Mild MR Research Articles

Clinical outcomes among patients with mitral valve regurgitation undergoing Impella-supported high-risk PCI

BackgroundMitral valve regurgitation (MR) is associated with worse outcomes in patients undergoing percutaneous coronary intervention (PCI). We sought to evaluate outcomes of Impella-supported high-risk PCI (HRPCI) patients according to MR severity. MethodsPatients from the PROTECT III study undergoing Impella-supported HRPCI were stratified into 4 groups according to MR severity: No or trace MR, mild MR, moderate MR, and severe MR. Immediate PCI-related complications, major adverse cardiovascular and cerebrovascular events (MACCE: all-cause death, myocardial infarction, stroke/transient ischemic attack, and repeat revascularization) at 90 days and death at 1-year were assessed. ResultsFrom March 2017 to March 2020, 631 patients who underwent Impella-supported HRPCI in the PROTECT III study had evaluable MR severity at baseline. Patients with severe MR had lower body mass indices, lower left ventricular ejection fractions (LVEFs), and were more frequently diagnosed with heart failure. The incidence of immediate PCI-related complications was similar between groups. Unadjusted 90-day MACCE and 1-year mortality rates were numerically higher in patients with severe MR compared to the other study groups yet without reaching statistical significance. In multivariable analyses, there was no significant association between the presence of severe MR for 90-day MACCE or 1-year mortality compared with other degrees of MR (adj. HR = 1.71, 95% CI [0.73, 3.98], p = 0.21; adj. HR = 1.79, 95% CI [0.86, 3.74], p = 0.12, respectively). ConclusionsImpella-supported HRPCI patients with moderate or severe MR exhibited a higher prevalence of heart failure, lower LVEF, and longer hospital stays. Patients with severe MR showed numerically higher unadjusted rates of 90-day MACCE and 1-year mortality compared to other groups, however these differences did not reach statistical significance even after adjustment for potential confounders. Clinical trial informationTrial Name: The Global cVAD Study (cVAD)ClinicalTrial.govIdentifier:NCT04136392URL: https://clinicaltrials.gov/ct2/show/NCT04136392?term=cvad&draw=2&rank=2

Long-term Outcomes of Mitral Valve Repair for Atrial Functional Mitral Regurgitation

BackgroundAtrial functional mitral regurgitation (AFMR), defined by normal left ventricular function, enlarged left atrium, and a dilated mitral valve annulus, has been a concept discussed for >10 years. However, there are still no established guidelines for its treatment in the American College of Cardiology/American Heart Association recommendations. This study aimed to determine the long-term outcomes of mitral annuloplasty as a treatment for AFMR. MethodsWe analyzed 1435 patients who underwent mitral valve repair at our institution between 2005 and 2020, with 162 classified as having AFMR. Exclusion criteria for AFMR were established based on preoperative echocardiography and operative notes. The primary outcome was overall mortality, and the secondary outcome was MR recurrence, which was defined as moderate or greater mitral regurgitation observed on echocardiography during the follow-up period, analyzed using our hospital’s medical records and data from the National Statistical Office. ResultsThe median follow-up duration for the entire patient cohort was 6.1 years (interquartile range, 3.2-11.2 years). Patients had a 5-year survival rate of 86% and a 10-year survival rate of 73%, with freedom from MR recurrence rates of 89% and 80% at 5 and 10 years, respectively. Although all 162 patients had moderate or greater MR before surgery, most experienced trivial or mild MR after mitral valve repair throughout the follow-up period. ConclusionsIn summary, mitral valve repair effectively treats patients with AFMR, addressing survival and mitigating MR recurrence.

Distinct leaflet-annular remodeling pattern in severe atrial functional mitral regurgitation: a three-dimensional echocardiography study

BackgroundAtrial functional mitral regurgitation (AFMR) is best described with normal left ventricular size and function, structurally normal mitral leaflets and dilated left atrium. Unlike the ventricular functional phenotype, changes in the annular geometry more than the tethering forces are the main culprit for mitral regurgitation. The aim of this study is to illuminate the leaflet-annular remodeling in patients with mitral regurgitation and atrial fibrillation (AF) using three-dimensional transesophageal echocardiography (3D TOE).ResultsConsecutive fifty patients with AFMR underwent transthoracic echocardiography and 3D TOE: 25 patients with AF and non-mild MR and 25 patients with AF and mild MR were studied. A special mitral valve analysis software was used to accurately assess the three unique pillars for MR: annular size, leaflets’ geometry and tenting parameters.Compared to the mild MR group, non-mild MR group had long-standing AF of more than 1 year and larger left atrial volumes (51.83 ± 12.07 ml/m2 vs 33.68 ± 10.97 ml/m2, p < 0.001). No significant differences were noted in respect of tenting height, area and volume (13.06 ± 2.57 mm vs 11.43 ± 2.89 mm, p = 0.064, 3.58 ± 1.26 cm2 vs 2.80 ± 0.95 cm2, 0.081 and 6.70 ± 2.96 cm3 vs 5.04 ± 2.32 cm3, p = 0.081). Conversely, the non-mild MR group had larger annular area and perimeter (16.20 ± 3.90 cm2 vs 13.51 ± 3.85 cm2, p = 0.023 and 14.73 ± 1.72 cm vs 13.46 ± 1.79 cm, p = 0.033). Similarly, the non-mild MR group had larger anterior and posterior leaflets’ areas (10.18 ± 4.02 cm2 vs 8.71 ± 3.08 cm2, p = 0.04 and 8.96 ± 2.60 cm2 vs 7.30 ± 2.17 cm2, p = 0.029). Correspondingly, more disproportionate leaflet-annular remodeling, as assessed by the ratio of total leaflets’ area to the annular area, was noted in the non-mild MR as opposed to the mild MR group (1.22 ± 0.04 vs 1.26 ± 0.04, p = 0.008).ConclusionsRecently, AFMR has been recognized as a remarkable entity of secondary MR with unique mechanisms. Annular dilatation with disproportionate leaflet remodeling can validate the central regurgitation. However, the call for more parameters is being emphasized to characterize the suitable candidates for percutaneous interventions.Graphical abstract

Antiarrhythmic Effect of SGLT-2 Inhibitors in high-degree AV Block Caused by Heart Failure: A Case Report

Highlights: 1. The antiarrhythmic effect of SGLT-2 inhibitors, particularly empagliflozin, is a very interesting topic to discuss further. 2. In patients with high degree AV block due to HF in rural areas, the use of SGLT-2 inhibitors is quite rare in Indonesia. - Background: According to WHO's Top 10 Global Health Threats, non-communicable diseases such as heart failure contribute to more than 70% of all deaths worldwide. Several studies have shown that SGLT-2 inhibitors can considerably reduce HF. As research progresses, SGLT-2 inhibitors may lessen the risk of arrhythmias in HF patients. Case Summary: A 57-year-old female with uncontrolled hypertension came to the ED after collapsing at home. The vital signs and physical examination are normal. The preliminary ECG showed a high degree AV Block with multiple multifocal PVC. Early laboratory revealed mild hypokalemia. The patient experienced a seizure the next day, and an ECG showed total AV block with a non-sustained VT episode with PVC R on T. Following critical cardiac care and stabilization, the patient underwent echocardiography, which showed mild MR and AR with a reduced ejection fraction (47.7%). Once the patient's condition has stabilized, the patient is given 1x10mg Empagliflozin PO. Discussion: SGLT-2 inhibitors are beneficial in the treatment of heart failure and arrhythmia. SGLT-2 inhibitors have antiarrhythmic effects through a variety of pathways, such as lowering preload and afterload, inhibition of sodium-hydrogen exchange in myocardial cells, and suppression of the sympathetic nervous system.

Potential Role of NT-proBNP and Tissue Doppler Indices to Assess the Severity of Rheumatic Heart Disease: A Cross-sectional Study

Introduction: Rheumatic Heart Disease (RHD) remains the primary cause of acquired Valvular Heart Disease (VHD) in developing countries. The role of Tissue Doppler Indices (TDI) in RHD is understudied. This study aims to fill evidence gaps identified by the American College of Cardiology/American Heart Association in the management of Valvular Heart Disease (VHD) by analysing newer echocardiographic techniques {Tissue Doppler Imaging (TDI)} and biochemical markers (NT-proBNP) against clinical parameters {New York Heart Association (NYHA)} in an understudied patient group. Aim: To evaluate the role of TDI and its association with the functional class of dyspnoea and serum NT-proBNP levels in RHD. Materials and Methods: This cross-sectional study was conducted in the Cardiology and Medicine departments, Central Gujarat, Western India, from January 2021 to June 2022. Fifty-seven consenting adult patients with RHD who underwent echocardiography with Standard Echocardiographic Techniques (SET) to stratify VHD severity were included. Patients were divided into three sub-groups: a) Isolated MR and MR with mild/moderate MS (n=23); b) Isolated MS and MS with mild MR (n=29); and c) Isolated MS and MS with mild or moderate MR (n=48). TDI parameters (e’, a’, e’/a’, and E/e’) at medial mitral, lateral mitral, and tricuspid annuli, NYHA classification, and serum NT-proBNP levels were analysed. The Analysis of Variance (ANOVA) was used to assess the association between NYHA class and clinical and NT-proBNP parameters. The Pearson correlation coefficient was employed to determine linear relationships between NT-proBNP and TDI parameters. Results: The mean age was 45.4±16 years, with the age groups 20-40 years (n=20) and 40-60 years (n=22) having a nearly equal distribution. The female-to-male ratio was 1.48 (34/23). In subgroup C, the a’ velocity decreased from 13.74±3.92 cm/s in NYHA I to 5.17±1.98 cm/s in NYHA IV (p=0.0312), and the e’/a’ ratio increased from 0.96±0.40 in NYHA I to 2.41±1.00 in NYHA IV (p=0.0210). These changes paralleled trends in a’ value (p=0.0306) and e’/a’ ratio (p=0.0157) with increasing NTproBNP levels. Conclusion: At the tricuspid annulus, the e’/a’ ratio and a’ velocity can complement NT-proBNP in cases where there is a discrepancy between the clinical status of the patient and the severity of the valve lesion as determined by SET. Larger-scale studies are needed to further evaluate the association between TDI parameters and long-term clinical outcomes, as well as to identify the optimal timing for surgical intervention in RHD patients.

Mitral valve repair using a semi-rigid posterior band: a 10-year Japanese single-center experience of 244 patients.

Mitral valve repair (MVr) is an established procedure for patients who require surgery for primary mitral regurgitation (PMR). The Colvin-Galloway Future Band (CGFB) is a semi-rigid posterior band expected to improve the clinical outcomes of MVr. However, information on the hemodynamic and functional performance and long-term outcomes of CGFB is limited. We evaluated the quality, durability, and clinical performance after MVr using CGFB for PMR as the cohort study. A total of 244 patients who underwent MVr with CGFB were enrolled. Clinical and echocardiographic assessments were performed (mean follow-up period, 4.0±2.4 years). Posterior mitral leaflet resection was the most common MVr procedure. CGFBs measuring 28 mm (35.2%) and 30 mm (36.5%) were used. The incidence of systolic anterior motion (SAM) was 1.6%. A total of 93.4% of the patients had no or trace MR at discharge. Over 90% of patients had no or mild MR at the last follow-up. The mean pressure gradient and mitral valve orifice area one year after MVr ranged between 2.6 and 3.6 mmHg and 2.3 and 3.4 cm2, respectively. At follow-up, 85.4% of the patients were New York Heart Association class I. Three patients underwent repeat mitral valve surgery. The CGFB demonstrates satisfactory quality and durability in MVr for PMR. Other advantages include a low occurrence of SAM and acceptable hemodynamic outcomes, particularly in patients requiring a smaller annuloplasty device.

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.

Artificial intelligence-enabled electrocardiogram in the detection of patients at risk of atrial functional mitral regurgitation

Abstract Background Atrial functional mitral regurgitation (AFMR) is an increasingly recognized cause of functional MR thought to result from left atrial enlargement and myopathy in the setting of preserved left ventricular geometry and function. AFMR mostly occurs in patients with atrial fibrillation (AF) and/or heart failure with preserved ejection fraction. Purpose We investigated whether the use of an artificial intelligence-based electrocardiogram (AI-ECG) can identify patients with new-onset AF and sinus rhythm (SR) who are at highest risk of developing AFMR. Methods Adults with a new diagnosis of AF between 2010 and 2021 who had a transthoracic echocardiogram (TTE) within 1 month after AF diagnosis were identified. Similarly, adults in SR who never had AF diagnosis and had a TTE during the same period were identified. Exclusion criteria from both groups included &amp;gt;mild MR at baseline, primary mitral valve disease, cardiomyopathy, ≥moderate aortic valve disease, current or previous low ejection fraction, enlarged left ventricle, cardiac devices, previous cardiac surgeries, and the absence of follow-up TTE ≥6 months from baseline. Only patients who had ECG within 10 days of the TTE were included. When multiple ECGs were available, the closest was considered. A previously trained AI-ECG algorithm to detect the probability of AF was utilized. Incident AFMR was defined as &amp;gt;mild functional MR in the absence of &amp;gt;mild left ventricle enlargement or dysfunction. Diastolic dysfunction was defined according to ASE/EACVI guidelines. Results Overall, 1,570 patients with new-onset AF (median age 67 years; 34% females) and 16,802 patients in SR (median age 59 years; 46% females) were included. The median AI ECG probability for AF was 43% (IQR 26%-59%) in the new-onset AF group and 2% (0.5%-7%) in the SR group, Figure 1. Incident AFMR occurred in 152 patients in the AF group over median 3.06 (IQR 1.5-5.2) years of follow-up and in 482 patients in the SR group over median 3.0 (1.5-5.6) years of follow-up. The probability of silent AF by the AI-ECG was associated with incident AFMR in the new-onset AF group [hazard ratio 1.19 (95% CI 1.11-1.28) per 10%, p &amp;lt;.001] and the SR group [hazard ratio 1.19 (95% CI 1.12-1.25) per 10%, p &amp;lt;.001]. The AI ECG-derived AF probability remained as an independent risk factor for AFMR in multivariable analysis in both AF and SR, Table 1. Conclusion The AI ECG for AF might be able to reflect the degree of left atrial myopathy and thus the risk of incident AFMR in patients with AF and SR.Distribution of AI ECG probability of AFMultivariable risk factors for AFMR

Prevalence and prognostic value of significant mitral regurgitation development after pacemaker implantation

Abstract Background Mitral regurgitation (MR) is one of the complications after pacemaker (PM) implantation. However, the underlying mechanism leading to MR progression after PM implantation is not yet fully understood. There is also a lack of information on the clinical impact of the development of MR after PM implantation. Purpose This study aims to evaluate the prevalence and mechanism of MR progression after PM implantation and to determine its prognostic value. Methods Patients who underwent de novo PM implantation at our university medical centre between 2010 and 2020 were included. Patients with previous mitral valve surgery, transcatheter edge-to-edge repair, or MR severity ≥ moderate before device implantation were excluded. The development of significant MR was defined as a worsening of MR severity ≥ moderate within five years after PM implantation. Clinical endpoints were defined as a composite of all-cause mortality or heart failure hospitalization. Results A total of 451 patients (mean age 69 ± 15 years, 61% male) were included. High-degree atrioventricular block (76%) was the main indication for PM implantation. Dual-chamber PM was implanted in 370 (82%) patients. The development of significant MR occurred in 131 (29%) patients at a median of 2.4 years [interquartile range (IQR): 1.0-3.8 years] after PM implantation. Multivariate logistic regression analysis demonstrated that implanted single-chamber PM, LV end-systolic volume index (LVESVI), and mild MR (vs no MR) at baseline were independently associated with the development of significant MR. Prespecified endpoints occurred in 143 patients (31.7%) during median follow-up of 5.4 years [IQR: 3.0-8.1 years] after PM implantation. The Kaplan-Meier analysis showed that patients with significant MR after PM implantation had a significantly higher incidence of endpoints than those without. (Figure) Multivariate Cox regression analysis demonstrated that the development of significant MR, age, male gender, and diabetes mellitus were independently associated with the occurrence of the combined endpoints. The development of significant MR had significant incremental prognostic value for the composite endpoints over the multivariate models including a decrease in LV ejection fraction of ≥ 10% (p = 0.008) or an increase in LVESVI of ≥ 20% (p = 0.016) after PM implantation. Conclusions The development of significant MR occurred in 131 patients after PM implantation. The development of significant MR was independently associated with cardiac events, and its prognostic value was also significant even when included in models including a decrease in LV ejection fraction or an increase in LVESVI after PM implantation.Figure:Kaplan-Meier Curve

M-mode proximal iso-velocity surface area-based dynamics of instantaneous flow rate and its implications for degenerative mitral regurgitation quantification

Abstract Background Instantaneous flow rate of degenerative mitral regurgitation (DMR) showed dynamic changes. However, inconsistencies exist across literatures about the timing of measurements for flow convergence in proximal iso-velocity surface area (PISA) calculation. While the 2017 ASE guideline suggested measurement of PISA radius and velocity should be performed at simultaneous moments of the regurgitant phase (PISApair), a few studies used max PISA radius (PISAmax) to calculate regurgitant volume and showed poor agreement with cardiac magnetic resonance (CMR) results. Purpose This study aimed to compare the above methods with M-mode PISA, thus to investigate the effect of instantaneous flow rate on the agreement of the diagnosis of severe mitral regurgitation (sMR). Methods We prospectively enrolled 75 DMR patients with a) at least mild MR, b) single and non- eccentric MR jet. Regurgitant volume (RVol) was calculated using three PISA methods, respectively. In 25 patients who received CMR, RVol was calculated using volumetric method. The correlation and agreement of RVol among three PISA methods and CMR were compared. The agreements of the diagnosis of sMR between PISA methods and ASE multi-parameter algorithm were analyzed using Cohen’s kappa analyses. Results The curve of instantaneous flow rate of DMR displayed unimodal pattern with at the mid-late systolic phase. The correlation of RVol between PISA methods and CMR were moderate for PISAmax (r = 0.77) and strong for PISApair and M-mode PISA ( r = 0.80 and 0.87, respectively). PISAmax derived RVol was larger than that of CMR (69.1 ± 37.1 mL versus. 49.0 ± 29.0 mL, P = 0.002). Compared to the ASE algorithm, only PISAmax significantly overestimated the percentages of sMR (74.7% versus 54.7%, P =0.010), but both PISAmax and PISApair showed moderate consistency (Kappa coefficient (k): 0.496 and 0.525, respectively). A strong agreement was found between M-mode PISA and the ASE algorithm with regard to the diagnosis of sMR (k = 0.867, P &amp;lt;0.05). Conclusion Based on the unimodal pattern of instantaneous flow rate in DMR patients, PISAmax significantly overestimated RVol and may expose a significant proportion of DMR patients to MR surgery.

Progression of non-significant mitral and tricuspid regurgitation after surgical aortic valve replacement for aortic regurgitation

Abstract Background There is limited evidence to guide the management of below moderate mitral and tricuspid regurgitation (MR and TR) during surgical aortic valve replacement (SAVR) for aortic regurgitation (AR). We assessed the long-term progression of these valvulopathies. Methods This is a single-center, retrospective analysis encompassing 7.0 (IQR, 3.4-12.1) years of follow-up after consecutive patients undergoing SAVR between 1995 and 2022. Cases with ≥moderate non-aortic valve disorders or congenital heart disease at baseline and those who had undergone prior or concomitant valvular interventions were excluded. The primary outcome was the incidence of ≥moderate MR or TR on the last documented echocardiogram. Results A total of 184 patients (141 (76.6%) males, median age 64 (IQR, 55-74) years, 134 (72.8%) with pure AR) were included. Of them, 46 (25.0%) underwent both SAVR and ascending aortic replacement. On the last echo study, performed at a median of 5.8 (IQR, 2.7-11.0) years after surgery, ≥moderate MR, ≥moderate TR, and either were evident in 20 (10.9%), 25 (13.5%), and 36 (19.6%) individuals, respectively. Of the latter, above moderate MR or TR occurred in 26 (72.2%). Survival rate was lower among patients with ≥moderate MR or TR on the last echocardiogram (47.2% vs 79.7%, p&amp;lt;0.001). After multivariable analysis, a higher risk for the primary outcome was associated with 4 baseline variables: mild to moderate (vs up to mild) MR or TR (OR 4.17, 95% CI 1.35-12.91, p=0.013), clinical heart failure (OR 7.42, 95% CI 3.47-14.82, p=0.004), atrial fibrillation (OR 3.30, 95% CI 1.10-9.85, p=0.033), and use of composite graft (OR 4.20, 95% CI 1.29-13.61, p=0.017). Conversely, echocardiographic measures of biventricular function and dimensions, aortic valve morphology, and surgical urgency were not predictive of the combined endpoint. Conclusion Among patients undergoing SAVR for AR, new significant MR or TR develop in one-fifth by 6 years and may be predicted by baseline clinical and echocardiographic observations.Risk Factors for the Primary Outcome

Abstract 14454: Catheter Ablation of Atrial Fibrillation Reverses Morphological Changes of the Mitral Valve and Ameliorates Atrial Functional Mitral Regurgitation

Background: We previously reported that atrial functional mitral regurgitation (A-FMR) occurs with morphological changes of the mitral valve and can be improved by catheter ablation (CA) of atrial fibrillation (AF). However, it is unclear whether the unique morphological changes in the time-course of AF persistence are reversible with sinus rhythm restoration with CA. Aims: The aims of this study were 1) to compare morphological differences among paroxysmal AF (PAF) w/o MR, non-paroxysmal AF (NPAF) w/o MR, and A-FMR, and 2) to examine changes in degree of MR and morphology of the mitral valve after CA in patients with A-FMR. Methods: This is a multicenter (4 hospitals in Fukuoka) retrospective observational study. Protocol 1 : Eighty-four patients undergoing initial CA for AF (from 2010.January to 2021.May) were selected and divided into 3 groups after matching on age (68±8 y.o), sex (19 males), and body surface area (1.7±0,2 m 2 ); PAF w/o MR, NPAF w/o MR, and A-FMR (n=28 in each group). A-FMR was defined as at least mild MR accompanying with NPAF, preserved LVEF (≧ 50%), and no evidence of valve degeneration and other structurally heart diseases. Protocol 2 : Fifty-five patients with A-FMR (19 males, 71±9 y.o.) undergoing initial CA were enrolled. Clinical variables and echocardiographic parameters were analyzed. Results: In protocol 1, tethering angles of anterior and posterior mitral leaflet (AML and PML) were smaller in patients with A-FMR compared with PAF w/o MR (Table1). PML length was shorter in A-FMR than other groups (Table1). In protocol 2, the degree of MR was significantly reduced (Figure, p=0.0013) associated with reduction in MR vena contracta width and MR area (p&lt;0.001) at 11±7 months after CA. Tethering angles of AML and PML were increased after CA (Table2). Conclusion: A-FMR occurs via unique morphological changes of the mitral apparatus along with AF persistence and can be improved by CA of AF with significant reversals of the morphological changes.

Clinical outcomes of septal myectomy in hypertrophic cardiomyopathy with refractory symptoms: A single institutional experience from India

BackgroundMyectomy is the surgical procedure for the treatment of hypertrophic cardiomyopathy (HCM) with refractory symptoms There is limited data available regarding the role of myectomy in HCM among the Indian population. This study is intended to assess the outcomes of myectomy in HCM. MethodsChange in the gradient across the left ventricular outflow tract and severity of mitral regurgitation after myectomy were studied using echocardiography. Functional status, exercise tolerance, and cardiac rhythm of the patients were studied before and after myectomy. ResultsThe study consists of eleven patients with HCM. Four patients were in NYHA grade II, seven were in NYHA grade III before surgery. After surgery nine were in NYHA grade I and two were in NYHA grade II. Exercise tolerance of the study group was in the range of 1 min before surgery and it improved to 6.27 min after surgery. LVOT gradient before surgery was 108.81 and 112.45 mm of Hg on TTE and TEE respectively and it was 17.9 and 15.63 mm of Hg on TEE and TTE respectively after myectomy. On TTE eight patients had severe MR and three had moderate MR before surgery, while nine of them had severe MR and two had moderate MR on TEE. In the immediate post-operative period nine had mild MR, one had moderate MR, whereas the remaining one patient underwent MVR. TTE at six months revealed mild MR in seven, moderate MR in two patients and one had no MR. ConclusionsSurgical septal myectomy is an effective treatment modality for obstructive HCM.

Incidence, risk factors, and outcomes of atrial functional mitral regurgitation in patients with atrial fibrillation or sinus rhythm.

Atrial functional mitral regurgitation (AFMR) has been associated with atrial fibrillation (AF) and heart failure with preserved ejection fraction. However, data on incident AFMR are scarce. We aimed to study the incidence, risk factors, and clinical significance of AFMR in AF or sinus rhythm (SR). Adults with new diagnosis of AF and adults in SR were identified. Patients with >mild MR at baseline, primary mitral disease, cardiomyopathy, left-sided valve disease, previous cardiac surgery, or with no follow-up echocardiogram were excluded. Diastolic dysfunction (DD) was indicated by ≥2/4 abnormal diastolic function parameters [mitral medial e', mitral medial E/e', tricuspid regurgitation velocity, left atrial volume index (LAVI)]. Overall, 1747 patients with AF and 29 623 in SR were included. Incidence rate of >mild AFMR was 2.6 per 100 person-year in new-onset AF and 0.7 per 100 person-year in SR, P < 0.001. AF remained associated with AFMR in a propensity score-matched analysis based on age, sex, and comorbidities between AF and SR [hazard ratio: 3.80 (95% confidence interval 3.04-4.76)]. Independent risk factors associated with incident AFMR were age ≥65 years, female sex, LAVI, and DD in both AF and SR, in addition to rate (vs. rhythm) control in AF. Incident AFMR was independently associated with all-cause death in both groups (both P < 0.001). AF conferred a three-fold increase in the risk of incident AFMR. DD, older age, left atrial size, and female sex were independent risk factors in both SR and AF, while rhythm control was protective. AFMR was universally associated with worse mortality.

A study of effectiveness of tendon transfers in upper extremity in the management of spastic hemiplegia

Over the years, most often the surgical management of cerebral palsy (CP) has focused only on lower extremities wherein surgeries are performed regularly for sitting, standing and ambulation. Upper extremity surgery is uncommonly done to improve the functions of the hand.To study effectiveness of tendon transfers in upper extremity in the management of spastic hemiplegiaThis was a prospective study, which included 24 patients with spastic hemiplegia, of either sex between the ages of 5 and 25 years. All the patients were admitted and evaluated in detail. Pre-operative functional assessment of the upper limb was done according to the House et al functional classification and recorded. IQ evaluation of all the patients was done. All the patients were subjected to the three surgical procedures.Majority (33.33%) belonged to 16–20 years and 66.67% were Females. 15 (62.5%) were having Rt. Sided involvement 20 (83.33%) were having a Normal IQ (&amp;#62;70). The pre-operative score significantly improved from 1.42 to 4.54 after surgery. No one was having excellent improvement but 25% had good improvement while 58.3% had fair improvement. 16.7% had poor improvement. Out of the four cases having Mild MR, majority, 3 (75%), showed Poor observed improvement scores. Out of the 20 cases having Normal IQ, majority, 13 (65%), showed Fair observed improvement scores.The appearance of the hand improved in all the 24 cases (100%) making improvement in the appearance of the hand a very important functional and psychological goal for surgical management even in severe cases

The relationship between mitral regurgitant severity, symptoms, and exercise capacity in primary degenerative mitral regurgitation.

Although it is assumed that more severe MR is associated with a greater burden of symptoms and lower exercise capacity, the relationship between symptoms, exercise capacity, and mitral regurgitant severity has not been well studied. We prospectively studied 67 (63 ± 11 years, 72% male) patients with at least mild degenerative MR and left ventricular ejection fraction ≥ 50% who underwent stress echocardiography, CMR, and evaluation with the Kansas City Cardiomyopathy questionnaire (KCCQ). Symptoms and exercise capacity were evaluated in the context of MR severity. Patients reporting dyspnea had lower KCCQ symptom scores (79 ± 23 vs. 96 ± 9, p = 0.01) and achieved lower percentage of age and gender predicted METs (114 ± 37 vs. 152 ± 43%, p < 0.001) compared to those without dyspnea. There was no significant difference in MR volume between those with vs. without dyspnea by CMR (43 ± 26 ml vs. 51 ± 28 ml, p = 0.3) or echocardiography (64 ± 28 vs. 73 ± 41ml, p = 0.4). Those with severe MR by CMR had similar KCCQ symptom scores (96 ± 10 vs. 89 ± 17, p = 0.04) and percentage of age and gender predicted METs (148 ± 42 vs. 133 ± 47%, p = 0.2) to those without severe MR. Those with severe MR by echocardiography had similar KCCQ symptom score (93 ± 15 vs. 89 ± 16, p = 0.3) and percentage of age and gender predicted METs (138 ± 43 vs. 153 ± 46%, p = 0.2) to those without severe MR. Patients with degenerative MR assessed by CMR and stress echocardiography, there was no relationship between MR severity and either symptoms or exercise capacity. These findings highlight the disconnect between symptoms and the severity of MR and challenge the assumption that correcting MR can be counted on to improve symptom status in patients with degenerative MR.

Incident atrial functional mitral regurgitation in atrial fibrillation and sinus rhythm

Abstract Funding Acknowledgements Type of funding sources: None. Background Atrial functional mitral regurgitation (AFMR) has been associated with atrial fibrillation (AF) and heart failure with preserved ejection fraction. However, data on its incidence, risk factors, and clinical outcomes are scarce. Objective We aimed to study the incidence, risk factors and clinical significance of AFMR, defined as &amp;gt;mild functional MR in the absence of more than mild left ventricle enlargement or dysfunction, in AF and sinus rhythm (SR). Methods Adults with a new diagnosis of AF between 2010–2021 who had a transthoracic echocardiogram (TTE) were identified (n=57,109). Similarly, adults with no diagnosis of AF who had a TTE between 2010–2021 were identified for comparison (n= 364,767). Patients with &amp;gt;mild MR at baseline, primary mitral valve disease, cardiomyopathy, ≥moderate aortic valve disease, current or previous low ejection fraction, enlarged left ventricle, cardiac devices, previous cardiac surgeries, or with no follow up TTE ≥6 months from baseline were excluded. Furthermore, patients with AF had to have a TTE within 1 month of AF diagnosis. The presence of ≥2 of 4 abnormal diastolic function parameters [mitral septal e’ &amp;lt;0.07 m/sec, mitral septal E/e’ &amp;gt;15 in SR and &amp;gt;11 in AF, TR velocity &amp;gt;2.80 m/sec, left atrial volume index &amp;gt;34 ml/m2] was determined. Cox proportional hazards regression was used to determine risk factors associated with incident AFMR and all-cause death. Patients without the event of interest were censored at last follow up. Patients who developed &amp;gt;mild MR of other types (primary or functional ventricular) were censored at that time. Results Overall, 1,747 (median age 67 years; 34% females) patients with AF and 29,623 (median age 59; 51% females) in SR were included. Incident AFMR occurred in 167 patients with AF over median 3.1 (IQR 1.6–5.1) years [incidence rate of 2.6 per 100-person year] and in 780 patients in SR over median 3.1 (IQR 1.5–5.8) years [incidence rate 0.7 per 100-person year] (Figure 1). AF remained associated with AFMR after adjusting to confounding factors [age ≥65, female sex, ≥2 abnormal diastolic function parameters, and low hemoglobin; adjusted HR 3.23 (2.71–3.85)]. Independent risk factors associated with incident AFMR in AF were age ≥65, female sex, persistent AF, and ≥2 abnormal diastolic function parameters, whereas successful rhythm control without recurrence was a protective factor (Figure 2a). Risk factors for AFMR in SR were age ≥65 years, female sex, presence of ≥2 abnormal diastolic function parameters, and low hemoglobin (Figure 2a). Incident AFMR was independently associated with all-cause death in both AF and SR (Figure 2b). Conclusions AF confers more than 3-fold increase in the risk of AFMR. Diastolic dysfunction, older age, and female sex were independent risk factors for incident AFMR in both SR and AF. Paroxysmal AF and successful rhythm control were protective factors against AFMR in AF. AFMR is universally associated with worse mortality.

P211 BLEEDING AND THROMBOSIS: A MULTIDISCIPLINARY SLALOM

Abstract GG is a 75 kg and 75 years old smoker man with metabolic syndrome, potus, OSAS and LBBB. In 1/2022 the echo imaging showed EF 35%, high dissincrony and PVCs so a myocardial SPECT had been recommended but not carried out by the patient. In 6/2022 new exertional dyspnea, orthopnea and peripheral oedema lead the patient to the Emergency Department: the ECG indicated new onset AF 75 bpm, at laboratory tests creatinine 1.8 mg/dL and NTproBNP 6200 pg/ml and echocardiography confirmed hypokinetic cardiopathy with EF 35%, mild–moderate mitral and tricuspidal regurgitation with pulmonary hypertension and vascular congestion. Admitted for heart failure and new onset AF, diuretic and levosimendan ev, MRA, BB and LMWH started with benefit. At the end of inotropic therapy, ARNI, SGLT2 and inhaled cortisone began. Myocardial SPECT proved moderate fixed inferior wall hypoperfusion. Hospitalization was complicated by ecchymoses and hematomas of abdomen superficial soft tissues during LMWH and proximal saphenous vein and III middle left thigh thrombophlebitis, so apixaban 5mg BID and elastic stockings started with resolution. The onset of paresthesias, pain and left leg progressive hyposthenia led to diagnosis of a partial hematoma of the ilio–psoas muscle resulting in a complete left femoral nerve lesion and severe obturator nerve and left lumbosacral trunk suffering plus further right iliac and rectus abdominis muscles hematomas. Discontinued apixaban, after 72 hours the hematoma was surgically removed without complications and fast recovery thanks to FKT. 9 days later left leg DVT recurrence was observed: in absence of absolute contraindications to anticoagulant therapy and blood count stability, without evident new bleedings, heparin infusion was set with maintenance of the aPTT values at the lower therapeutic range limits. One week later radiological imaging demonstrated reduction of left retroperitoneal hematoma so dabigatran 150 mg BID was initiated. Control echo showed EF 42%, mild MR and TR. Regular the subsequent rehabilitation course: the patient was discharged with dabigatran 110 mg twice daily to limit long–term bleeding risk. The thrombotic/bleeding risks require a complex therapeutic modulation in a multidisciplinary teamwork.

Machine Learning–Based Phenogrouping in MVP Identifies Profiles Associated With Myocardial Fibrosis and Cardiovascular Events

BackgroundStructural changes and myocardial fibrosis quantification by cardiac imaging have become increasingly important to predict cardiovascular events in patients with mitral valve prolapse (MVP). In this setting, it is likely that an unsupervised approach using machine learning may improve their risk assessment. ObjectivesThis study used machine learning to improve the risk assessment of patients with MVP by identifying echocardiographic phenotypes and their respective association with myocardial fibrosis and prognosis. MethodsClusters were constructed using echocardiographic variables in a bicentric cohort of patients with MVP (n = 429, age 54 ± 15 years) and subsequently investigated for their association with myocardial fibrosis (assessed by cardiac magnetic resonance) and cardiovascular outcomes. ResultsMitral regurgitation (MR) was severe in 195 (45%) patients. Four clusters were identified: cluster 1 comprised no remodeling with mainly mild MR, cluster 2 was a transitional cluster, cluster 3 included significant left ventricular (LV) and left atrial (LA) remodeling with severe MR, and cluster 4 included remodeling with a drop in LV systolic strain. Clusters 3 and 4 featured more myocardial fibrosis than clusters 1 and 2 (P < 0.0001) and were associated with higher rates of cardiovascular events. Cluster analysis significantly improved diagnostic accuracy over conventional analysis. The decision tree identified the severity of MR along with LV systolic strain <21% and indexed LA volume >42 mL/m2 as the 3 most relevant variables to correctly classify participants into 1 of the echocardiographic profiles. ConclusionsClustering enabled the identification of 4 clusters with distinct echocardiographic LV and LA remodeling profiles associated with myocardial fibrosis and clinical outcomes. Our findings suggest that a simple algorithm based on only 3 key variables (severity of MR, LV systolic strain, and indexed LA volume) may help risk stratification and decision making in patients with MVP. (Genetic and Phenotypic Characteristics of Mitral Valve Prolapse, NCT03884426; Myocardial Characterization of Arrhythmogenic Mitral Valve Prolapse [MVP STAMP], NCT02879825)

Differences in clinical and echocardiographic features and outcomes between atrial functional mitral regurgitation patients with and without posterior mitral leaflet bending

BackgroundPosterior mitral leaflet (PML) bending is a cause of atrial functional mitral regurgitation (AFMR). We aimed to investigate differences in clinical and echocardiographic features and outcomes between AFMR patients with and without PML bending. MethodsWe retrospectively examined 118 AFMR patients with atrial fibrillation (AF), mild or greater MR without degenerative mitral valve changes, and left ventricular ejection fraction ≥50 %. Patients were classified by the presence of PML bending: PML bending (n=24) and no PML bending (n=94). PML bending was defined as PML-to-anterior mitral leaflet angle ratio ≥3.1 calculated using receiver operating characteristics analysis for eccentric MR jet toward left atrial posterior wall. The study endpoint was a composite of cardiac death, admission for heart failure, and mitral valve surgery. ResultsOverall, a total of 88 patients (75 %) had mild MR. There were no between-group differences in clinical and echocardiographic characteristics including AF duration and cardiac cavities size except for the length of inward bending of the left ventricular posterobasal wall and the mitral annular area. The 36-month event-free survival for the composite endpoint was significantly lower in the PML bending group (63 % vs. 78 %; Log-rank p=0.047). In multivariate analysis, PML bending was also associated with the composite outcome. ConclusionsAFMR patients with PML bending may have worse outcomes than those without PML bending despite similar clinical features.