Ischemic Mitral Regurgitation Research Articles

Simulated Effects of Acute Left Ventricular Myocardial Infarction on Mitral Regurgitation in an Ovine Model.

Ischemic mitral regurgitation (IMR) occurs from incomplete coaptation of the mitral valve (MV) after myocardial infarction (MI), typically worsened by continued remodeling of the left ventricular (LV). The importance of LV remodeling is clear as IMR is induced by the post-MI dual mechanisms of mitral annular dilation and leaflet tethering from papillary muscle (PM) distension via the MV chordae tendineae (MVCT). However, the detailed etiology of IMR remains poorly understood, in large part due to the complex interactions of the MV and the post-MI LV remodeling processes. Given the patient-specific anatomical complexities of the IMR disease processes, simulation-based approaches represent an ideal approach to improve our understanding of this deadly disease. However, development of patient-specific models of left ventricle-mitral valve (LV-MV) interactions in IMR are complicated by the substantial variability and complexity of the MR etiology itself, making it difficult to extract underlying mechanisms from clinical data alone. To address these shortcomings, we developed a detailed ovine LV-MV finite element (FE) model based on extant comprehensive ovine experimental data. First, an extant ovine LV FE model (Sci. Rep. 2021 Jun 29;11(1):13466) was extended to incorporate the MV using a high fidelity ovine in vivo derived MV leaflet geometry. As it is not currently possible to image the MVCT in vivo, a functionally equivalent MVCT network was developed to create the final LV-MV model. Interestingly, in pilot studies, the MV leaflet strains did not agree well with known in vivo MV leaflet strain fields. We then incorporated previously reported MV leaflet prestrains (J. Biomech. Eng. 2023 Nov 1;145(11):111002) in the simulations. The resulting LV-MV model produced excellent agreement with the known in vivo ovine MV leaflet strains and deformed shapes in the normal state. We then simulated the effects of regional acute infarctions of varying sizes and anatomical locations by shutting down the local myocardial contractility. The remaining healthy (noninfarcted) myocardium mechanical behaviors were maintained, but allowed to adjust their active contractile patterns to maintain the prescribed pressure-volume loop behaviors in the acute post-MI state. For all cases studied, the LV-MV simulation demonstrated excellent agreement with known LV and MV in vivo strains and MV regurgitation orifice areas. Infarct location was shown to play a critical role in resultant MV leaflet strain fields. Specifically, extensional deformations of the posterior leaflets occurred in the posterobasal and laterobasal infarcts, while compressive deformations of the anterior leaflet were observed in the anterobasal infarct. Moreover, the simulated posterobasal infarct induced the largest MV regurgitation orifice area, consistent with experimental observations. The present study is the first detailed LV-MV simulation that reveals the important role of MV leaflet prestrain and functionally equivalent MVCT for accurate predictions of LV-MV interactions. Importantly, the current study further underscored simulation-based methods in understanding MV function as an integral part of the LV.

Percutaneous Coronary Intervention as a Non-Surgical Treatment for Ischemic Mitral Regurgitation in Patients with Multi-Vessel Coronary Artery Disease.

BACKGROUND Multi-vessel coronary artery disease (MVD) represents a severe type of coronary artery disease (CAD). Ischemic mitral regurgitation (IMR) is a common mechanical complication in patients with CAD. This study aimed to retrospectively investigate the efficacy of percutaneous coronary intervention (PCI) on moderate/severe IMR in patients with MVD. MATERIAL AND METHODS Clinical data were collected from 15 patients who underwent successful treatment for MVD combined with moderate/severe IMR through the PCI procedure and achieved complete revascularization between January 2014 and December 2022. Cardiac structural and functional parameters were assessed through echocardiographic evaluations. Color flow recordings of MR jets were obtained through an enlarged view of the 4-chamber cut, and the diagnosis of MR was categorized into mild (<4 cm²), moderate (4-8 cm²), and severe (>8 cm²), based on the MR area. RESULTS The common features of the selected cases were advanced age, low body weight, and renal insufficiency. Cardiac echocardiography revealed an augmentation in the left atrial anteroposterior diameter and left ventricular internal diameter at end-systole after PCI, while the left ventricle internal diameter in diastole, left ventricular ejection fraction, and left ventricular fractional shortening were comparable to preoperative values. All patients had moderate/severe MR preoperatively, and MR improved at 1 month (2.73±0.69) and 12 months (2.26±0.58) after PCI. CONCLUSIONS In cases of MVD accompanied by moderate/severe IMR, undergoing PCI can spare certain elderly patients with low body weight and renal insufficiency from high-risk surgery, alleviating the severity of MR without undergoing mitral valve intervention.

Mitral Valve Repair vs. Replacement by Different Etiologies - A Nationwide Population-Based Cohort Study.

When mitral valve (MV) surgery is indicated, repair is preferred over replacement; however, this preference is not supported by evidence from clinical trials. Furthermore, the benefits of MV repair may not be universal for all etiologies of MV disease.Methods and Results: This study identified a total of 18,428 patients who underwent MV repair (n=4,817) or MV replacement (n=13,611) during 2001-2018 from Taiwan's National Health Insurance Research Database. These patients were classified into 4 etiologies: infective endocarditis (IE, n=2,678), rheumatic heart disease (RHD, n=4,524), ischemic mitral regurgitation (IMR, n=3,893), and degenerative mitral regurgitation (DMR, n=7,333). After propensity matching, all-cause mortality during follow-up was lower among patients receiving MV repair than among patients receiving MV replacement in the IE, IMR, and DMR groups (hazard ratio [HR]=0.72, 95% confidence interval [CI]: 0.55-0.93; HR=0.82, 95% CI: 0.73-0.92; and HR 0.73, 95% CI: 0.64-0.84, respectively). However, in the RHD group, the MV reoperation rate was higher after MV repair than after MV replacement (subdistribution HR=1.91, 95% CI: 1.02-3.55). In comparison with MV replacement, MV repair was associated with a lower late mortality in patients with IE, IMR, and DMR, and a higher risk of reoperation in patients with RHD.

Efficacy of mitral valve repair in combination with coronary revascularization for moderate ischaemic mitral regurgitation: a systematic review and meta-analysis of randomized controlled trials.

The efficacy of mitral valve repair (MVR) in combination with coronary artery bypass grafting (CABG) for moderate ischaemic mitral regurgitation (IMR) remains unclear. To evaluate whether MVR + CABG is superior to CABG alone, the authors conducted a systematic review and meta-analysis of existing randomized controlled trials (RCTs). The authors searched PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials for eligible RCTs from the date of their inception to October 2023. The primary outcomes were operative (in-hospital or within 30 days) and long-term (≥ 1 year) mortality. The secondary outcomes were postoperative stroke, worsening renal function (WRF), and reoperation for bleeding or tamponade. The authors performed random-effects meta-analyses and reported the results as risk ratios (RRs) with 95% CIs. Six RCTs were eligible for inclusion. Compared with CABG alone, MVR + CABG did not increase the risk of operative mortality (RR, 1.244; 95% CI, 0.514-3.014); however, it was also not associated with a lower risk of long-term mortality (RR, 0.676; 95% CI, 0.417-1.097). Meanwhile, there was no difference between the two groups in terms of postoperative stroke (RR, 2.425; 95% CI, 0.743-7.915), WRF (RR, 1.257; 95% CI, 0.533-2.964), and reoperation for bleeding or tamponade (RR, 1.667; 95% CI, 0.527-5.270). The findings of this meta-analysis suggest that MVR + CABG fails to improve the clinical outcomes of patients with moderate IMR compared to CABG alone.

Effects of mitral valve disease etiology on the outcomes of mechanical and biological valve replacement: retrospective cohort study.

The choice of an artificial mitral valve (MV) is a crucial clinical decision that affects the long-term survival and quality of life of patients. However, current guidelines recommend selecting MV based on patient age and life expectancy at the time of MV replacement (MVR), without considering the etiology of MV disease. This study aimed to investigate whether MV disease etiology should be considered when choosing a valve for MVR and to evaluate the impact of MV disease etiology on long-term patient survival. Using data (2002 to 2018) from Taiwan's National Health Insurance Research Database, we conducted a nationwide retrospective cohort study to compare the biological and mechanical valves in terms of all-cause mortality as the primary outcome. The inverse probability of the treatment weighting method was used to reduce the effects of the confounding factors. The following etiologies were assessed: infective endocarditis (IE), rheumatic heart disease (RHD), ischemic mitral regurgitation (IMR), and degenerative mitral regurgitation (DMR). In patients aged <70 years, it was observed that mechanical valves demonstrated an association with benefits compared to biological valves in the context of survival. In patients with IE aged <72 years, mechanical valves were associated with survival benefits, but not in those with stroke during hospitalization. These valves were also found to be linked with survival advantages for patients with RHD aged <60 years and for those with DMR aged < 72 years. However, no age-dependent effects of valve type on all-cause mortality were observed in patients with IMR. The etiology of MV disease appears to be important in the selection of a suitable MV and determination of a cutoff age for mechanical and biological MVR.

The high-risk features among patients undergoing mitral valve operation for ischemic mitral regurgitation: The 3-strike score

ObjectiveIschemic mitral regurgitation is prevalent and associated with high surgical risk. With the less-invasive option of transcatheter edge-to-edge repair, the optimal patient selection for mitral valve operation for ischemic mitral regurgitation remains unclear. We sought to identify high-risk features in this group to guide patient selection. MethodsUsing the Cardiothoracic Surgery Trial Network's severe ischemic mitral regurgitation trial data, we identified patient and echocardiographic characteristics associated with an increased risk of 2-year mortality using the support vector classifier and Cox proportional hazards model. We identified 6 high-risk features associated with 2-year survival. Patients were categorized into 3 groups, each having 1 or less, 2, or 3 or more of the 6 identified high-risk features. ResultsAmong the 251 patients, the median age was 69 (Q1 62, Q3 75) years, and 96 (38%) were female. Two-year mortality was 21% (n = 53). We identified 6 high-risk preoperative features: age 75 years or more (n = 69, 28%), prior sternotomy (n = 49, 20%), renal insufficiency (n = 69, 28%), gastrointestinal bleeding (n = 15, 6%), left ventricular ejection fraction less than 40% (n = 131, 52%), and ventricular end-systolic volume index less than 50 mL/m2 (n = 93, 37%). In patients who had 1 or less, 2, and 3 or more high-risk features, 90-day mortality was 4.2% (n = 5), 9.9% (n = 4), and 20.0% (n = 10), respectively (P = .006), and 2-year mortality was 10% (n = 12), 22% (n = 18), and 46% (n = 23) (P < .001), respectively. ConclusionsWe developed the 3-strike score by identifying high-risk preoperative features for mitral valve surgery for ischemic mitral regurgitation. Patients having 3 or more of such high-risk features should undergo careful evaluation for surgical candidacy given the high early and late mortality after mitral valve operations.

Moderate ischemic mitral regurgitation in ischemic heart disease: to operate or not? A meta-analysis.

Deciding whether to perform coronary artery bypass grafting (CABG) alone or in combination with mitral valve repair is a common dilemma encountered by surgeons when treating patients with ischemic mitral regurgitation, a common condition related to coronary artery disease. Although ischemic mitral regurgitation after CABG has been linked to unfavorable results, the benefits of including mitral valve repair are still unknown. This discrepancy led us to undertake a systematic review and meta-analysis to determine whether combining CABG with mitral valve surgery leads to better clinical results than CABG alone. Studies comparing the results of CABG versus CABG with mitral valve replacement were searched in the databases of PubMed and Google Scholar. There were six randomized clinical trials included in this study. We analyzed 852 patients' data. There were no significant variations between patients who acquired CABG alone or CABG+(MVR) in terms of their risk of death at one year, stroke, atrial fibrillation, or hospitalization for heart failure. For recurrent/residual mitral regurgitation; it revealed an RR=5.42, 95% CI, 0.77 to 37.98, and a P value of =0.065. According to the analysis of study heterogeneity, no apparent heterogeneity was identified in the outcomes of death after one year, stroke, atrial fibrillation, or hospitalization for heart failure. However, the outcome of recurrent or residual mitral regurgitation showed significant variation (I2=66%). Patients who underwent CABG alone versus CABG plus MVR did not differ significantly from one another. However, the comparison of CABG alone with CABG plus MVR underlines the need for customized treatment plans based on the unique characteristics of each patient.

The Impact of Mitral Valve Replacement in Treating Moderate-to-Severe Ischemic Mitral Regurgitation on Preservation of the Left Ventricular Function

The Impact of Mitral Valve Replacement in Treating Moderate-to-Severe Ischemic Mitral Regurgitation on Preservation of the Left Ventricular Function

Ischemic mitral regurgitation: To repair or replace? A single center experience.

Recent reports on ischemic mitral valve (MV) regurgitation surgical strategies have suggested better hemodynamic performance with MV replacement (MVR) than MV repair (MVr) with no survival difference at 2 years. We evaluated the difference between MVR and MVr outcomes in patients with ischemic MR, including hemodynamic MV performance at 1 and 2 years postoperatively. A single center cardiac surgery database was queried for patients (aged >/ = 18 years) requiring mitral valve surgery with concomitant CABG or PCI between January 2010 and June 2018. Patients were separated into two groups: mitral valve repair using ring annuloplasty (MVr) and mitral valve replacement (MVR). A total of 111 patients (median age 66 years, 76% male) underwent an operation for ischemic mitral regurgitation during the study period. (44%) had MVr and 62 (56%) had MVR. Both groups had > 80% concomitant CABG. The MVr group had lower EF (40% vs. 55%, p < 0.01), shorter cardiopulmonary bypass time (117 vs. 164 minutes, p < .01) and shorter aortic cross-clamp time (80 vs. 116 minutes, p < .01). The in-hospital mortality (6% vs. 10%, p = 1.00) and 1-year mortality (14% vs. 18%, p = 0.17) were similar between the groups. Pre-operative left ventricular internal diameter at end-diastole was greater in the MVr group (5.6cm vs. 4.6cm, p < .01). At 1-year, more patients in the MVR group had no or trace regurgitation (29% vs. 61%, p = 0.01), however, the number of patients with moderate or greater mitral regurgitation was similar (6% vs. 12%, p = 0.69). At 2-years, the MVr and MVR groups had no difference in moderate or severe mitral regurgitation (7% vs. 13%, p = 0.68). Our findings demonstrate similar early mortality and mid-term mitral valve performance, suggesting that MV repair could be a good surgical option in patients with ischemic MR requiring surgical revascularization.

Mitral valvular surgery outcomes in a centre with a dedicated mitral multi-disciplinary team.

International guidelines recommend 'heart teams' as the preferred method for decision-making. Heart team processes, mandatory attendees and investigations vary significantly between hospitals. We assessed outcomes following mitral valvular surgery in a tertiary referral centre with a dedicated mitral multi-disciplinary team (MDT). This was a single-centre retrospective review of prospectively collected data within the 'mitral database' of mitral valvular disease patients. The 'mitral MDT' meeting involved pre-operative imaging and clinical data review, including mandatory transoesophageal echocardiography; recommendation for planned procedure, as well as an appropriate surgeon; and review of echocardiography images and clinical outcomes after surgery had been performed. Between 2016 and 2020, 395 patients with mitral valvular disease were discussed at MDT. Of these, 310 patients underwent surgery. During the same time interval, 75 patients had surgery without MDT discussion: 84% of patients not discussed were urgent or emergent procedures and, in these, the most common pathology was degenerative mitral regurgitation (DMR, 46%) followed by infective endocarditis (30%). Of those discussed at MDT the pathology was: DMR 65%; mitral stenosis 14%; functional mitral regurgitation (MR) 5%; rheumatic MR 4%; endocarditis 4%; ischaemic MR 4%; and other pathologies 4%. For patients with DMR having elective surgery, the repair rate was 93% with mortality 2% and median (IQR) length of stay 5 (4-6) days. Postoperative transthoracic echocardiography demonstrated 99% of elective DMR patients had ≤2+ MR and <1% severe (3+) MR. In conclusion, a dedicated 'mitral MDT' can enhance the safe delivery of care with consistently high repair rates for DMR patients with excellent outcomes.

Coronary artery bypass on survival in patients with moderate ischemic mitral regurgitation: meta-analysis

Coronary artery bypass on survival in patients with moderate ischemic mitral regurgitation: meta-analysis

FREQUENCY OF ACUTE ISCHEMIC MITRAL REGURGITATION IN PATIENTS OF ACUTE ST-SEGMENT ELEVATED MYOCARDIAL INFARCTION IN PATIENTS PRESENTING AT TERTIARY CARE HOSPITAL OF PESHAWAR

This study aimed to determine the frequency of acute ischemic mitral regurgitation in patients with acute ST-segment elevated myocardial infarction. This descriptive cross-sectional study was conducted at the Cardiology Department of Lady Reading Hospital in Peshawar from March 18, 2019, to September 18, 2019. The study was conducted at Peshawar's Cardiology Department of Lady Reading Hospital. A total of 126 patients were observed, and all of them were subjected to a detailed history, including their past medical history, age, sex, and smoking status. They also underwent a routine physical examination baseline investigation, including ECG (cardiofax) and transthoracic echocardiography (Siemens' Accuson CV-70). The data was recorded in a pre-designed proforma. The mean age of the patients in this study was 53 years, with a standard deviation of ±11.23. 68% of the patients were male, while 32% were female. Additionally, 5% of the patients had ischemic mitral regurgitation, while 95% of the patients did not have ischemic mitral regurgitation. This study concludes that the frequency of acute ischemic mitral regurgitation in patients with acute ST-segment elevated myocardial infarction was 5%.

Moderate Ischemic Mitral Regurgitation with Ejection Fraction

Numerous studies have examined the therapeutic effects of mitral valve repair during revascularization on moderate ischemic mitral regurgitation (IMR), as well as the incremental benefit of subvalvular repair alongside an annuloplasty ring. However, the impact of depressed left ventricular (LV) function on the surgical outcome of patients with moderate IMR has been rarely investigated. The aims of this single-center, retrospective, observational study were firstly to evaluate short- and medium-term outcomes in this patient group after undergoing mitral valve repair during revascularization, and secondly to assess the impact of depressed LV function on surgical outcomes. A total of 272 eligible patients who had moderate IMR and underwent concomitant mitral valve repair and revascularization from January 2010 to December 2017 were included in the study. These patients were categorized into different groups based on their ejection fraction (EF) levels: an EF 40% group (n = 90) and an EF 40% group (n = 182). The median time course of follow-up was 42 months and the shortest follow-up time was 30 months. This study compared in-hospital outcomes (major postoperative morbidity and surgical mortality) as well as midterm outcomes (moderate or more mitral regurgitation, all-cause mortality, and reoperation) of the two groups before and after propensity score (PS) matching (1:1). No significant difference was observed in surgical mortality between groups (8.9% vs. 3.3%, p = 0.076). More patients in the EF 40% group developed low cardiac output (8.9% vs. 2.7%, p = 0.034) and prolonged ventilation (13.3% vs. 5.5%, p = 0.026) compared to the EF 40% group. Propensity score (PS) matching successfully established 82 patient pairs in a 1:1 ratio. No significance was discovered between the matched cohorts in terms of major postoperative morbidity and surgical mortality, except for prolonged ventilation. Conditional mixed-effects logistic regression analysis revealed that EF 40% had an independent impact on prolonged ventilation (odds ratio (OR) = 2.814, 95% CI 1.321-6.151, p = 0.031), but was not an independent risk factor for surgical mortality (OR = 2.967, 95% CI 0.712-7.245, p = 0.138) or other major postoperative morbidity. Furthermore, the two groups showed similar cumulative survival before (log-rank p = 0.278) and after (stratified log-rank p = 0.832) PS matching. Cox regression analysis suggested that EF 40% was not related to mortality compared with EF 40% (PS-adjusted hazard ratio (HR) = 1.151, 95% CI 0.763-1.952, p = 0.281). Patients with moderate IMR and EF 40% shared similar midterm outcomes and surgical mortality to patients with moderate IMR and EF 40%, but received prolonged ventilation more often. Depressed LV function may be not associated with surgical or midterm mortality.

What Happens to Mild-to-Moderate Chronic Ischemic Mitral Regurgitation Following Isolated Coronary Artery Bypass Surgery?

Introduction: The aim of this study was to assess the efficacy of isolated coronary artery bypass grafting (CABG) on preoperatively existing mild-to-moderate chronic ischemic mitral regurgitation. Patients and Methods: A retrospective analysis was conducted on 30 patients who had coronary artery disease and chronic ischemic mitral regurgitation, and underwent isolated CABG at the Department of Cardiovascular Surgery, Kocaeli University, between January 2012 and February 2014. Preoperative demographic and clinical characteristics, as well as postoperative outcomes, were evaluated. The degree of IMR, left ventricular ejection fraction (LVEF), left ventricular end-systolic dimension (LVESD), left ventricular end-diastolic dimension (LVEDD), and left atrial dimension (LAD) were assessed preoperatively, and at the postoperative 12th month. Results: There was no mortality during the early postoperative period. There were statistically similar measurements for LVEF, LVESD, LVEDD, and LAD between preoperative and postoperative periods (p&gt; 0.05). However, a decrease in the degree of IMR was detected during the specified periods (p&lt; 0.05). Conclusion: Isolated CABG can be safely performed in patients with mild/moderate chronic ischemic mitral regurgitation. The efficacy of isolated CABG was demonstrated to improve the degree of mitral regurgitation in selected patients based on echocardiographic measurements.

Ten-year outcomes of surgical treatment of ischemic mitral regurgitation-a retrospective study

Background: Mitral regurgitation (MR) is a prevalent form of valvular heart disease, affecting millions of people worldwide. Primary MR occurs due to mitral valve dysfunction, while secondary MR is caused by left ventricle remodelling. The study aimed to investigate the long-term outcomes of patients with IMR after undergoing coronary surgeries, including coronary artery bypass graft (CABG) with or without mitral valve repair or replacement. Methods: Retrospective, observational study design was planned. Pre-operative and postoperative data were collected from 68 patients with ischemic MR who underwent coronary artery bypass surgery, with or without Mitral valve replacement or mitral valve repair. (That is CABG only/CABG+MVR/CABG+MVr) in the year between 2001 and 2010. Patients followed up at 3 months, 1 year, and 10 years after the procedure. Results: Significant improvements in New York heart association (NYHA) functional class and MR status were observed for all three surgical groups, namely, a) CABG surgery, b) coronary artery bypass graft surgery with mitral valve replacement (CABG+MVR), and c) coronary artery bypass graft surgery with mitral valve repair (CABG+MVr). After 10 years, redo surgery rates were minimal for CABG only and CABG+MVR groups of patients, while CABG+MVr required 20% redo surgery. Postoperative complications, such as left ventricle failure, were seen in the immediate postoperative period, leading to the death of those patients 3 months following the surgery. After 3 months, complications decreased over time for all groups. Conclusions: Surgical interventions effectively improved functional outcomes and reduced MR severity in patients with ischemic MR. Redo surgery rates were low for most patients, indicating the success of the initial procedures.

Edge-to-edge with partial band mitral valve repair compared to replacement and undersized restrictive annuloplasty for ischemic mitral regurgitation

ObjectiveEvidence supports replacement over repair for ischemic mitral regurgitation due to improved durability; however, the latter often involves an undersized ring annuloplasty that does not include edge-to-edge approximation. The objective of this study was to evaluate the outcomes of replacement, edge-to-edge leaflet approximation with mild-undersized annuloplasty and undersized ring annuloplasty for ischemic mitral regurgitation. MethodsThis is a single-center retrospective study of patients undergoing mitral surgery for moderate-severe or greater ischemic mitral regurgitation, between 2004 and 2020, with mild-undersized annuloplasty, mitral valve replacement, or undersized restrictive annuloplasty (undersized ring annuloplasty). The primary outcome was all-cause mortality. Secondary outcomes included first recurrence of mitral regurgitation, heart failure hospitalization, and composite of valve-related events (bleeding, thromboembolism, endocarditis, and mitral valve reoperation). ResultsThere were 121, 93, and 78 patients in the mitral valve replacement, mild-undersized annuloplasty, and undersized restrictive annuloplasty groups, respectively, with a median follow-up of 3.1, 5.9, and 3.8 years, respectively. Both mitral valve replacement (hazard ratio, 1.87; 95% CI, 1.029-3.415) and undersized restrictive annuloplasty (hazard ratio, 2.73; 95% CI, 1.480-5.061) were associated with worse survival compared with mild-undersized annuloplasty. At 2 years, the rate of mild-moderate mitral regurgitation was greater in the mild-undersized annuloplasty group compared with the mitral valve replacement group (P = .001) but less than in the undersized restrictive annuloplasty group (P = .001). The rate of recurrent moderate or greater mitral regurgitation at 2 years was similar between mild-undersized annuloplasty and mitral valve replacement groups but significantly higher after undersized restrictive annuloplasty (P < .0001). Mitral valve replacement and undersized restrictive annuloplasty were associated with a significant increase in the incidence of first heart failure hospitalization compared with mild-undersized annuloplasty (P < .001 and P = .001, respectively). Mitral valve replacement was associated with an increased incidence of valve-related events compared with mild-undersized annuloplasty (P = .002). ConclusionsSurgical edge-to-edge approximation in addition to a mild-undersizing annuloplasty offers similar durability compared with replacement, with a lower rate of hospitalization for heart failure, and may confer a survival advantage.

Handgrip echocardiography predicts clinical outcomes in patients with ischemic mitral regurgitation

Abstract Background Mitral regurgitation (MR) is frequent in patients with ischemic heart disease and carries a dismal prognosis. Previous studies already demonstrated the prognostic benefit of bicycle exercise testing in patients with ischemic MR. Thus, current guidelines emphasize the role of exercise testing in patients with valvular heart disease. Isometric handgrip exercise resembles an alternative exercise intervention, that can also be performed in frail, comorbid patients. Until now, there are no data on the prognostic impact of handgrip echocardiography in heart failure patients with ischemic MR. Purpose To assess the prognostic benefit of isometric handgrip testing in heart failure patients with ischemic MR. Methods We prospectively enrolled patients with ischemic cardiomyopathy (left ventricular ejection fraction &amp;lt;50%) and at least mild MR that underwent echocardiography at rest and during handgrip exercise between January 2019 and September 2021. Patients were followed-up for one year to assess clinical outcomes. The combined endpoint included all-cause mortality, heart failure hospitalisation, ventricular assist device implantation (VAD), heart transplantation and mitral valve (MV) surgery/intervention. Results We included 133 patients (mean age was 75±10 years, 21% were female). Seventy patients (53%) presented with mild MR, while 54 patients had moderate MR (41%), and 9 patients (7%) showed severe MR at rest. Twenty-five patients (20%) with non-severe MR at rest, developed severe MR during handgrip exercise. One-year follow-up (median 321 (162-427) days) was complete in 128 patients (96%). Seventy-one patients (56%) experienced an adverse event: 13 patients (10%) died, 33 patients (26%) were re-admitted to hospital due to heart failure symptoms, 30 patients (24%) underwent MV transcatheter edge-to-edge repair, six patients (5%) received MV surgery, one patient (1%) underwent VAD implantation, and another three patients (4%) underwent heart transplantation. According to MR severity at rest, there was no difference in outcomes in patients with mild, moderate and severe MR (p=0.189). As expected, patients with severe MR at rest more often tended to undergo mitral valve surgery/interventions compared to the other groups (p=0.064). However, patients with non-severe MR at rest and exercise-induced severe MR presented with adverse outcomes similar to patients with severe MR at rest (p=0.005). Furthermore, patients with severe MR at rest and patients with dynamic severe MR underwent mitral valve surgery/interventions more frequently than patients with non-severe MR (p&amp;lt;0.001). Conclusion(s) In heart failure patients with ischemic MR, isometric handgrip testing unmasks severe MR in approximately every fifth patient with non-severe MR at rest. These patients showed similar clinical outcomes as compared to patients with severe MR already at rest. Thus, handgrip exercise testing might be a useful tool to guide further therapeutic decision making.

Surgical versus Interventional Mitral Valve Repair: Analysis of 1,100 Propensity Score-Matched Patients

Objective. We aimed to investigate outcomes in transcatheter versus surgical mitral valve repair in patients with secondary mitral regurgitation (MR) by leveraging a global, multi-institutional federated network database. Methods. Using validated ICD-10 and CPT codes, the TriNetX Analytics Research Data Network (a global federated database of electronic health records from 58 healthcare organizations) was queried to identify patients diagnosed with chronic, severe, ischemic MR and undergoing either transcatheter mitral valve repair (TMVr) or surgical mitral valve repair (SMVr) between January 1, 2015 and December 31, 2020. To adjust for baseline differences, 1 : 1 propensity score matching was performed via logistic regression using the nearest-neighbor approach and matching for 29 covariates including demographics, comorbidities, surgical history, preoperative medications, left ventricular function and heart failure status. We compared 1- and 3-year mortality rates and 1- and 3-year mitral valve reoperation rates in the matched cohorts using Kaplan-Meier estimates and adjusted Cox proportional hazards models. Results. A total of 2,352 patients met inclusion criteria (1,392 in the surgical mitral valve repair group and 960 in the TMVr group). After 1 : 1 propensity score matching, a total of 550 patients undergoing surgical mitral valve repair (SMVr) were compared to 550 patients undergoing TMVr. All characteristics were adequately matched between the cohorts (standardized mean difference &lt;0.1). At 1- and 3-years respectively, mortality rate was 13.4% and 20.7% for surgical patients and 19.8% and 40.3% for TMVr patients. When compared to TMVr, patients undergoing SMVr were significantly less likely to face mortality at 3 years (HR: 0.42, 95% CI: 0.31–0.56, p &lt; 0.0001 ). At 1- and 3-years respectively, mitral valve reoperation was 2.2%, and 2.4% for surgical patients and 6.6% and 7.8% for TMVr patients. When compared to TMVr, patients undergoing SMVr were significantly less likely to undergo mitral valve reintervention at 3 years (HR: 0.29, 95% CI: 0.14–0.58, p = 0.0002). Conclusion. In a real-world, propensity score matching analysis of a large cohort of patients with chronic ischemic MR, surgical mitral valve repair had significantly better survival rates and significantly lower reintervention rates at 1- and 3-years compared to TMVr.

Management of Moderate Ischemic Mitral Regurgitation in Patients Undergoing Surgical Revascularization

Abstract Background Chronic ischemic mitral regurgitation (IMR) is not uncommonly seen in association with patients diagnosed with coronary artery disease and represents a late sequel of chronic myocardial ischemia and infarction. It adversely affects cardiovascular mortality and morbidity especially in patients undergoing coronary artery bypass grafting (CABG) surgery. We aim to identify the optimal management of moderate IMR in patients undergoing coronary artery bypass grafts surgery (CABG), whether to address this pathology during revascularization surgery or not. Methods 100 patients diagnosed with Ischemic Heart Disease (IHD) associated with moderate IMR undergoing Coronary Artery Bypass Grafting (CABG). Patients were divided into two equal groups according to their Mitral valve intervention: Group A; 50 Patients with IMR planned for complete revascularization only and Group B; 50 patients planed for revascularization combined with mitral valve surgery. The two groups were compared demographically, for intraoperative and post-operative events. The primary end point was hospital mortality, secondary end points included post-operative improvement in the NYHA functional class, improvement of EF % and reduction of LV dimensions in post-operative echocardiography and finally, the incidence of neurological dysfunction in both groups. Results All the patients in both groups underwent CABG surgery using cardiopulmonary bypass machine. Patients in group B underwent combined Mitral valve surgery in the form of; Mitral valve replacement using a mechanical valve in 7 patients, Mitral valve repair with downsizing annuloplasty surgery using complete semi-rigid ring in 43 patients, of which 13 patients required additional chordal repair with artificial chordea. Group (A) patients were found to have statistically significant shorter total bypass time 72.2± 17.6 vs 113.5± 14.3 (p &amp;lt; 0.001), ischemic time 47.4 min ± 12.1 vs 79.7 min ± 12.3 (p &amp;lt; 0.001), mechanical ventilation duration 10.9 hours ±14.9 vs 14.9 hours ±12.1 (p &amp;lt; 0.001), total period of ICU stay was 46.1 hours ±21.2 vs 63.7 hours ±22.2 and ward stay 5.7 days ±2.3 vs 6.8 days ±2.9 vs (p &amp;lt; 0.001) in group A vs group B respectively. Hospital mortality was insignificant between the 2 groups [(5 patients in group A (10%) vs 4 patients in group B (8%) P = 0.84)]. One month post-surgery, all survivors showed improvement of their ejection fraction and reduction in left ventricular and left atrial dimensions in Transthoracic echo however, there were no statistical significant improvement when comparing patients in both groups. Both groups showed similar improvement in Dyspnea score at one month follow up. Neurological insults were comparable in both groups (none vs one patient in group A vs B simultaneously. Conclusion Addition of mitral-valve surgery to CABG in patients with moderate degree of Ischemic Mitral regurgitation did not show significant benefit on survival, post-operative NYHA class of the patients, the echocardiographic findings or stroke incidence during the short term follow up. On the contrary, it resulted in longer durations of cardiopulmonary bypass, aortic cross-clamp time and longer ICU stay. Longer term follow-up is required to identify its potential benefit.

Long-term outcomes of left ventricular posterior wall plication for ischemic mitral regurgitation.

To evaluate the early and long-term outcomes of left ventricular posterior wall plication for ischemic mitral regurgitation. Patients with ischemic mitral regurgitation who underwent left ventricular posterior wall plication via right-sided left atriotomy at our institution between 2010 and 2020 were retrospectively reviewed. Cases with normal cardiac function, left ventricular end-systolic diameter < 50mm, and left ventriculotomy approach were excluded. The mean follow-up period was 5.3years [standard deviation (SD) = 3.5], with a maximum of 10years. Among the 21 patients enrolled, 9 had New York Heart Association (NYHA) class ≥ III. Three patients required preoperative inotrope support, while two preoperative ventilator support. The mean left ventricular ejection fraction was 31.4% (SD: 8.6), and 16 patients had mitral regurgitation grade ≥ III. All patients underwent coronary artery bypass grafting and mitral annuloplasty. Concomitant surgeries included 11 chordae cutting and 3 tricuspid annuloplasties. One in-hospital death occurred due to sepsis. At the follow-up, echocardiographic data showed significant improvement in cardiac dilation and function and good control of mitral regurgitation. The serum brain natriuretic peptide level was significantly reduced, and 85% of patients improved to NYHA class I. Four deaths occurred later due to sudden, unknown causes. The 5- and 8-year survival rates were 60.2% and 46.8%, respectively, and the 5- and 8-year hospitalization rates due to heart failure were 14.9% and 21.3%, respectively. The long-term outcomes of left ventricular posterior wall plication were satisfactory for controlling heart failure and improving survival rate and patient prognosis. The online version contains supplementary material available at 10.1007/s12055-023-01527-2.