Improvement Of Functional Mitral Regurgitation Research Articles

Short-term study of atrial shunt and improvement of functional mitral regurgitation

BackgroundThis study used an atrial septal shunt to compare the treatment progress and prognosis for patients with heart failure (HF) who have different ejection fractions.MethodsTwenty HF patients with pulmonary hypertension, who required atrial septal shunt therapy, were included in this study. The patients underwent surgery between December 2012 and December 2020. They were divided into two groups based on their ejection fraction: a group with reduced ejection fraction (HFrEF) and a group with preserved ejection fraction(HFpEF) + mid-range ejection fraction (HfmrEF). Echocardiography was utilized to evaluate parameters such as left ventricular dimension (LVD), left ventricular ejection fraction (LVEF), and left ventricular end-diastolic volume (LVEDV). Hemodynamic parameters were measured using cardiac catheterization. The patient's cardiac function was assessed using the six-minute walking test (6MWT), KCCQ score, NYHA classification, and the degree of functional mitral regurgitation (FMR). Followed-up visits were conducted at 1, 3, and 6 months, and any adverse effects were recorded.ResultsThe LVEF values were consistently higher in the HFpEF+HFmrEF group than HFrEF group at all periods (P < 0.05). Differences in LVD were observed between the two groups before the surgery. Statistically, significant differences were found at the preoperative stage, 1 month, and 3 months (P < 0.05, respectively). However, the LVEDV showed a significant difference between the two groups only at 3 months (P = 0.049). Notably, there were notable variations in LAPm, LAPs, and the pressure gradient between the LA-RA gradient at baeline, after implantation, and during the 6 months follow-up (all P < 0.05).ConclusionFollowing treatment, the HFpEF+HFmrEF group exhibited more significant improvements in echocardiographic and cardiac catheterization indices than the HFrEF group. However, there was no statistically significant difference between the two groups regarding the 6MWT and KCCQ scores. It is important to note that the findings of this study still require further investigation in a large sample size of patients.

Abstract 17540: Functional Mitral Regurgitation is Associated With Decreased Papillary Muscle Viability Patients With Non-Ischemic Dilated Cardiomyopathy

Background: The underlying mechanisms of functional mitral regurgitation (FMR) in non-ischemic cardiomyopathy (NICM) are incompletely understood. Aims: We investigated the correlation between papillary muscle viability and FMR in NICM. Methods: We enrolled 66 patients with NICM (LVEF&lt;40%, NHYA III) undergoing CD34 + cell transplantation. At baseline, patients underwent electroanatomical mapping; papillary muscle viability was quantified by local unipolar voltage (UV) measurement, and decreased viability was defined as UV&lt;8.3 mV. All patients received granulocyte-colony stimulating factor; CD34 + cells were collected by apheresis and delivered by transendocardial injections. Echocardiography was performed at baseline and 6 months after cell therapy; severity of FMR was graded by multi-parametric approach. FMR improvement was defined as a reduction in FMR by ≥1 grade when compared to baseline. Results: At baseline, papillary muscle viability was decreased in 24 (36%) and preserved in 42 (64%) of patients. Moderate to severe (2-3+) FMR was more common in patients with decreased papillary muscle viability (6/24; 25%) than in patients with preserved viability (2/42; 5%, P=0.015). Transendocardial cell injections were performed in the papillary muscle area in 26 patients (Group A) and in other areas of the left ventricle in 40 patients (Group B). The groups did not differ in age (56±11 years in Group A vs. 54±10 years in Group B, P=0.32), sex (male: 96% vs. 85%, P=0.21), creatinine (0.98±0.27 mg/dL vs. 0.96±0.28 mg/dL, P=0.92), bilirubin (0.89±0.37 mg/dL vs. 0.92±0.35 mg/dL, P=0.45), LVEF (34±9% vs. 31±7%, P=0.12), NT-proBNP levels (1196±994 pg/mL vs. 1077±1176 pg/mL, P=0.68), the degree of FMR (1.28±0.78 vs. 1.02±0.38, P=0.20), or papillary muscle viability (9.9±3.0 mV vs. 10.3±3.2 mV, P=0.62). At 6 months after cell injection, FMR improved in 77% of patients in Group A vs. 13% in Group B (P=0.001). On multivariate analysis, cell injection in the papillary muscle area was an independent correlate of FMR improvement (P=0.01). Conclusions: FMR in patients with NICM is associated with decreased papillary muscle viability. Transendocardial injection of CD34 + cells in the papillary muscle area may improve FMR in this patient population.

Association Between Catheter Ablation for Nonparoxysmal Atrial Fibrillation and Functional Mitral Regurgitation in Patients With Heart Failure With Preserved Ejection Fraction

Functional mitral regurgitation (FMR) often coexists with atrial fibrillation (AF) and may have a causal relation with AF persistence and exacerbation of heart failure (HF). The purpose of this study was to investigate the impact of FMR on AF catheter ablation (AFCA) outcomes and improvement in FMR after AFCA in patients with HF with preserved ejection fraction (HFpEF) and nonparoxysmal AF. Excluding patients with primary valve disease or post-mitral valve repair, 280 patients with HFpEF who underwent CA for nonparoxysmal AF were retrospectively included. All patients completed 1-year follow-up and were assessed for FMR, AF recurrence and HF parameters, including echocardiography. At baseline, FMR was present in 153 (54.6%) patients (mild, n=112; moderate, n=40; severe, n=1), and these were decreased to 70 (25%) significantly 1year after AFCA (mild, n=64; moderate, n=6), 119 patients (78%) had improvement in MR (a decrease of ≥1 level in the severity from baseline to 1year on echocardiography). Overall, 274 patients (97.9%) had sinus rhythm at the 1-year examination, and recurrent AF-free survival did not differ in patients with and without MR improvement (83.2% vs 82.4%, p=0.908). However, the MR improvement group had a significantly lower cardiothoracic ratio, left atrial diameter, E/e', and B-type natriuretic peptide levels after 1year than those in the MR nonimprovement group. In conclusion, the majority of the HFpEF patients with nonparoxysmal AF had improvement of FMR after AFCA with the high maintenance of sinus rhythm, leading to a virtuous cycle of cardiac function.

Impact of Residual Functional Mitral Regurgitation After Atrial Fibrillation Ablation on Clinical Outcomes in Patients With Left Ventricular Systolic Dysfunction

Functional mitral regurgitation (FMR) negatively impacts the prognosis in patients with atrial fibrillation (AF) and reduced left ventricular (LV) ejection fraction (LVEF). Although structural reverse remodeling after AF ablation can reduce FMR severity, the prognostic impact of FMR and its evolution remain unclear. Of 491 patients with baseline LVEF <50% who underwent first-time AF ablation, 134 patients (27%) had grade 2 to 4 FMR at baseline. Among them, 88 patients (66%) exhibited FMR improvement to grade 0 to 1 FMR 6months after AF ablation. Conversely, among 357 with baseline grade 0 to 1 FMR, 13 patients (3.6%) exhibited FMR worsening to grade 2 to 4 FMR despite AF ablation. Assessment with multidetector computed tomography revealed that an increase in the left atrial emptying fraction (odds ratio 3.55 per 10% increase; 95% confidence interval 2.12 to 5.95) and a reduction in the LV end-diastolic volume index (1.35 per 10-ml/m2 decrease; 1.04 to 1.76) were identified as contributors to the FMR improvement. During a follow-up of 43months, patients with postprocedural grade 2 to 4 FMR more frequently experienced hospitalizations for heart failure or cardiovascular death than those with grade 0 to 1 FMR (30.5% vs 4.6%, log-rank p <0.001). An age-adjusted multivariate Cox regression analysis including baseline and postprocedural FMR revealed that postprocedural grade 2 to 4 FMR (hazard ratio, 3.24; 95% confidence interval 1.43 to 7.35) was significantly associated with unfavorable events. In conclusion, AF ablation modified and often improved FMR severity in patients with reduced LVEF. Residual grade 2 to 4 FMR 6months after AF ablation was associated with a poor prognosis.

Treatment of Moderate Functional Mitral Regurgitation during Aortic Valve Replacement: A Cohort Study

Background: Treatment of moderate functional mitral regurgitation (FMR) during aortic valve replacement (AVR) is controversial. This study aimed to evaluate the effect of different surgical strategies in patients with moderate FMR undergoing AVR. Methods: A total of 468 patients with moderate FMR undergoing AVR from January 2010 to December 2019 were retrospectively studied comparing 3 different surgical strategies, namely isolated AVR, AVR + mitral valve repair (MVr) and AVR + mitral valve replacement (MVR). Survival was estimated using the Kaplan-Meier method and compared with the log-rank test, followed by inverse probability treatment weighting (IPTW) analysis to adjust the between-group imbalances. The primary outcome was overall mortality. Results: Patients underwent isolated AVR (35.3%), AVR + MVr (30.3%), or AVR + MVR (34.4%). The median follow-up was 27.1 months. AVR + MVR was associated with better improvement of FMR during the early and follow-up period compared to isolated AVR and AVR + MVr (p &lt; 0.001). Compared to isolated AVR, AVR + MVR increased the risk of mid-term mortality (hazard ratio [HR]: 2.13, 95% confidence interval [CI]: 1.01–4.48, p = 0.046), which was sustained in the IPTW analysis (HR: 4.15, 95% CI: 1.69–10.15, p = 0.002). In contrast, AVR + MVr showed only a tendency to increase the risk of follow-up mortality (HR: 1.63, 95% CI: 0.72–3.67, p = 0.239), which was more apparent in the IPTW analysis (HR: 2.54, 95% CI: 0.98–6.56, p = 0.054). Conclusions: In patients with severe aortic valve disease and moderate FMR, isolated AVR might be more reasonable than AVR + MVr or AVR + MVR.

Surgical treatment of patients with aortic valve disease complicated with moderate functional mitral regurgitation and heart failure with midrange ejection fraction: a cohort study.

Background Controversies exist on the treatment of moderate functional mitral regurgitation (FMR) in patients with severe aortic valve disease undergoing the aortic valve replacement (AVR). While a substantial proportion of these patients can be complicated with heart failure with midrange ejection fraction (HFmrEF), established studies show that the latter might compromise the patient outcome. This study was aimed to evaluate the prognostic value of concomitant mitral valve surgery during AVR in patients with severe aortic valve disease followed by moderate FMR and HFmrEF.MethodsA total of 78 consecutive patients were retrospectively recruited. Patients were divided into control (isolated AVR) and treatment (AVR + mitral valve surgery) groups. Follow-up outcomes were compared by Kaplan-Meier method, followed by multiple adjustment with inverse probability treatment weighting (IPTW) analysis. The primary outcome was the occurrence of major adverse cardiovascular and cerebrovascular events (MACCE).ResultsThirty-six patients received isolated AVR, while 42 received AVR with mitral valve repair or replacement. The median follow-up time was 28.7 months. Unadjusted analysis showed that there was no significant difference in the rate of MACCE between the two groups [hazard ratio (HR): 1.14, 95% confidence interval (CI): 0.48–2.69, Plogrank=0.770], which was sustained in IPTW analysis (HR: 1.64, 95% CI: 0.59–4.55, Plogrank=0.342). In addition, while concomitant mitral valve surgery improved follow-up FMR more completely (P=0.026) in the IPTW analysis, the ejection fraction was comparable between the two groups (P=0.276). Furthermore, IPTW analysis also showed that mitral valve surgery was associated with the increased risk of postoperative acute kidney injury (P=0.007).ConclusionsIn patients with aortic valve disease followed by moderate FMR and HFmrEF, mitral valve surgery concomitant to AVR may not bring extra benefit in the MACCE-free survival and the improvement of HFmrEF. However, while concomitant mitral valve surgery has priority on the complete improvement of FMR, it might increase the risk of postoperative acute kidney injury.

The role of three dimensional transesophageal echocardiography in predicting the effect of cardiac resynchronization therapy on mitral regurgitation in patients with low ejection fraction heart failure.

Cardiac resynchronization therapy (CRT) positively affects the improvement of functional mitral regurgitation (MR) in patients with heart failure with reduced ejection fraction (HFrEF). However, geometric changes in the mitral valve apparatus, subvalvular structures and their contribution to improving mitral regurgitation after CRT have not been clearly defined. Our study aimed to evaluate the geometric parameters of mitral valve apparatus measured with three-dimensional (3D) transesophageal echocardiography (TEE) before CRT implantation and to determine the parameters predicting the improvement of MR after CRT. In this prospective study, we included thirty patients with moderate or severe MR and HFrEF planned for CRT implantation who had an indication for TEE. Before CRT implantation, effective regurgitant orifice (ERO) and regurgitant volume (RV) measurements were performed. Detailed quantitative measurements of the mitral valve were done from recorded images by 3D TEE. ERO and RV measurements were repeated to evaluate MR at the end of the third month. There were no significant changes in left ventricular EF and left ventricular diameters at third-month follow-up, whereas ERO and RV values were decreased. The posterior leaflet angle was higher in the non-responder group than the responder group (28.93 ± 8.41vs 41.25 ± 10.90, p=0.006). The posterior leaflet angle was an independent predictor of decreased RV and ERO. Among HFrEF patients with moderate or severe functional MR who underwent CRT implantation had a lower posterior leaflet angle, which was measured by 3D TEE, in the patient group whose MR improved after CRT.

B-PO03-081 CLINICAL SIGNIFICANCE OF POST-PROCEDURAL FUNCTIONAL MITRAL REGURGITATION AFTER ATRIAL FIBRILLATION ABLATION IN PATIENTS WITH LEFT VENTRICULAR SYSTOLIC DYSFUNCTION

Functional mitral regurgitation (FMR) is a common finding in patients with atrial fibrillation (AF) and reduced left ventricular (LV) ejection fraction (LVEF). Although association between FMR severity and prognosis is reported in heart failure patients, structural reverse remodeling after AF ablation can reduce the FMR severity, and the clinical significance of this change is still unclear. The purpose of the present study was as follows: (1) to examine the change of FMR severity before and after AF ablation in patients with reduced LVEF, (2) to evaluate the contribution of left atrial (LA) and LV reverse remodeling to the FMR improvement, and (3) to investigate the impact of pre- and post-procedural FMR on long-term clinical outcomes. A total of 407 patients with baseline LVEF of <50% who underwent first-time AF ablation were retrospectively evaluated. Patients were divided into 4 groups according to the pre- and post-procedural FMR severity: no or mild FMR at baseline which remained unchanged at 6 months after AF ablation (group 1), moderate to severe FMR which improved to no or mild (group 2), no or mild FMR which worsened to moderate to severe (group 3), and moderate to severe FMR which remained unchanged (group 4). The endpoint was composite of heart failure hospitalization and cardiovascular death. The number of patients with group 1, 2, 3, and 4 were 283 (69%), 74 (18%), 11 (3%), and 39 (10%), respectively. Reduction in LA volume (47±25ml vs. 30±23 ml, p <0.001) and LV end-systolic volume (37±30 ml vs. 23±21 ml, p <0.001) was significantly larger in patients with group 2 compared to the other patients. Over a median follow-up of 3 months, 28 patients experienced the endpoint. The event rate was 2.8%, 8.1%, 27.3%, and 25.6% in patients with group 1, 2, 3, and 4, respectively (log-rank p <0.001). Age-adjusted multivariate cox regression analysis including pre- and post-procedural FMR severity revealed that moderate to severe FMR at 6 months (hazard ratio, 3.28; 95% confidence interval 1.26-8.54) was significantly associated with the unfavorable events. AF ablation modified the FMR severity. Moderate to severe FMR at 6 months after AF ablation was strongly associated with unfavorable events in patients with reduced LVEF.

The role of three dimensional transeosephageal echocardiography in predicting the effect of cardiac resynchronization therapy on mitral regurgitation in patients with low ejection fraction heart fail

Abstract Funding Acknowledgements Type of funding sources: None. Purpose Cardiac resynchronization therapy (CRT) has a positive effect on the improvement of functional mitral regurgitation in patients with low ejection heart failure. However geometric changes in the mitral valve apparatus, subvalvular structures and their contribution to the improvement of mitral regurgitation after CRT have not been clearly defined. The aim of our study was to evaluate the geometric parameters of mitral valve apparatus measured with 3Dimensional (3D) transesophageal echocardiography (TEE) before CRT implantation and to determine the parameters predicting the improvement of mitral regurgitation after CRT. Methods Thirty patients with moderate or severe mitral regurgitation with low EF heart failure planned for CRT implantation and had an indication for TEE were included in the study. Effective regurgitant orifice (ERO) and regurgitant volume (RV) measurements were performed before CRT implantation. Detailed quantitative measurements of mitral valve were done from recorded images by 3D TEE. ERO, RV measurements were repeated to evaluate mitral regurgitation at the end of 3rd month. Results There were no significant changes in left ventricular EF and left ventricular diameters at the end of 3rd month, whereas ERO and RV values were decreased. A statistically significant difference was found in posterior leaflet angle between mitral regurgitation responder and non-responder groups. (28,93 ± 8,41 vs 41,25 ± 10,90, p = 0,006). Conclusion Heart failure patients with moderate or severe functional mitral regurgitation who underwent CRT implantation were found to have lower posterior leaflet angle measured by 3D TEE in the patient group whose mitral regurgitation improved after CRT. Abstract Figure.

Papillary Muscle Viability Correlates with Changes of Functional Mitral Regurgitation in Patients with Non-Ischemic Dilated Cardiomyopathy

Functional mitral regurgitation (FMR) in non-ischemic cardiomyopathy (NICM) may be partly related to the dysfunction of subvalvular apparatus. Thus, we sought to investigate the correlation between papillary muscle viability and FMR changes in NICM. Of 35 patients with NICM (LVEF<40%, NHYA III) undergoing repeated CD34+ cell transplantation we enrolled 30 patients (86%) who presented with ≥1+ grade FMR. At baseline, all patients underwent electroanatomical mapping, and papillary muscle viability was defined by local unipolar voltage measurement. All patients received granulocyte-colony stimulating factor; CD34+ cells were collected by apheresis and delivered by transendocardial injections. At 6 months, electroanatomical mapping was repeated. Echocardiography was performed at baseline and 6 months, and severity of FMR was graded by multi-parametric approach. FMR improvement was defined as a reduction in FMR by ≥1 grade when compared to baseline. At baseline, FMR grade was mild (1+) in 19 patients (63%), moderate (2+) in 8 patients (27%), and severe (3-4+) in 3 patients (10%). During follow-up, we found improvement of FMR in 15/30 patients (Group A), and in 15 FMR did not improve (Group B). At baseline, Groups A and B did not differ in age (55±9 years in Group A vs. 54±11 years in Group B, P=0.42), sex (male: 94% vs. 87%, P=0.54), creatinine (0.84±0.22 mg/dL vs. 0.89±0.29 mg/dL, P=0.66), bilirubin (0.87±0.35 mg/dL vs. 0.90±0.45 mg/dL, P=0.41), LVEF (33.8±10.0% vs. 33.6±9.3%, P=0.26), NTproBNP levels (1441±1257 pg/mL vs. 1321±1175 pg/mL, P=0.78), or the degree of FMR (1.27±0.79 vs. 1.32±0.82, P=0.27). However, on baseline electroanatomical mapping we found significantly higher papillary muscle viability in Group A than in Group B (9.6±3.8 mV vs. 7.5±2.5 mV, P=0.01). At 6 months, there was a significant increase in papillary muscle viability in Group A (+3.1±1.3 mV, P=0.02), but not in Group B (+0.2±0.4 mV, P=0.89). On multivariate analysis, baseline papillary muscle viability >8 mV was an independent correlate of FMR improvement (P=0.01). Papillary muscle viability appears to correlate with changes in FMR in patients with NICM. Further studies are warranted to investigate whether measurement of papillary muscle viability may improve patient selection for mitral valve repair in NICM.

Evolution of concomitant moderate and moderate to severe functional mitral regurgitation, following aortic valve surgery for severe aortic stenosis

Background/Aim. Functional mitral regurgitation (FMR) is a common entity in patients with aortic stenosis (AS) undergoing aortic valve replacement (AVR). The aim of this study was to examine evolution of moderate and moderate to severe FMR after an isolated AVR, to identify prognostic indicators for persistent MR postoperatively, and to offer the recommendation regarding surgical intervention for moderate and moderate to severe FMR at the time of AVR for AS. Methods. We retrospectively reviewed 39 consecutive patients with moderate and moderate to severe FMR at the time of isolated AVR from January 2007 to December 2013. We collected preoperative and postoperative echocardiographic data to determine the evolution of FMR after AVR. Patients were divided into the persistent (n = 14) and improved FMR group (n = 25). Secondary division was into the prosthesis-patient mismatch (PPM, n = 7) and non prosthesis-patient mismatch group (non PPM, n = 32 patients). Late follow-up echocardiography was completed in 100% (39/39) of patients. Results. FMR improved postoperatively (MR ? 2+) in 64% (25/39) of patients, while 36% (14/39) of patients had persistent MR ? 2). In comparison to the persistent group, the patient with improved FMR had significant decrease in the left ventricular enddiastolic diameter, left ventricular end-systolic diameter, posterior wall and septum thickness postoperatively. The same indicators of reverse remodeling were found in the non PPM group in comparison to the PPM group. The incidence of postoperative FMR improvement was higher in the non PPM group (65.6%, p = 0.001) in comparison to the PPM group (42.9%, p = 0.125). The mean follow-up duration was 39.5 ? 23.5 months. Conclusion. In accordance with previous studies, this study also showed improvement in FMR following AVR surgery. Improvement in MR degree was associated with echocardiographic parameters of reverse left ventricular remodeling. Conservative approach is advisable in patients with moderate and moderate to severe FMR, believing that repair or replacement is unnecessary at the time of AVR for severe AS. PPM could prevent downgrading of FMR, stressing out the importance of choosing the prosthesis of adequate size.

P1369 Mitral regurgitation reduction after transcatheter aortic valve implantation (TAVI)

Abstract BACKGROUND Concomitant mitral regurgitation (MR) is frequently observed in patients with severe aortic stenosis. Improvement of functional MR after TAVI has previously been reported, although influence of TAVI on organic MR remains unclear. METHODS We analyzed 136 patients who underwent TAVI in years 2017-2018 in our center. 16 of them had none or trivial preprocedural MR, 80 had mild preprocedural MR (nonsignificant MR group) and 40 had moderate or severe regurgitation (significant MR group). Specific etiology of each significant MR was classified as functional (11 patients), organic or mixed (29 patients). In addition, left ventricular ejection fraction (EF) was assessed using Simpson"s method. Follow-up (discharge) transthoracic echocardiographywas performed 1 to 5 days after TAVI. RESULTS MR diminished in 33,9% of patients undergoing TAVI (nonsignificant and significant MR group, p = 0,0118). Reduction of MR was pronounced in both: functional MR (45,4%, p = 0,0152) and organic or mixed etiology (72,4%, p = 0,0000). Left ventricular EF did not change after TAVI (p = 0,976). CONCLUSIONS Mitral regurgitation decreases significantly after TAVI, regardless of the etiology.

5943Mechanistic insights of papillary muscle dyssynchrony mediated function mitral regurgitation and modulation by cardiac resynchronization

Abstract Abstract Background Mechanistic features of functional mitral regurgitation (FMR) include papillary muscle displacement due to left ventricular remodeling. Intraventricular conduction delay might further augment this condition by introducing interpapillary muscle dyssynchrony. Objectives To define this mechanism as a major contributing factor in FMR and prove the reversibility of FMR by interpapillary muscle resynchronization. Methods We enrolled 269 chronic HFrEF patients with conduction delay and comprehensively assessed dyssynchrony by complementary echocardiographic techniques. Opposing wall delay, calculated by speckle tracking, was determined as the time difference between peak longitudinal strain of the mid-anterior and inferior wall from a 2-chamber view. Furthermore, opposing wall delay was assessed as the time difference between peak strain values from tissue Doppler velocity-coded data of the mid-inferior septal and mid-lateral wall segments. Results Patients with severe FMR had markedly increased interpapillary longitudinal dyssynchrony (160ms [IQR 120–200]) compared to those with moderate (70ms [IQR 40–110]), no, or mild FMR (60ms [IQR 30–100]; P&lt;0.001). Increased interpapillary muscle dyssynchrony was correlated with effective regurgitant orifice area (P&lt;0.001; Figure A), regurgitant volume (P&lt;0.001, Figure B) and vena contracta width (P&lt;0.001, Figure C). Restoration of longitudinal papillary muscle synchronicity by cardiac resynchronization therapy (CRT) was correlated with FMR regression, as reflected by the reduction in regurgitant volume (P&lt;0.001) and vena contracta width (P&lt;0.001). Conversely, the improvement of FMR was associated with improved interpapillary radial (P=0.006) and longitudinal (P&lt;0.001) dyssynchrony. The improvement of dyssynchrony-mediated FMR signified a better prognosis compared to no improvement in FMR during the 8-year follow-up period even after comprehensive adjustment by a bootstrap-selected confounder model (adj. HR of 0.41; 95% CI 0.18–0.91; P=0.028; Figure D). The results remained virtually unchanged after adjustment for left bundle branch block. Figure 1. Dyssynchrony-FMR-CRT Conclusion Intraventricular dyssynchrony introduces unequal contraction by papillary muscle bearing walls, which has an adverse effect on FMR. CRT can effectively restore interpapillary balance and thus create a less tented leaflet configuration, resulting in a clinically meaningful reduction of FMR. The restoration of papillary muscle synchronicity in dyssynchrony-mediated FMR translates into a significantly better prognosis.

Cell Therapy is Associated with Reduction of Functional Mitral Regurgitation in Cardiomyopathy Patients with High End-Diastolic Volumes

Purpose In nonischemic cardiomyopathy (NICM), CD34+ cell transplantation was shown to improve left ventricular dimensions and function. We sought to investigate the effects of such therapy on functional mitral regurgitation (FMR) in this patient cohort. Methods Of 134 consecutive patients with NICM (LVEF Results During follow-up, 2 patients died, and 1 underwent heart transplantation. In the remaining cohort we found improvement of FMR in 41/109 patients (38%, Group A), and in 68/109 (62%) FMR did not improve (Group B). At baseline, Groups A and B did not differ in age (53±11 years in Group A vs. 54±10 years in Group B, P=0.38), sex (male: 88% vs. 84%, P=0.57), creatinine (0.94±0.21 mg/dL vs. 1.00±0.30 mg/dL, P=0.27), bilirubin (0.92±0.45 mg/dL vs. 0.93±0.53 mg/dL, P=0.68), LVEF (31.7±7.7% vs. 30.6±8.0%, P=0.23), or NTproBNP levels (1620±1978 pg/mL vs. 1490±1984 pg/mL, P=0.73). In contrast, baseline end-diastolic volume (EDV) was significantly higher in Group A than in Group B (245±56 mL vs. 190±82 mL, P Conclusion Transendocardial CD34+ cell transplantation appears to be associated with an improvement in FMR in nonischemic cardiomyopathy patients with high EDV. Further studies are warranted to investigate whether such approach can be used in broader population of chronic heart failure patients or in conjunction with percutaneous mitral valve repair.

Papillary Muscle Dyssynchrony-Mediated Functional Mitral Regurgitation: Mechanistic Insights and Modulation by Cardiac Resynchronization

ObjectivesThis study sought to define interpapillary muscle dyssynchrony as a major contributing factor in functional mitral regurgitation (FMR) and prove the reversibility of FMR by interpapillary muscle resynchronization. BackgroundMechanistic features of FMR include papillary muscle displacement due to left ventricular remodeling. Intraventricular conduction delay might further augment this condition by introducing interpapillary muscle dyssynchrony. MethodsWe enrolled 269 chronic heart failure with reduced ejection fraction patients with conduction delay and comprehensively assessed dyssynchrony by complementary echocardiographic techniques covering the entire spectrum of dyssynchrony. ResultsPatients with severe FMR had markedly increased interpapillary longitudinal dyssynchrony (160 ms [interquartile range (IQR): 120 to 200 ms]) compared with those with moderate (70 ms [IQR: 40 to 110 ms]), no, or mild FMR (60 ms [IQR: 30 to 100 ms]; p < 0.001). Increased interpapillary muscle dyssynchrony was correlated with regurgitant volume (r = 0.50; p < 0.001) and vena contracta width (r = 0.49; p < 0.001). Restoration of longitudinal papillary muscle synchronicity by cardiac resynchronization therapy was correlated with FMR regression, as reflected by the reduction in regurgitant volume (r = 0.46; p < 0.001) and vena contracta width (r = 0.58; p < 0.001). Conversely, the improvement of FMR was associated with improved interpapillary radial (p = 0.006) and longitudinal (p < 0.001) dyssynchrony. The improvement of dyssynchrony-mediated FMR signified a better prognosis compared with no improvement in FMR during the 8-year follow-up period even after comprehensive adjustment by a bootstrap-selected confounder model (adjusted hazard ratio: 0.41; 95% confidence interval: 0.18 to 0.91; p = 0.028). The results remained virtually unchanged after adjustment for left bundle branch block. ConclusionsIntraventricular dyssynchrony introduces unequal contraction by papillary muscle bearing walls, which has an adverse effect on FMR. Cardiac resynchronization therapy can effectively restore interpapillary balance and thus create a less tented leaflet configuration, resulting in a clinically meaningful reduction of FMR. The restoration of papillary muscle synchronicity in dyssynchrony-mediated FMR translates into a significantly better prognosis.

Impact of atrial fibrillation on improvement of functional mitral regurgitation in cardiac resynchronization therapy

Functional mitral regurgitation (FMR) and atrial fibrillation (AF) are frequent heart failure (HF) complications. Cardiac resynchronization therapy (CRT) can improve FMR; however, little is known about the influence of AF on FMR improvement. The purpose of this study was to investigate the mechanisms and impact of baseline AF on FMR improvement after CRT. CRT recipients with HF, AF, or sinus rhythm (SR) at baseline with moderate or severe FMR, were included from an ongoing registry. Left atrial (LA), mitral annular (MA), and left ventricular (LV) dimensions were evaluated echocardiographically. FMR improvement was defined as ≥1 grade decrease from baseline to 6-month follow-up. Clinical and echocardiographic measurements were performed at baseline and 6-month follow-up. A total of 419 patients (age 66 ± 8 years; 73% male) were analyzed. At 6-month follow-up, FMR improved in 145 patients (45.6%) with SR vs 31 of AF patients (30.7%) (P = .011). Despite similar LV reverse remodeling at 6 months after CRT (LV end-systolic volume decreased by 32.1 ± 43.2 mL in the SR group and by 27.7 ± 6.3 mL in those with AF; P = .353), patients with SR exhibited smaller LA volumes (63.0 ± 26.5 mL vs 103.1 ± 41.0mL; P <.001) and MA diameters (42.3 ± 5.6 mm vs 46.1 ± 5.8 mm; P <.001) compared to AF patients. FMR improvement is more common in CRT recipients in SR vs AF, despite a similar degree of LV remodeling. LA volume and MA diameter are greater in the AF group, causing the negative impact of AF on FMR improvement in CRT, as well as indicating a potential therapeutic target (ie, AF rhythm control).

Long-term clinical and echocardiographic outcomes of Mitraclip therapy in patients nonresponders to cardiac resynchronization.

This study deals with clinical and echocardiographic outcomes in cardiac resynchronization therapy (CRT) nonresponders patients undergoing Mitraclip procedure. Functional mitral regurgitation (FMR) occurs in approximately one-third of heart failure (HF) patients. Resynchronization therapy may correct FMR in patients with HF; however, significant FMR persists in 20-25% of CRT patients. All patients included were previously treated with CRT for at least 6 months and remained classified as New York Heart Association (NYHA) functional class III or IV despite optimal medical therapy; the echocardiographic assessment showed lack of decrease of the left ventricular end-systolic volume (LVESV) of at least 10% and residual moderate-to-severe or severe FMR. Clinical and echocardiographic follow-up was scheduled at 1, 3, 6, and 12 months after Mitraclip implantation, and every 6 months thereafter. Thirty patients fulfilled inclusion criteria. Before Mitraclip implantation NYHA class was III in 83% and IV in 17% of patients; after CRT no patient experienced an improvement in FMR. There was a significant improvement in NYHA class from baseline to 6 months, which remained sustained at 12 and 24 months. The degree of FMR significantly improved from baseline to 6 months and from 6 to 12 months. There was left ventricle remodeling with significant reduction of LVESV and an increase of left ventricle ejection fraction at 6 and 12 months, while the opposite trend was noted between 12 and 24 months CONCLUSION: Treatment of moderate to severe FMR in CRT nonresponder is feasible, safe, and reasonably effective in reducing cardiac symptoms.

Minimally invasive mitral valve annuloplasty confers a long-term survival benefit compared with state-of-the-art treatment in heart failure with functional mitral regurgitation

BackgroundClinical impact of the minimally invasive surgical mitral valve annuloplasty (MVA) of functional mitral regurgitation (FMR) in systolic heart failure on top of the state-of-the-art standards of care remains controversial. Therefore, we aimed to compare clinical outcomes of isolated MVA using the mini-invasive videothoracoscopic approach versus the state-of-the-art (CON=conservative) treatment in patients with chronic systolic heart failure and symptomatic FMR. MethodsThe study population consisted of 379 patients (age 68.9±11.0years, 62.8% males) with left ventricular (LV) systolic dysfunction, symptomatic FMR and previous heart failure hospitalization. A total of 167 patients underwent undersized MVA and 212 patients were treated conservatively. A concomitant MAZE was performed in 53 (31.7%) patients. ResultsIn the MVA group, the periprocedural and the 30-day mortality were 1.2% and 4.8%, respectively. During the median follow-up of 7.1years (IQR 3.5–9.8years) a total of 74 (44.3%) and 138 (65.1%) died in the MVA and the CON group, respectively (p<0.001). The lowest mortality was observed in MVA combined with MAZE (22.6%; p<0.01). In Cox regression analysis, age, MVA with MAZE emerged as independent predictors of both all-cause mortality and rehospitalizations for heart failure (all p<0.05). MVA was associated with significantly greater symptomatic improvement and reduction of FMR than the conservative treatment (both p<0.001). Reverse LV remodeling was observed only in the MVA combined with MAZE group (p<0.01). ConclusionsIn patients with symptomatic FMR, minimally invasive MVA, in particular in combination with MAZE, confers an independent long-term survival benefit compared with the state-of-the-art treatment.

Abstract 121: Improvement in Functional Mitral Regurgitation After Isolated Aortic Valve Replacement for Aortic Insufficiency

Objective: Aortic insufficiency (AI) can lead to left ventricular (LV) remodeling characterized by dilation and increased LV mass. This remodeling can cause altered mitral valve coaptation and functional mitral regurgitation (FMR). While there is growing evidence that aortic valve replacement (AVR) for aortic stenosis promotes sufficient ventricular reverse remodeling that FMR improves or resolves, this effect is not well characterized for patients with AI. Methods: All cases of AVR for AI that were performed at a single center between January 2003 and December 2015 were reviewed. Cases with any concomitant procedures, any degree of aortic stenosis, any evidence of ischemic etiology, absence of mitral regurgitation, or significant primary mitral pathology were excluded from analysis. The primary outcome was change in FMR after isolated AVR. Secondary outcomes included change in LV ejection fraction (EF), left atrial (LA) dimension, and change in end-diastolic and –systolic LV dimensions. Two-tailed paired t-test was used to evaluate for difference between the two time points. Results: Over the course of 13.4 years, 31 cases of isolated aortic valve replacement for pure aortic insufficiency with concurrent functional mitral regurgitation were identified. 54.8% (17/31) of cases had some evidence of bacteremia or aortic vegetations at time of surgery, with 41.9% (13/31) of cases completed urgently. Postoperatively, FMR was improved in 74.2% (23/31) of the patients, and decreased by a mean 1.0 ± 0.8 grades (1.6 ± 0.8 vs 0.6 ± 0.7, p &lt; 0.001). There was no significant change in LV EF (50.5 ± 13.4 vs. 50.2 ± 12.9, p = 0.892) or LA dimension (42.5 ± 7.2 vs 40.7 ± 5.9, p = 0.341), but there were significant reductions in the dimension of the LV at end-diastole (56.7 ± 7.1 vs 47.7 ± 8.5, p &lt; 0.001) and end-systole (38.5 ± 9.7 vs 34.0 ± 8.3, p = 0.011). Conclusions: Significant reduction in ventricular size and subsequent improvement in functional mitral regurgitation is expected after isolated aortic valve replacement for pure aortic insufficiency.

Percutaneous Trans-Coronary Venous Mitral Annuloplasty in Patients With Functional Mitral Regurgitation: Analysis of Poznan Carillon Registry Data.

The purpose of our study is to verify, whether percutaneous mitral annuloplasty results in reverse remodeling in patients with functional mitral regurgitation (FMR) and impaired ejection fraction (EF) and to investigate which echo parameters may help in prediction of the efficacy of the procedure. FMR exacerbates left ventricular (LV) dilatation and contributes to both LV remodeling and heart failure. We analyzed baseline and 1 month follow-up data in 22 consecutive patients with FMR, who underwent successful percutaneous trans-coronary venous mitral annuloplasty with the Carillon device. Significant reduction of FMR echo parameters, including vena contracta (VC), effective regurgitant orifice area (EROA), and regurgitant volume (RV) were observed and maintained throughout 1 month follow up and did not correlate with baseline annular, LV or with the left atrial diameters. Baseline mitral tenting area correlated negatively with the relative improvement (% difference) of EROA (r = -0.5898) and RV (r = -0.4363), but not with VC (r = 0.1341). In addition, increased EF as well as a significant reduction in left ventricular diameters were noted. The increase in EF negatively correlated with the change in EROA (r = -0.50058), PISA (r = -0.5327), and RV (r = -0.5457). Baseline mitral tenting area significantly correlated with the 1 month change in EF (r = 0.5946) and stroke volume (r = 0.6913). The improvement of FMR after treatment with the Carillon device is associated with LV reverse remodeling and an increase in systolic performance, that correlates with the reduction in mitral regurgitation, being not dependent on baseline heart diameters. Mitral tenting area seems to be an important parameter in prediction of benefit from percutaneous mitral annuloplasty.