Functional Mitral Regurgitation Research Articles

External Validation of COAPT Risk Score in Patients Undergoing Transcatheter Edge-To-Edge Repair of Severe, Functional Mitral Regurgitation: a Multicenter, Observational Italian-Polish Study

COAPT Risk Score predicts the risk of death or hospitalization for heart failure (HFH) within 2 years after transcatheter edge-to-edge repair (TEER) of mitral regurgitation (MR) using MitraClip device. We performed an international validation of the Score in patients undergoing TEER in Italian and Polish cardiology centers. Patients with severe, functional MR who underwent TEER with MitraClip between March 2012 and July 2023 were included. Patients were categorized as COAPT eligible or COAPT non-eligible based on the COAPT trial criteria. Clinical data were collected from medical records and COAPT Risk Score was calculated for each patient. The primary endpoint was a composite of all-cause mortality and HFH at 2-year follow-up. Among 344 patients, 218 (63%) were COAPT eligible and 126 (37%) COAPT non-eligible. Higher COAPT Score correlated with increased risk of primary endpoint in the overall population (p<0.001), COAPT eligible (p=0.020) and COAPT non-eligible group (p=0.042). COAPT Score had poor predictive value for the primary endpoint in every group (AUC ≤0.61 for all). It performed better among lower-risk patients (<4 points), compared to higher-risk patients (≥4 points) (AUC 0.658 vs. AUC 0.523). COAPT Score was independently associated with an increased risk of primary endpoint in patients with <4 points (adjusted HR 1.338, 95% CI 1.031-1.737, p=0.028), but not those with higher Score values. In conclusion, COAPT Risk Score has poor performance in COAPT-eligible and -non-eligible patients with severe FMR. The Score performance depends on the patient baseline risk, with better accuracy in lower-risk patients.

Implications of Tricuspid Regurgitation Severity in Patients Undergoing Mitral Transcatheter Edge-to-Edge Repair.

Prognostically meaningful tricuspid regurgitation (TR) is not well-defined in the mitral transcatheter edge-to-edge repair arena. We aimed to explore the prevalence, correlates, and consequences of TR grades and postprocedural trends in this setting. A single-center registry of isolated, first-time interventions was retrospectively assessed for pre-, intra-, and postprocedural aspects up to 1 year, of them the primary composite outcome of all-cause deaths or heart failure (HF) hospitalizations, all according to TR severity at baseline and at 1 month following mitral transcatheter edge-to-edge repair. Overall, 1287 individuals (60.3% men, age 78 [interquartile range, 69-85] years, 52.9% with functional mitral regurgitation) were included. Below-moderate, moderate, and above-moderate TR affected 48.4%, 29.5%, and 22.1% of patients, respectively. Increasing TR severity was accompanied by higher rates of functional, severe mitral regurgitation, greater comorbidity, and more advanced heart failure. Although not affecting technical and echocardiographic procedural success, moderate-and-above TR degrees were associated with higher incidence of mortality, heart failure admissions, and functional class III to IV postprocedure, with moderate-to-severe and greater TR independently conferring increased risk for the various outcomes (primary end point; HR, 1.36 [95% CI, 1.21-1.80]; P=0.027). One-month postprocedural TR severity directly correlated with, and was mostly similar to or worse than, its baseline counterpart. Rather than the change between the two, moderate-and-above grade at 1 month, observed in 37.1% of eligible cases, emerged as predictive of the primary outcome's risk. Among patients undergoing mitral transcatheter edge-to-edge repair, above-moderate TR at baseline and the closely related moderate-and-above TR at 1 month postprocedure are highly prevalent and signal a suboptimal course.

Catheter Ablation or Surgical Therapy in Severe Atrial Functional Mitral Regurgitation Caused by Long-Standing Persistent Atrial Fibrillation-Propensity Score Analysis.

There is no consensus on the treatment strategy for patients with severe atrial functional mitral regurgitation combined with heart failure (HF), with a lack of comparative studies in patients with long-standing persistent atrial fibrillation and severe atrial functional mitral regurgitation. We aim to compare mitral valve repair combined with the maze procedure with catheter ablation in patients with severe atrial functional mitral regurgitation due to long-standing persistent atrial fibrillation. Patients with severe atrial functional mitral regurgitation and long-standing persistent atrial fibrillation were included in this retrospective cohort study. Surgical patients underwent mitral valve repair combined with the Cox maze procedure, whereas catheter patients underwent catheter radiofrequency ablation. Mortality, atrial fibrillation recurrence, and HF readmission were assessed using overlap propensity score weighting. Then, between 2018 and 2022, we identified 302 patients: 215 in the surgical group and 87 in the catheter group. There were significant differences in the baseline characteristics between groups. The surgical group had lower rates of atrial fibrillation recurrence (P=0.03), HF readmission (P=0.03), and mitral regurgitation grade >2 at discharge (P<0.01) and follow-up (P<0.01). However, there were no significant differences in the 5-year freedom from death (log-rank P=0.87), atrial fibrillation recurrence (log-rank P=0.36), or HF readmission rates (log-rank P=0.18). Compared with surgical patients, the catheter group had higher atrial fibrillation recurrence and HF readmission rates; however, the difference was not significant after overlap propensity score weighting. Although the proportion of patients with significant mitral regurgitation at the last follow-up was higher after catheter ablation, most patients still showed an effective decrease in mitral regurgitation severity.

Transcatheter mitral valve replacement - a new option for a selected group of patients?

Mitral regurgitation (MR) is the second most common valvular disease. Symptomatic MR is associated with a poor prognosis. Cardiac surgery is recommended in the severe form of the disease. If the surgical risk is high or functional mitral regurgitation repair/replacement cannot be combined with aorto-coronary bypass graft surgery, a transcatheter edge-to-edge valve repair should be considered. Currently, there is no recommended procedure in patients with severe symptomatic MR, high cardiac surgical risk, and low probability of success or contraindications to the percutaneous edge-to-edge treatment. A recent alternative is the mitral valve implantation using a transapical approach or through the interatrial septum. Currently, the only CE-marked transcatheter bioprothesis valve using transapical approach and implanted without extracorporeal circulation support is the Tendyne valve. This paper discusses the safety, clinical efficacy and cost effectiveness of this valve and the size of the target population in Poland. The clinical efficacy was evaluated in a study of 100 patients with severe symptomatic MR. The total 2-year mortality was 39%. The hospitalisation rate due to heart failure decreased from 1.3 events/year prior to the surgery to 0.51. MR was not recorded in 93.2% of the survivors. An economic analysis accounting for the survival, health-related quality of life, and the risk of hospitalisation due to heart failure showed that the Tendyne system is cost-effective compared to pharmacological treatment: the incremental cost-utility ratio equalled 93,324-110,696 PLN, depending on the approach, clearly below the official threshold in Poland. The annual number of eligible patients was estimated at 60.

Left atrial rupture during on-pump beating coronary artery bypass grafting

BackgroundOn-pump beating coronary artery bypass grafting (CABG) is a procedure that uses cardiopulmonary bypass to maintain circulation and it is a useful technique for CABG in patients with severely impaired cardiac function. Here, we report a case of left atrial rupture that occurred during CABG. Reports of left atrial injury are rare, and there have been no previous reports of such cases associated with on-pump beating CABG.Case presentationAn 80-year-old man with a history of myocardial infarction was admitted to another hospital for acute heart failure. Coronary angiography revealed triple-vessel disease, and echocardiography showed reduced left ventricular function and moderate mitral regurgitation. He was transferred to our hospital for coronary artery bypass grafting and the operation was scheduled. Surgery was started with the intention of off-pump CABG, but due to circulatory instability, the patient was converted to on-pump beating CABG. While the heart was being dislocated and anastomosis was being performed, sudden bleeding from the left atrium occurred. To achieve hemostasis, we needed to arrest the patient's heart. A 5-cm laceration along the posterior mitral annulus was found in the left atrium and repaired with a bovine pericardial patch. Mitral annuloplasty with a flexible ring was performed simultaneously. He recovered uneventfully.ConclusionsThe left atrial rupture during on-pump beating coronary artery bypass grafting is extremely rare. The wall of the atrium is thought to have been damaged by the stress applied during the displacement of the heart and the impact of the enlarged mitral regurgitant jet. Repair under cardiac arrest is necessary, and in some cases, mitral annuloplasty may be additionally required.

Mitral Transcatheter Edge-to-Edge Repair in INTERMACS 3-4 Profile Patients with Severe Mitral Regurgitation.

Heart transplantation and left ventricular assist device (LVAD) implementation are effective treatments for advanced heart failure (HF), although their use is limited by organ availability and the high incidence of adverse events. The efficacy of mitral transcatheter edge-to-edge repair (TEER) as a bridge to transplantation or as a destination therapy in advanced HF is still debated. A total of 63 patients with INTERMACS class 3 or 4 with contraindications for LVAD and severe functional mitral regurgitation (FMR) were evaluated for TEER implantation eligibility. The primary endpoint was a composite of death, urgent heart transplantation and LVAD implantation at 12 months. A total of 36 patients underwent TEER, while 27 patients received optimal medical therapy (MT) alone. In the intervention group, 35 patients (97%) were discharged alive. In the MT group, two in-hospital deaths occurred, two patients underwent urgent heart transplantation, and three patients were discharged on inotropes. At the 12-month follow-up, the incidence of the primary endpoint occurring was lower in the TEER group (25% vs. 70%, HR 0.25, 95% CI 0.11-0.60, p < 0.01) and the tolerance to neurohormonal therapy was higher (53% vs. 30%, p = 0.03). In advanced HF patients with INTERMACS profile 3 or 4 and severe FMR, TEER on top of optimal MT was associated with a lower incidence of death, urgent heart transplantation or LVAD implantation at 12 months compared to optimal MT alone.

Abstract 4137175: Functional Mitral Regurgitation as a Predictor of Atrial Fibrillation Recurrence Following Catheter Ablation: A Systematic Review and Meta-Analysis

Background: Recent studies showed that functional mitral valve regurgitation (FMR) was associated with higher long-term mortality in chronic heart failure patients and poorer outcomes in those with atrial fibrillation (AF), including a higher risk of atrial cardiomyopathy. However, the effect of baseline FMR on outcomes post-AF catheter ablation remains unclear due to inconsistent evidence. Methods: We systematically reviewed studies from Medline and EMBASE databases from inception to April 2024. Eligible studies must report the association between baseline FMR and risk of AF recurrence post-AF catheter ablation compared to individuals without FMR. Relative Risk (RR) or hazard ratio (HR) and 95% CIs were retrieved from each study and combined using the generic inverse variance method. Results: Our meta-analysis included 7 cohort studies and found that baseline FMR was associated with a higher risk of AF recurrence compared to those without FMR. The pooled risk ratios (RR) were 1.40 (95% CI 1.11-1.78, I2 = 31%, p = 0.005). No publication bias was identified on the funnel plot. Conclusions: Our pooled analysis found that patients with FMR who underwent AF catheter ablation had a higher risk of AF recurrence compared to those without FMR. Further research is needed to explore the underlying mechanisms and their clinical implications. Keyword: Functional mitral regurgitation, Atrial fibrillation, Catheter ablation, Atrial fibrillation recurrence, Systematic review, Meta-analysis

Abstract 4144585: Association of renal function with mortality and heart failure hospitalization rates after Transcatheter Mitral Valve Edge to Edge Repair

Background: Transcatheter edge to edge repair (TEER) is an established treatment for patients with symptomatic severe functional MR on optimal medical therapy or severe symptomatic primary MR and high surgical risk. Renal dysfunction is associated with adverse outcomes but the threshold at which risks rise are uncertain. Aim To determine the association of estimated glomerular filtration rate (eGFR) with adverse outcomes in patients undergoing TEER for severe symptomatic mitral regurgitation (MR) in Ontario, Canada. Methods: This was a population-based retrospective cohort study using linked administrative datasets of patients who underwent TEER in Ontario, Canada, between 2011 and 2023. The key exposure was eGFR, which was modeled using restricted cubic splines. Outcomes were 1-year mortality, cardiovascular mortality (CV) and heart failure hospitalization (HF). Cause-specific hazards regression was used to model the association between eGFR and outcomes, utilizing eGFR 30ml/min/1.73m2 as the reference value. Results: We studied 2076 patients, of whom 294 (14.2%) had eGFR &lt;30ml/min/1.73m2 and 841 (40.5%) had eGFR 30-60ml/min/1.73m2. The incidence at one year was 16.8% for all-cause mortality, 11% for CV mortality and 14.2% for HF hospitalizations. The Figure illustrates that the predicted incidence of adverse outcomes increases with lower eGFR, with subtle differences in patterns of change in risk at lower eGFR levels such that all-cause mortality and CV mortality begin to rise rapidly at eGFR values ≤30ml/min/1.73m2, while HF hospitalization increases linearly at eGFR ≤50ml/min/1.73m2. Conclusions: There was a progressive increase in all-cause, CV mortality and HF hospitalization after TEER for patients with lower eGFR, particularly those with values &lt;30 ml/min/1.73m2. This data can inform patient discussions and guide post-procedural follow-up.

Qualitative and Quantitative Assessment of Atrial Functional Mitral Regurgitation: analysis from the REVEAL-AFMR registry.

The prevalence, characteristics, and prognosis of atrial functional mitral regurgitation (AFMR) based on severity remain unclear. No studies have systematically evaluated quantitative thresholds, such as effective regurgitant orifice area (EROA) or regurgitant volume, in relation to outcomes in AFMR. This multicenter study aimed to clarify the clinical implications of both qualitative and quantitative assessments of AFMR severity. In this first multicenter study across 26 centers, patients with at least moderate AFMR-defined by preserved left ventricular (LV) function, enlarged left atrium (LA), and absence of primary mitral valve changes-were retrospectively analyzed. AFMR severity was evaluated using a comprehensive approach, including EROA, regurgitant volume, and regurgitant fraction. Among 1,007 patients, 728 (72.3%) had moderate, 146 (14.5%) moderate-to-severe, and 133 (13.2%) severe AFMR. Age, sex, natriuretic peptide levels, and LV ejection fraction were similar across all groups. Patients with severe AFMR had longer atrial fibrillation history, worse heart failure symptoms, larger LV and LA, and more severe tricuspid regurgitation. AFMR severity was independently associated with a higher risk of death, heart failure hospitalization, and mitral valve intervention (HR 1.51, p=0.001 for moderate-to-severe, 2.80, p<0.001 for severe). Quantitative thresholds showed a significantly higher event risk with EROA ≥0.30, regurgitant volume ≥60 mL, and regurgitant fraction ≥50%. Severe AFMR was common and linked to greater atrial fibrillation burden, cardiac structural issues, and an increased risk of adverse clinical events. Quantitative thresholds offer valuable guidance for clinical decision-making and treatment planning.

To clip or not to clip moderate-to-severe functional mitral regurgitation in patients with heart failure?

Functional mitral regurgitation (FMR) is associated with a poor prognosis, with one-year mortality rates ranging from 15% to 40%.

Biological plausibility and implications of obesity associated valvular heart diseases

Obesity contributes to the development and progression of cardiovascular risk factors and diseases, but so far not much attention has been given to obesity and valvular heart disease. Several observational and mendelian randomization studies have reported an association between body mass index with aortic valve stenosis, but also with secondary functional mitral regurgitation and tricuspid regurgitation in a more indirect manner. Several mechanisms can lead to the link between obesity and valvular heart diseases: left ventricular dilation, as obesity directly contributes to ischemic heart disease and ventricular remodeling, atrial myopathy as well as atrial remodeing and arrhythmias, such as atrial fibrillation, that predispose to valvular regurgitation, but also pulmonary hypertension, which could be the consequence of obesity-related inflammation, insulin resistance, and oxidative stress, valvular calcification which is often associated with adiposity and as a direct effect of increased epicardial adipose tissue and pericardial restraint. Individuals with obesity associated valvular heart disease may experience worse symptoms, quality-of-life, exercise capacity, and risk for adverse outcomes. The effect of and the mechanism for various vavular heart diseases in relation to obesity has not been investigated in depth. Recently, incretin-based drugs and sodium-glucose cotransporter-2 inhibitors have been shown to reduce adiposity, and improve HF outcomes; however, the implications of these drugs on valvular heart diseases have not been evaluated. With innovations in therapies for obesity, several questions merit discussion. Considering the prevalence of obesity and its association with valvular heart diseases, not studying these common comorbid conditions represents a significant missed opportunity.

Infrequent Need for Temporary Mechanical Circulatory Support After Mitral Valve Surgery

BackgroundTemporary mechanical circulatory support (tMCS) may be necessary to treat low cardiac output syndrome after mitral valve surgery (MVS) for chronic severe mitral regurgitation (MR). However, prevalence and predictors remain undetermined. MethodsThis single-center retrospective cohort study included 443 patients who underwent primary MVS for degenerative, ischemic, or functional MR between January 2013 and June 2023. Patients requiring tMCS intraoperatively or postoperatively were compared with patients who did not require tMCS. Multivariable logistic regression identified independent risk factors for tMCS requirement. ResultstMCS was required in 12 of 443 patients (2.7%), with degenerative (2.1%), functional (1.8%), and ischemic (8.3%) MR. Independent risk factors for tMCS requirement were preoperative left ventricular ejection fraction <50% (odds ratio, 4.94; P = .01) and mitral valve replacement (odds ratio, 5.85; P = .005). MR type was not independently influential. The 30-day mortality was 41.7% (5 of 12) in the tMCS group vs 3.5% (15 of 431) in the non-tMCS group (P < .0001). ConclusionsRequirements for tMCS after MVS for MR are infrequent, but tMCS is associated with high mortality. Low preoperative left ventricular ejection fraction and mitral valve replacement are independent risk factors, thus suggesting that careful surgical planning and meticulous postoperative monitoring are warranted in high-risk cases.

Commentator Discussion: Durability of annuloplasty in patients with atrial functional mitral regurgitation associated with atrial fibrillation

Commentator Discussion: Durability of annuloplasty in patients with atrial functional mitral regurgitation associated with atrial fibrillation

Cutting-Edge Echocardiographic Tools for Enhanced Understanding and Management of Atrial Functional Mitral Regurgitation.

Cutting-Edge Echocardiographic Tools for Enhanced Understanding and Management of Atrial Functional Mitral Regurgitation.

Weekly Journal Scan: RESHAPing potential treatment indications for functional mitral regurgitation in heart failure.

Weekly Journal Scan: RESHAPing potential treatment indications for functional mitral regurgitation in heart failure.

The prognostic role of left atrial mechanics but not left ventricular function in functional mitral regurgitation

Abstract Introduction When atrial dilatation or ventricular dysfunction underline the development of functional mitral regurgitation (FMR), FMR has been categorized into ventricular and atrial type. Due to limited evidence of surgical correction, majority of patients with FMR were left untreated. We therefore investigated the clinical outcomes related to different phenotypes of FMR and the prognostic factors. Methods Subjects with severe or moderate to severe FMR, diagnosed by transthoracic echocardiography were eligible for this analysis. Three phenotypes of FMR, including atrial, ischemic and ventricular FMR were then classified. The left atrial (LA) strain and left ventricular (LV) global longitudinal strain (GLS) were measured. The study population were followed for a year. Results A total of 298 subjects (mean age 72.3 ± 14.0 years; 68% male) were enrolled, including 165 subjects of ischemic-type FMR (iFMR), 77 subjects of non-ischemic ventricular-type FMR (vFMR), and 56 subjects of atrial-type FMR (aFMR). The baseline characteristics, including age, gender, demography, and morbidities were similar between three groups, but aFMR group had higher LA reservoir strain and better LV GLS. During a mean follow-up duration of 283 days, there were 50 (17%) cases died within the first year. The Kaplan Meier curve analysis showed similar survival rate between three phenotypes of FMR. Body mass index (BMI), systolic blood pressure, diastolic blood pressure, history of myocardial infarction (MI), RV dysfunction, and a lower LA reservoir strain, but not LV GLS were crudely related to one-year mortality. In the multivariable Cox proportional regression analysis, LA reservoir strain was independently predictive of mortality (Hazard ratio for 1% increase and 95% confidence intervals: 0.943, 0.895-0.994). Conclusions Patients with aFMR also have despaired clinical outcomes as patients with vFMR or iFMR. LA reservoir function but not LV systolic function was predictive of worse clinical outcomes. The results may encourage the transcatheter therapy, approved for ventricular-type FMR, for the treatment of aFMR.Kaplan Meier curve analysisMultivariable CPH regression model

ECG as a screening tool for detection of significant functional mitral regurgitation in patients with left bundle branch block

Abstract Background Functional mitral regurgitation (FMR) may occur in the left bundle branch block (LBBB) due to mechanical left ventricular (LV) dyssynchrony, by the imbalance between the tethering and the closing forces exerted on the mitral apparatus1-3. Progressive FMR and LV remodeling result in a reciprocal worsening downward spiral and worse clinical outcomes1-3. Therefore, timely screening and follow-up of these patients to prevent the irreversible progression of FMR is required. To date, only LBBB morphology and QRS duration have been proven predictors of FMR4. Purpose This study aimed to assess the relationship between ECG parameters of LV dyssynchrony and the severity of FMR in patients with LBBB. Methods We retrospectively included 154 consecutive patients with LBBB, in sinus rhythm, who had an echocardiogram, with no more than mild organic valvular heart disease. We measured the following intraventricular dyssynchrony markers: LV activation times (LVAT), intrinsicoid deflection (ID) in lateral and aVF leads and a newly defined marker – the difference (Diff) between aVL and aVF ID’s (Diff_IDaVL_aVF). These two leads record the electrical activation of the two opposing myocardial segments adjacent to the posteromedial and anterolateral papillary muscles, respectively5 (Figure 1). Based on the severity of FMR, the patients were divided into two groups: no/mild FMR (grade II or less) (61%), and significant FMR (grade III and IV) (39%). Results In patients with significant FMR, the LVAT measured in lateral leads, the IDaVL and Diff_IDaVL_aVF were significantly longer, but IDaVF was significantly shorter compared to patients with no/mild FMR (p&amp;lt;0.001). Of all studied ECG parameters, the Diff_IDaVL_ aVF was the parameter that had the strongest correlation with significant FMR (r correlation coefficient 0.82, p &amp;lt; 0.001). In multivariable analysis the Diff_IDaVL_aVF (p = 0.010) was the only parameter independently correlated with significant FMR. On ROC analysis the best cut-off for significant FMR prediction was 55 ms (AUC of 0.99, sensitivity 90% and specificity 97%) (Figure 2). Conclusions In LBBB, a simple intraventricular dyssynchrony ECG parameter can provide insights into FMR severity. A 55 msec Diff_IDaVL_aVF identifies significant FMR that may benefit from early medical or CRT treatment to avoid progression and worse prognosis.

Atrial and ventricular mitral regurgitation in the general population

Abstract Background Functional mitral valve regurgitation (FMR) is the result of two concurrent pathomechanisms: (1) the dilatation of mitral valve annulus (atrial) or (2) remodelling of the left ventricle (ventricular) in the absence of relevant leaflet degeneration¹. Even though FMR has been reported to be the most common cause of relevant MR², there is no general accepted definition of the two subtypes, nor are there population-based data regarding their prevalence, distribution and risk profiles¹. Purpose We aimed to evaluate the prevalence of FMR and to provide an in-depth characterisation of the subtypes aFMR and vFMR in the general population. Methods The study included the first 10,000 participants of the population-based Hamburg City Health Study enrolled between 2016 and 2019. Of these, 8.543 echocardiographic samples were available for analysis. Mitral valve was assessed by two independent investigators. Isolated degenerative MRs as determined by valve mobility (prolapse or restrictive) were excluded. FMR was classified as ventricular when fulfilling one of the following criteria: history of myocardial infarction or coronary artery disease, left ventricular ejection fraction (LVEF) ≤ 40%, restrictive leaflet, tenting area ≥ 150 mm² or coaptation depth ≥ 10 mm. All FMR with LVEF &amp;gt; 55% were classified as atrial. Results After excluding the samples with an insufficient image quality or missing data and re-assessment by the second investigator, 216 of 282 participants with a relevant MR (i.e. moderate or severe) remained (2,6% of the total cohort, see figure 1). In the next step, 153 participants were classified as pure FMR (68.9%), the remaining were mainly functional with minor degenerative features. A total of 31 (14.4%) MRs were classified as vFMR, the remaining 185 participants had an aFMR. Female gender was significantly more common in the aFMR cohort. The remaining demographic variables (age, body mass index) as well as established cardiovascular risk factors (i.e., diabetes, smoking, hypertension) were comparable between the vFMR and aFMR cohort. However, vFMR patients had significantly higher levels of NT-proBNP or NHYA state and presented more frequently with an atrial fibrillation (see figure 2). LVEF and LV stroke volume, TAPSE, left atrial ejection fraction and E/A ratio as a parameter of diastolic dysfunction were lower in the vFMR cohort whereas tenting area and left atrial endsystolic volume was significantly increased. Conclusion In our population-based study, aFMR was found to be the predominant subtype of FMR. The established cardiovascular risk factors were comparable in the vFMR and aFMR cohort. Echocardiographic variables differed significantly and indicate more advanced heart failure and LV remodelling in the vFMR cohort. Further categorization of FMR, in particular regarding the prognostic impact and long-term outcomes, is strongly warranted to allow a clinically relevant definition of aFMR and vFMR.Figure 1:Overview of sample sizeFigure 2:Baseline characteristics

Prognostic implications of guideline-directed medical therapy in functional mitral regurgitation: a meta-analysis

Abstract Background Randomized evidence of the role of heart failure medical therapy for patients with functional mitral regurgitation (FMR) is lacking. Purpose The present meta-analysis sought to investigate the independent long-term prognostic impact of the different medical categories recommended in heart failure, for subjects with FMR. Methods A systematic literature review was conducted in electronic databases to identify studies reporting the association of renin angiotensin system inhibitors (RASi), beta-blockers (BBs), and mineralocorticoid receptor antagonists (MRAs) with outcomes in FMR. A random-effects meta-analysis was conducted to quantify the unadjusted and adjusted hazard ratios [(a)HRs] for all-cause death and the composite outcome in each medical category. Results The final sample comprised 12 studies with 6,715 FMR patients (Picture 1). The use of RASi and BBs was associated with a significantly lower risk for all-cause mortality (HR 0.52 [0.39-0.68]; p &amp;lt;0.00001, I2 =62 % and HR 0.62 [0.49-0.77]; p &amp;lt;0.0001, I2 =44 % respectively) and for the composite outcome (HR 0.54 [0.44-0.67]; p &amp;lt;0.00001, I2 =33 % and HR 0.62 [0.52-0.75], p &amp;lt;0.00001, I2 =35% respectively) in unadjusted models (Picture 2). Both RASi (aHR 0.73 [0.56-0.95], p =0.02, I2 =52%) and BBs (aHR 0.60 [0.41-0.88], p = 0.009, I2 =55%) retained their association with the composite outcome in pooled adjusted models (Picture 2). The prognostic benefit of using RASi or BBs was retained in subgroup analysis including only patients with moderate of severe FMR. MRAs did not demonstrate a significant association with improved outcomes in FMR. Conclusions RASi and BBs appear to have a favorable prognostic impact in patients with FMR, regardless of regurgitation severity.Study flow chart for study selectionPharmacotherapy and prognosis in FMR

Significance of mitral annulus apparatus morphometry in patients with persistent atrial fibrillation

Abstract Background Few data about mitral valve apparatus components deformation in patients with persistent atrial fibrillation are available. Four-dimensional transesophageal echocardiography (4DTEE) is an ideal imaging technique to evaluate the complex morphology of the mitral valve apparatus. Purpose The study aimed to find some characteristics in patients presenting with persistent atrial fibrillation and if some of them could be indicative of relapse after cardioversion. Methods The study enrolled 133 patients with persistent atrial fibrillation and mild/moderate functional mitral regurgitation (FMR) before cardioversion. 101 of the patients were at the first persistent atrial fibrillation episode, and 32 with relapse. After performing two-dimensional transthoracic echocardiography (2DTTE), the study included only patients with mild/moderate FMR. 4D TEE permitted a detailed examination of the mitral annulus and valve leaflets, using an E95 machine for acquisition and an ECHOPAC 204 for image postprocessing with mitral valve quantification (MVQ) software. The studied measured: annulus area (AA)3D, annulus perimeter (AP), antero-posterior diameter (APD), posteromedial-anterolateral diameter (PM-ALD), commissural diameter (CD), inter-trigonal distance (ITd), non-planar angle (NPa), mitral-aortic angle (MAa), and for the leaflets, morphological measured parameters were: anterior leaflet area (ALA), posterior leaflet area (PLA), anterior leaflet length (ALL), posterior leaflet length (PLL), anterior leaflet angle (ALa), posterior leaflet angle (PLa), tenting height (TH), tenting area (TA), tenting volume), closure line length (CLL). Results 1. We found significant statistic differences between mitral annulus apparatus components in patients with (32) and without relapse (101) after initial cardioversion: AA 3D: 3.12 vs. 11.65 (p=0.003), AP: 13.23 vs. 12.1 (p=0.0001), APD: 3.76 vs. 3.45 (p=0.0003), PM-ALD: 4.21vs 3.93 (p=0.004), CD:4.17 vs. 3.89 (p=0.002), ITd: 2.82 vs 2.74 (p=0.2), NPa: 158.5 vs 155.2 (p=0.09), MAa: 122 vs 120,7 (p=0.5), ALA: 5.73 vs. 5.18 (p=0.006), PLA: 7.04 vs. 6.09 (p &amp;lt; 0.0001), ALL: 2.19 vs. 2.07 (p=0.036), PLL: 1,73 vs. 1,6 (p=0.03), ALa: 15.31 vs. 18.82 (p=0.002), PLa: 21.38 vs. 25.31 (p=0.01), TH: 0.83 vs. 0.63 (p=0.001), TA: 1.63 vs. 1.32 (p=0.007), TV: 2.75 vs. 2.13 (p=0.007). 2. We found correlations between mitral valve leaflets area and coaptation length in atrial fibrillation patients with (ALA: r=0.72, PLA r=0.65) and without relapse. (ALA: r=0.76, PLA r=0.64). Conclusions 1. 4D TEE identified a more significant mitral annulus and leaflet remodeling in atrial fibrillation patients with relapse after initial cardioversion than in atrial fibrillation patients admitted with a first atrial fibrillation episode. 2. Mitral valve leaflets area correlated with the coaptation length. 3. Mitral annulus complex morphology in patients with atrial fibrillation could be essential in predicting relapse after initial cardioversion.Mitral annulus parameters evaluationMitral leaflets parameters evaluation