified by mitral regurgitation (MR) in the Arabian Gulf. Patients from the Gulf CARE registry were identified from 47 hospitals in seven Arabian Gulf countries (Yemen, Oman, Kuwait, Qatar, Bahrain, the United Arab Emirates, and Saudi Arabia) from February to November 2012. The cohort was stratified into two groups based on the presence of MR. Univariable and multivariable statistical analyses were performed. The population cohort included 5005 consecutive patients presenting with AHF, of whom 1491 (29.8 %) had concomitant MR. The mean age of patients with AHF and concomitant MR was 59.2 ± 14.9 years, and 63.1 % (n = 2886) were male. A total of 58.6 % (n = 2683) had heart failure (HF) with reduced ejection fraction (EF) (HFrEF), 21.0 % (n = 961) had HF with mildly reduced EF (HFmrEF), and 20.4 % (n = 932) had HF with preserved EF (HFpEF). Patients with MR had a lower haemoglobin (Hb) level (12.4 vs. 12.7 g/dL; p < 0.001), and a higher prevalence of left atrial enlargement (80.2 % vs. 55.1 %; p < 0.001), cardiogenic shock (9.7 % vs. 7.3 %; p = 0.006) and atrial fibrillation (7.6 % vs. 5.6 %; p = 0.006), and HFrEF (71.0 % vs. 52.6 %; P < 0.001). Multivariable analysis demonstrated that MR was independently associated with increased all-cause mortality at 1-year and 3-month HF rehospitalization [1-year all-cause mortality, adjusted odds ratio (aOR), 1.40; 95 % confidence interval (Cl): 1.13–1.74; p = 0.002; 3-month HF rehospitalization, aOR, 1.26; 95 % Cl: 1.06–1.49; p = 0.009]. In an Arabian Gulf cohort with AHF, concomitant MR was associated with an increased risk of 1-year mortality and 3-months HF rehospitalization.

Incidence and management of multiple native valvular heart disease in patients undergoing TAVR: Impact of staged valvular interventions on outcomes

Abstract Background Multiple valvular heart disease (VHD) is a prevalent condition among patients undergoing TAVR. Previous studies have reported increased one-year mortality in TAVR patients with concomitant mitral (MR) and tricuspid regurgitation (TR). However, the long-term impact of multiple VHD on TAVR outcomes is not known. Moreover, most studies investigating additional VHD either focus on the evaluation of MR or TR, without a head-to-head comparison of VHD. Finally, it is not known whether an additional staged transcatheter valvular intervention for concomitant VHD may improve outcomes. Purpose Our Aim was to evaluate the incidence of multiple VHD in a real-world TAVR cohort, to assess and compare the impact of concomitant severe MR and TR on outcomes at one and five years after TAVR, and to examine the rate and impact of a staged edge-to-edge intervention for concomitant VHD. Methods The study cohort included 2058 patients with severe aortic stenosis undergoing TAVR between February 2014 and May 2022. All patients have been screened for additional staged valvular intervention. Clinical endpoints included one- and five-year mortality following TAVR. Results A concomitant severe VHD was observed in 168 (8.2%) patients undergoing TAVR, of whom 68 (3.3%) patients had a severe TR and 100 (4.9%) had a severe MR. A moderate TR was seen 240 (11.7%) patients, whereas a moderate MR was detectable in 477 (23.2%) patients. An additional staged edge-to-edge valvular intervention was performed in 20 (1.0%) and 37 (1.8%) patients due to a severe TR and MR, respectively. The overall one- and five-year all-cause mortality rates were 11.2% and 27.3% following TAVR. The one-year all-cause mortality was significantly higher in patients with a concomitant severe VHD (17.9%) as compared to patients with mild/no VHD (9.0%, p&amp;lt;0.01). Of interest, the highest one-year mortality was observed in patients with a concomitant severe TR (20.6%), followed by patients with a severe MR (16.0%) and mild/no VHD (9.0%, p&amp;lt;0.01), Figure 1. This difference was sustained for up to five years after TAVR (Figure 2 A, p&amp;lt;0.01). An additional staged edge-to-edge valvular intervention was associated with decreased one-year mortality rate as compared to patients with a persistent severe VHD (5.2% vs 18.9%, p=0.02). This association was sustainable over the follow-up period of five years (Figure 2 B, p&amp;lt;0.01). Multivariate regression analyses revealed that a concomitant severe TR (OR: 2.53 [95% CI: 1.42 – 4.50], p&amp;lt;0.01) was independently associated with the mortality following TAVR. Conclusion Severe concomitant VHD was associated with an increased one- and five-year mortality following TAVR. In this context, a severe TR appears to be associated with a higher mortality rate as compared to a severe MR. A staged edge-to-edge valvular intervention for concomitant VHD may improve outcomes in these patients and should be critically evaluated in patients with persistent severe VHD after TAVR.Figure 1Figure 2

Interventional rhythm control is associated with an improved long-term prognosis of patients with atrial fibrillation undergoing transcatheter edge-to-edge mitral valve repair

Abstract Background Atrial fibrillation (AF) is the most common concomitant disease in patients undergoing transcatheter edge-to-edge repair (TEER) for severe mitral regurgitation (MR) and detrimentally affects their long-term survival. While the prognostic improvement of catheter ablation (CA) of AF in the overall cohort of heart failure (HF) patients as well as that of surgical ablation of AF with concomitant MR surgery are well established, data on the outcomes of CA of AF in TEER patients are lacking. Methods In a multicenter retrospective observational cohort study, consecutive patients undergoing TEER were enrolled and long-term survival of patients receiving catheter ablation (CA) for AF was compared with that of patients on pharmacological AF treatment and with that of patients without a history of AF, using propensity score matching and multivariable Cox regression analyses. Results A total of 821 patients were identified who successfully underwent TEER procedure. Within this cohort, 608 (74.1%) had concomitant AF, of which 48 patients received CA. Patients with CA of AF showed significantly higher cumulative survival 5 years after the TEER procedure compared with propensity score-matched patients on pharmacological rhythm control of AF (64.6% [31/48] vs. 33.3% [64/192], p=0.01) or on rate control of AF (64.6% [31/48] vs. 25.0% [24/96], p=0.0015). Multivariable Cox regression analysis confirmed that CA of AF was independently associated with significantly better long-term outcome than pharmacological rhythm control and rate control of AF (hazard ratio [HR] 0.4, 95%-confidence interval [CI] 0.2-0.9, p=0.02 and HR 0.4, 95%-CI 0.2-0.7, p=0.004, respectively). CA even offsets the prognostic disadvantage of coexisting AF, as the cumulative survival 5 years after TEER intervention is not significantly different from propensity score-matched TEER patients without a history of AF (64.6% [31/48] vs. 38.9% [56/144], p=0.3). Conclusion Using established statistical methods of propensity score matching and multivariable Cox regression, we demonstrate a significantly improved long-term outcome of TEER patients undergoing CA of concomitant AF compared with pharmacological AF management. CA even offsets the prognostic disadvantage of coexisting AF, as the outcome is not significantly different from that of TEER patients without a history of AF. In light of the growing evidence of prognostic benefit and safety of CA of AF in the overall cohort of HF patients, our data, albeit not randomized, provide strong evidence for interventional rhythm control of AF as an essential part of a modern and holistic management of TEER patients. We alert to the importance of treating concomitant AF, as this is a very promising approach to improve the prognosis of this unique and continually growing HF population.Flow chart of the study designSurvival analyses of PSM cohorts

Abstract 17855: Improvement of Mitral Valve Regurgitation Severity Following Catheter Ablation for Atrial Fibrillation

Background: The presence of concomitant mitral valve regurgitation (MR) in patients with atrial fibrillation (AF) is well known, yet the degree of MR improvement after catheter ablation is not well studied. We investigated the effect of catheter ablation on the degree of MR in patients with baseline ≥moderate MR and AF. Methods: We retrospectively reviewed charts of AF catheter ablation patients at Montefiore Medical Center (2018-2019). Patients with prior or subsequent mitral valve surgeries were excluded. Degree of MR, assessed through echocardiograms, was compared at baseline and follow-up. Early follow-up was defined as 6 months post-ablation. Patients were stratified by left atrial size and left ventricular ejection fraction (LVEF) to assess the influence of these parameters on MR severity after ablation. Results: A total of 202 patients were included in our analysis with an average age of 64 years. At baseline there were 149 patients (74%) with &lt;moderate MR and 44 patients with ≥moderate MR (22%). There was a statistically significant reduction in the number of patients with ≥moderate MR following ablation both at early and late follow-up (p&amp;lt;0.0001, Figure 1). Our results remained statistically significant after stratification by LVEF (&lt;40% vs ≥ 40%) and LA dimension (&lt;4.5cm vs ≥ 4.5cm) (p&amp;lt;0.001, Figure 2). Conclusions: Catheter ablation of AF improved the degree of MR severity in patients with baseline ≥moderate MR and AF. Our findings were preserved across stratification by left atrial size and LVEF subgroups. Further investigation is necessary to validate our findings.

Endovascular Low-Pass Filter: Performing Mitral Edge-to-Edge Repair With PASCAL Through an Inferior Vena Cava Filter

We present the case of an 82-year-old man with a history of inferior vena cava filter implantation and concomitant severe mitral regurgitation requiring transcatheter edge-to-edge repair. Despite being deemed ineligible for transfemoral access as technically challenging, he successfully underwent mitral transcatheter edge-to-edge repair after crossing and dilatation of the inferior vena cava filter. (Level of Difficulty: Intermediate.)

Predictors of Residual Severe Tricuspid Regurgitation After Transcatheter Mitral Valve Repair

BackgroundSevere tricuspid regurgitation (TR) may persist after a mitral transcatheter edge-to-edge repair (M-TEER) and is associated with worsened clinical outcomes and survival. It is unclear which patients with concomitant mitral regurgitation (MR) and TR will have TR reduction after M-TEER. The aim of this study was to identify the predictors of residual TR after transcatheter edge-to-edge repair (TEER).MethodsData were collected from the Northwell TEER registry, a prospectively maintained mandatory database including 4 high-volume transcatheter aortic valve replacement/TEER centers. Transthoracic echocardiograms, both pre-TEER and post-TEER, were evaluated. Univariate and multivariate logistic regression analyses were performed to identify predictors of severe TR after M-TEER. Significant TR reduction was defined as a reduction in TR grade by at least 1+ with moderate (2+) or less TR at 1 month.ResultsOf the 479 patients who underwent M-TEER, 107 patients with concomitant severe MR/TR were included. Successful MR reduction occurred in 89 patients (84%) and a significant TR reduction in 45 (42%). On the univariate analysis, the only predictors of severe residual TR were right atrial area and unsuccessful M-TEER. On the multivariate logistic regression model, the only predictor variable for patients with a reduction in TR was MR reduction of ≥3+ with M-TEER.ConclusionsIn patients with concomitant severe MR and TR, TR reduction after isolated M-TEER occurs in only ∼40% of patients. MR grade reduction ≥3+ was the only independent predictor for TR reduction. Other clinical and echocardiographic variables (including pulmonary hypertension, right ventricular function, tricuspid annular dilation, atrial fibrillation, and presence of a cardiac implantable electrical device) were not associated with residual TR. Inability to predict TR reduction after M-TEER highlights the importance of establishing transcatheter tricuspid valve therapies and should factor in heart-team discussions.

Total regurgitant fraction to predict aortic valve surgery in patients with concomitant aortic and mitral regurgitation

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Both aortic regurgitation (AR) and mitral regurgitation (MR) produce left ventricular (LV) volume overload (1). Current prognostic assessment of AR does not include the presence and magnitude of MR. Therefore, in patients with concomitant AR and MR we might be underestimating the future need of valve replacement surgery. Cardiac magnetic resonance (CMR) is a very precise tool to quantify LV volumes together with aortic and mitral regurgitant volumes. Combining data from cine and phase contrast sequences it is possible to obtain a set parameter: total regurgitant fraction (TRF). Purpose To describe the prognostic value of TRF in patients with concomitant AR and MR. Methods Patients with concomitant AR and MR with CMR studies were retrospectively recruited in three tertiary hospitals. Cases of at least moderate AR and any grade of MR were included in the analysis. Patients with indication of aortic valve surgery (symptoms, severe LV dilatation or reduced LV eyection fraction) in the moment of the CMR were excluded. Aortic regurgitant fraction (ARF) was calculated from the phase constrast data as the ratio of AR volume and LV forward volume. Mitral regurgitant Fraction (MRF) was calculated from the cine sequences as the ratio of the MR volume and the LV stroke volume (LVSV) . TRF was calculated as the ratio of mitral plus aortic regurgitant volumes and the LVSV (MRV+ARV/LVSV) Results 35 cases were analyzed, with a mean follow up period of 40 months. 9 patients developed indications of aortic valve surgery. TRF had an area under curve (AUC) to predict aortic valve surgery of 0.82, in opposite to aortic regurgitant fraction (ARF) which had an AUC of 0.75 (Figure 1) The optimum cutoff value of TRF and ARF to predict the need of surgery in our series were 38% and 27%, respectively. After 3 years of follow up 53% of patients with TRF &amp;gt; 38% had to be intervened (Figure 2A). In contrast, 32% of patients with ARF &amp;gt;27% had to be intervened (Figure 2B) Conclusion MR presence increases volume overload in patients with moderate or severe AR. TRF is a promising parameter to predict the need of aortic valve surgery in this patients

Importance of concomitant functional mitral regurgitation on survival in severe aortic stenosis patients undergoing aortic valve replacement

Mitral regurgitation (MR) is commonly seen in patients with severe aortic stenosis (AS) undergoing aortic valve replacement (AVR). But the long-term implications of MR in AS are unknown. To investigate MR's impact on survival of patients undergoing surgical AVR for severe AS. Of the 740 consecutive patients with severe AS evaluated between 1993 and 2003, 287 underwent AVR forming the study cohort. They were followed up to death or till the end of 2019. Chart reviews were performed for clinical, echocardiographic, and therapeutic data. MR was graded on a 1-4 scale. Mortality data was obtained from chart review and the Social Security Death Index. Survival was analyzed as a function of degree of MR. The mean age of the severe AS patients who had AVR (n = 287) was 72 ± 13 years, 46% women. Over up to 26 years of follow up, there were 201 (70%) deaths, giving deep insights into the determinants of survival of severe AS who had AVR. The 5, 10 and 20 years survival rates were 75%, 45% and 25% respectively. Presence of MR was associated with higher mortality in a graded fashion (P = 0.0003). MR was significantly associated with lower left ventricular (LV) ejection fraction and larger LV size. Impact of MR on mortality was partially mediated through lower LV ejection fraction and larger LV size. By Cox regression, MR, lower ejection fraction (EF) and larger LV end-systolic dimension were independent predictors of higher mortality (χ2 = 33.2). Presence of greater than 2+ MR in patients with severe AS is independently associated with reduced survival in surgically managed patients, an effect incremental to reduced EF and larger LV size. We suggest that aortic valve intervention should be considered in severe AS patients when > 2+ MR occurs irrespective of EF or symptoms.

P49 THE IMPACT OF MITRAL VALVE SURGERY ON VENTRICULAR ARRHYTHMIAS IN PATIENTS WITH BARLOW’S DISEASE: PRELIMINARY RESULTS OF A PROSPECTIVE STUDY

Abstract Background Barlow’s disease is associated with malignant ventricular arrhythmias (VA) and sudden cardiac death. No definitive data are available on baseline arrhythmic burden and evolution of VA in pts undergoing mitral surgery for concomitant severe mitral regurgitation (MR), therefore we started a prospective, single–center study with these two aims. Materials &amp; Methods From February 2021 to May 2022, 88 consecutive pts with severe MR and Barlow’s disease were admitted to our Institution for surgical treatment of MR and were prospectively enrolled in this study. All pts underwent 24–hour Holter monitoring before surgery. A subgroup of them (16 pts, 18.2%) also had either cardiac MRI or CT scan, to detect myocardial fibrosis. Sixty–three mitral repair pts completed 3 months echocardiographic and Holter follow–up. Significant arrhythmic burden was defined as &amp;gt;= 1% premature ventricular beats (PVB)/24 h or at least one episode of non sustained ventricular tachycardia (NSVT), ventricular tachycardia (VT) or ventricular fibrillation (VF). Preoperative, intra and postoperative variables were compared between arrhythmogenic (AR) and non–arrhythmogenic (NAR) pts. Results At baseline (88 patients): • 29 patients (33%) had significant arrhythmic burden (median 2000 PVB/24h) and 59 did not (67%, median 24 PVB/24h) • AR pts tended to be more often females with history of palpitations. Changes in VA were assessed in 63 mitral repair pts who completed 3 months follow–up. Among them, those with significant arrhythmic burden at baseline (20 pts) did not show significant VA at follow–up in 55 % of cases, while pts without relevant VA at baseline remained free from them in 81.4% of cases and worsened in 18.6% (8 pts). Conclusions In our experience, 1/3 of Barlow’s pts with severe MR, referred for mitral surgery, showed a significant arrhythmic burden.These pts more frequently experienced palpitations and were affected by polymorphic PVB, but no other differences were found in clinical or echocardiographic characteristics (including MAD prevalence) between AR and NAR subjects. Almost half of pts with arrhythmic burden at baseline were free from significant VA after mitral repair. However, a minority (18.6%) of subjects without arrhythmic burden at baseline experienced a significant PVB burden at follow–up. Our prospective study will continue to enroll pts to investigate in a larger sample with longer follow–up the role of MV repair on VA.

Outcome for concomitant mitral regurgitation after surgery for aortic insufficiency.

Moderate/severe aortic regurgitation (AR) with concomitant mitral regurgitation (MR) is a common multiple valve disease for which treatment strategies are controversial. The current study explored long-term outcomes of concomitant MR after AR surgery and the effect of combined mitral valvuloplasty. A total of 506 patients with moderate/severe AR and concomitant MR undergoing aortic valve surgery between January 2013 and December 2021 in our cardiac center were enrolled. Risk factors for early mortality, late mortality and persistent MR were identified by logistic regression and generalized linear mixed model. At least one follow-up record was available for 96.3% patients up to May 2022 and 264 (66.8%) patients had no or trivial MR, 112 (28.4%) had mild MR, 16 (4.1%) had moderate MR and 3 (0.8%) patients had severe MR. Persistent MR was recorded for 92 (23.3%) patients during follow-up. Combined mitral valvuloplasty (odds ratio: 0.23; 95% confidential interval: 0.08-0.64; p = 0.005) and better left ventricular reverse remodeling (odds ratio: 0.99; 95% confidential interval: 0.986-0.996); p < 0.001) were found likely to reduce the possibility of persistent MR during follow-up. Most patients with moderate/severe AR and concomitant MR had a good long-term post-surgical outcome for MR. However, a few had persistent MR during follow-up. Combined mitral valvuloplasty and better left ventricular reverse remodeling reduced the possibility of long-term persistent MR.

Giant Partial Endocardial Cushion Defect Challenging Mitral Valve Replacement in Adults: Surgical Approach.

Atrial septal defect (ASD) is one of the most common congenital heart diseases diagnosed in children and adults [ [1] Steele P.M. Fuster V. Cohen M. Ritter D.G. McGoon D. Isolated atrial septal defect with pulmonary vascular obstructive disease – long-term follow-up and prediction of outcome after surgical correction. Circulation. 1987; 76: 1037-1042 Crossref PubMed Scopus (236) Google Scholar ]. Interventional closure devices or surgical patch closure are potential treatment options in haemodynamically relevant ASD. Concomitant severe mitral valve regurgitation is impeded by persisting type I ASD, as a congenital partial endocardial cushion defect (PECD) might be present. Partial endocardial cushion defect is a rare form of congenital heart failure, accounting for about 3% of the overall incidence [ [2] Robinson C.L. Merriman J.E. Kilduff C.J. Partial endocardial cushion defects. Can Med Assoc J. 1963; 88: 1147-1154 Google Scholar ].

Impact of Concomitant Mitral Regurgitation on the Hemodynamic Indicators of Aortic Stenosis.

Background In patients with aortic stenosis (AS), the presence of mitral regurgitation (MR) can lead to underestimation of AS severity and worse clinical outcomes. The objective of this study was to characterize the magnitude of the effects of concomitant MR on hemodynamic indicators of AS severity using clinical data and a computational cardiovascular simulation. Methods and Results Echocardiographic data from 1427 patients with severe AS were used to inform a computational cardiovascular system model, and varying degrees of MR and AS were simulated. Hemodynamic data, including left ventricular and aortic pressure waveforms, were generated for all simulations. Simulated reduction in mean transaortic pressure gradient (MPG) associated with MR was then used to calculate the adjusted MPG in the clinical cohort. MR was present in 861 (60%) patients. Compared with patients without MR, patients with MR had a lower aortic-valve area (0.83±0.2 cm2 versus 0.75±0.2; P<0.001) and were more likely to have a low-gradient pattern (MPG <40 mm Hg) (45% versus 54%; P<0.001). Simulations showed that the presence of concomitant mild, moderate, and severe MR with AS was accompanied by a mean reduction in MPG of 10%, 29%, and 40%, respectively. For patients with MR, their calculated adjusted MPG was on average 24% higher than their MPG (52±22 versus 42±16 mm Hg). Of the 467 patients with low-gradient AS and MR, 240 (51%) would reclassify as high gradient based on their adjusted MPG. Conclusions Concomitant MR results in lower MPG and reduced forward flow compared with isolated AS. Careful quantitation of MR should be factored into the assessment of AS severity to mitigate for potential underestimation.

The fate of concomitant mild mitral regurgitation in aortic insufficiency: A neglected subject.

Mitral regurgitation (MR) is commonly experienced by patients with aortic insufficiency (AI), and in its mild form, it is considered benign. However, the progression of concomitant mild regurgitation after the aortic valve surgery (AVS) for AI is poorly characterized. The current study aimed to define the long-term outcomes of MR after surgery and identify the risk factors involved in deterioration. Patients presenting with moderate/severe AI and concomitant mild MR (n = 347) between January 2013 and December 2021 were enrolled. MR grade was assessed by transthoracic echocardiography during the follow-up, and deterioration is defined as an increase in grade to moderate or severe MR from the previous follow-up echocardiography. Analysis of risk factors for early mortality, MR deterioration, and long-term mortality was performed. A total of 278 patients (84.8%) among 328 survivors had at least one follow-up echocardiography, and complete follow-up occurred for 316 patients (96.3%). Mild MR improved to trivial or none in 194 patients (69.8%), progressed to persistent mild MR for 74 patients (26.6%), and deteriorated for 10 patients (3.6%). Preoperative atrial fibrillation [odds ratio (OR), 23.09; 95% confidence interval (CI), 4.35-122.54] and rheumatic AI (OR, 11.61; 95% CI, 1.26-106.85) were shown to be independent risk factors for MR deterioration by generalized linear mixed analysis. Progression of concomitant mild MR is rare in patients with AI after AVS. However, rheumatic AI and preoperative atrial fibrillation increase the probability of MR deterioration. Careful follow-up for this cohort of patients is recommended.

Impact of concomitant mitral regurgitation during transcatheter aortic valve replacement on 1-year survival outcomes

BackgroundWe investigated the influence of concomitant mitral regurgitation (MR) in patients undergoing transcatheter aortic valve implantation on the 1-year outcome using Japan Transcatheter Valve Therapy (J-TVT) registry data. MethodsThe patients who underwent the transcatheter aortic valve implantation for aortic stenosis performed from August 2013 to December 2019 in Japan were included. History of previous valve surgery and dialysis patients were excluded. A total of 24,979 patients were included, and 1-year follow-up data were obtained from the registry (follow-up rate 98.5 %). Propensity-score matching, using multivariable logistic regression and 1:1 matching without replacement, was performed between the patients with grade 3–4 MR (MR 3–4 group) and those with grade 0–2 MR (MR 0–2 group). All-cause death and the composite outcome of death and/or heart failure events were compared. ResultsAfter propensity score matching, 3920 cases (1960 cases each in MR 0–2 group and MR 3–4 group) were extracted. The procedure success rate was 96.4 % in MR 0–2 and 96.0 % in MR 3–4 group (p = 0.56) and the surgical conversion rate was 0.7 % in MR 0–2 group and 0.8 % in MR 3–4 group (p = 0.58). Cox regression model showed no statistical difference in 1-year survival rate between MR 0–2 group (89.4 %) and MR 3–4 group (89.6 %) (p = 0.80). However, freedom from 1-year death and/or heart failure event was lower in MR 3–4 (86.3 %) than in MR 0–2 group (88.9 %) (p = 0.01). This trend was also found in the subgroup of New York Heart Association (NYHA) class 1–2 but not in the subgroup of NYHA class 3–4. ConclusionsOne-year survival rate was not different between groups but freedom from death and/or heart failure events was lower in patients with preoperative MR grade 3–4 than in patients with preoperative MR grade 0–2 after transcatheter aortic valve replacement.

Abstract 9838: Safety and Feasibility of Staged or Concomitant Transcatheter Edge-to-Edge Mitral Valve Repair After Transcatheter Aortic Valve Replacement

Introduction: The data on safety and feasibility of performing concomitant or staged Transcatheter Edge-to-Edge Repair (TEER) of the mitral valve with Transcatheter Aortic Valve Replacement (TAVR) remains limited. Hypothesis: Methods: The Nationwide Readmission Database (NRD) was utilized to identify TEER and TAVR procedures from 2015, to 2019, using ICD-10-CM administrative claim codes. Results: A total of 28,180 weighted cases of TEER were included in the analysis. Of the included cases 27,562 underwent TEER as a separate procedure and were compared with TEER cases performed concomitantly with TAVR (n=174) or performed as a staged procedure (n=453). In terms of crude outcomes, in-hospital mortality (4.4% vs 2.1%, p&lt;0.01) and associated complications including cardiogenic shock (8.5% vs 4.5%, p&lt;0.01), acute kidney injury (27.7% vs 15.2%, p&lt;0.01) and pacemaker implantation rates (3.7% vs 0.6%, p&lt;0.01) were higher for concomitant or staged procedures. However, in the propensity matched group there was no difference between the two groups in terms of in-hospital mortality (4.4% vs 6.2%, p0.13) and associated complications. Furthermore, in the matched group there was no difference in terms of hospital length of stay (3 days vs 3 days, p0.21) and hospitalization cost (USD 49,356 vs USD 49,037, p0.46) for TEER alone compared with concomitant or staged TEER procedures. Conclusions: TEER performed in the same admission as TAVR or as a staged procedure maybe safe and a feasible treatment option for patients with concomitant mitral regurgitation and severe aortic stenosis compared with TEER alone.

Aortic stenosis and mitral regurgitation modify the effect of venoarterial extracorporeal membrane oxygenation on left ventricular function in cardiogenic shock

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is widely used in the treatment of patients experiencing cardiogenic shock (CS). However, increased VA-ECMO blood flow (EBF) may significantly impair left ventricular (LV) performance. The objective of the present study was to assess the effect of VA-ECMO on LV function in acute CS with concomitant severe aortic stenosis (AS) or mitral regurgitation (MR) in a porcine model. Eight female swine (45 kg) underwent VA-ECMO implantation under general anaesthesia and mechanical ventilation. Acute CS was induced by global myocardial hypoxia. Subsequently, severe AS was simulated by obstruction of the aortic valve, while severe MR was induced by mechanical destruction of the mitral valve. Haemodynamic and LV performance variables were measured at different rates of EBF rates (ranging from 1 to 4 L/min), using arterial and venous catheters, a pulmonary artery catheter, and LV pressure–volume catheter. Data are expressed as median (interquartile range). Myocardial hypoxia resulted in declines in cardiac output to 2.7 (1.9–3.1) L/min and LV ejection fraction to 15.2% (10.5–19.3%). In severe AS, increasing EBF from 1 to 4 L/min was associated with a significant elevation in mean arterial pressure (MAP), from 33.5 (24.2–34.9) to 56.0 (51.9–73.3) mmHg (P ˂ 0.01). However, LV volumes (end-diastolic, end-systolic, stroke) remained unchanged, and LV end-diastolic pressure (LVEDP) significantly decreased from 24.9 (21.2–40.0) to 19.1 (15.2–29.0) mmHg (P ˂ 0.01). In severe MR, increasing EBF resulted in a significant elevation in MAP from 49.0 (28.0–53.4) to 72.5 (51.4–77.1) mmHg (P ˂ 0.01); LV volumes remained stable and LVEDP increased from 17.1 (13.7–19.1) to 20.8 (16.3–25.6) mmHg (P ˂ 0.01). Results of this study indicate that the presence of valvular heart disease may alleviate negative effect of VA-ECMO on LV performance in CS. Severe AS fully protected against LV overload, and partial protection was also detected with severe MR, although at the cost of increased LVEDP and, thus, higher risk for pulmonary oedema.