Mitral Annular Dimensions Research Articles

3-Dimensional Echocardiographic Prediction of Left Ventricular Outflow Tract Area Prior to Transcatheter Mitral Valve Replacement

BackgroundNew postprocessing software facilitates 3-dimensional (3D) echocardiographic determination of mitral annular (MA) and neo–left ventricular outflow tract (neo-LVOT) dimensions in patients undergoing transcatheter mitral valve replacement (TMVR). ObjectivesThis study aims to test the accuracy of 3D echocardiographic analysis as compared to baseline computed tomography (CT). MethodsA total of 105 consecutive patients who underwent TMVR at 2 tertiary care centers between October 2017 and May 2023 were retrospectively included. A virtual valve was projected in both baseline CT and 3D transesophageal echocardiography (TEE) using dedicated software. MA dimensions were measured in baseline images and neo-LVOT dimensions were measured in baseline and postprocedural images. All measurements were compared to baseline CT as a reference. The predicted neo-LVOT area was correlated with postprocedural peak LVOT gradients. ResultsThere was no significant bias in baseline neo-LVOT prediction between both imaging modalities. TEE significantly underestimated MA area, perimeter, and medial-lateral dimension compared to CT. Both modalities significantly underestimated the actual neo-LVOT area (mean bias pre/post TEE: 25.6 mm2, limit of agreement: −92.2 mm2 to 143.3 mm2; P < 0.001; mean bias pre/post CT: 28.3 mm2, limit of agreement: −65.8 mm2 to 122.4 mm2; P = 0.046), driven by neo-LVOT underestimation in the group treated with dedicated mitral valve bioprosthesis. Both CT- and TEE-predicted-neo-LVOT areas exhibited an inverse correlation with postprocedural LVOT gradients (r2 = 0.481; P < 0.001 for TEE and r2 = 0.401; P < 0.001 for CT). ConclusionsTEE-derived analysis provides comparable results with CT-derived metrics in predicting the neo-LVOT area and peak gradient after TMVR.

Association of Mitral Valve Geometry at CT with Secondary Mitral Regurgitation after Transcatheter Aortic Valve Replacement in Patients with Aortic Regurgitation.

The improvement rate and predictors of secondary mitral regurgitation in patients with aortic regurgitation undergoing transcatheter aortic valve replacement (TAVR) remain unclear. This study aimed to identify predictors of persistent moderate to severe secondary mitral regurgitation after TAVR in patients with aortic regurgitation by assessing mitral valve geometry with computed tomography (CT). This retrospective cohort study reviewed 242 consecutive patients with aortic regurgitation who underwent TAVR between May 2014 and December 2022. Patients with primary or less than moderate mitral regurgitation were excluded. Mitral annular dimensions (area, perimeter, anteroposterior, intercommissural, and trigone-to-trigone diameter), mitral valve tenting geometry (mitral valve tenting area [MVTA] and mitral valve tenting height [MVTH]), and papillary muscle displacement were systematically measured at CT. Mitral regurgitation improvement was assessed at 3 months after TAVR by echocardiography. Logistic regression was performed to explore the association of mitral valve geometry with mitral regurgitation improvement after TAVR. A total of 75 patients (mean age, 74 7 years; 32.0% female) with moderate to severe secondary mitral regurgitation were included in the final analysis. Mitral regurgitation improved in 49 patients and remained unchanged in 26 patients. Mitral annular dimensions, including area, perimeter, anteroposterior, and intercommissural diameter, were associated with mitral regurgitation improvement. MVTA and MVTH were risk factors for sustained mitral regurgitation. In addition, QRS duration 120 ms and atrial fibrillation had an impact on the mitral regurgitation improvement. Mitral annular area (odds ratio [OR], 1.41; 95% confidence interval [CI]: 1.05, 1.90; p = 0.02) and MVTA (OR, 7.24; 95% CI: 1.72, 30.44; p = 0.007) were independent predictors of persistent secondary mitral regurgitation after TAVR. Mitral annular area and MVTA were independent predictors of persistent secondary mitral regurgitation after TAVR.

Reverse remodeling of mitral leaflets after medical treatment in recent-onset dilated cardiomyopathy.

The growth of mitral leaflets (MLs) adaptive to left ventricluar (LV) remodeling has been observed. However, the elasticity of MLs upon mechanical stimuli would be supposed if it shrinks with LV reverse remodeling (LVRR). Patients with idiopathic recent-onset dilated cardiomyopathy (RODCM) (n = 82) and 50 matched normal controls (NC) were prospectively enrolled. Echocardiography was performed at baseline and 6 months of follow-up for the anterior and posterior mitral leaflet (AML and PML) length, mitral annular dimension (MAD), and tenting height (TH). LVRR was measured as a ≥ 15% reduction in LV end-diastolic volume (LVEDV). After 6 months, LVRR was achieved in 69.5% of patients. The AML (28 ± 3 vs. 26 ± 3 mm, p = 0.004) and PML (19 ± 4 vs. 17 ± 3 mm, p < 0.001) decreased in length, as well as the MAD (31 ± 5 vs. 28 ± 5 mm, p = 0.001) and TH (10 ± 3 vs. 8 ± 2 mm, p < 0.001). Compared with the NC group, the AML and PML of the RODCM group were 16.7% and 35.7% longer at baseline and remained 8.3% and 21.2% longer at follow-up, respectively. The change in AML or PML correlated moderately with that in LVEDV (r = 0.487, p < 0.001; r = 0.516, p < 0.001, respectively). The AML and PML length decreased in the LVRR (+) subgroup (AML, 28 ± 3 vs. 26 ± 3 mm, p = 0.001; PML, 20 ± 4 vs. 16 ± 3 mm, p < 0.001), but remained the same in the LVRR (-) subgroup (27 ± 4 vs. 28 ± 4 mm, p = 0.318; 17 ± 3 vs. 17 ± 3 mm, p = 0.790). Enlarged MLs could reverse accompanied by LV reverse remodeling. This study provided the other facet of ML plasticity adaptive to mechanical stretching.

Mitral leaflet retraction and left ventricular reverse remodeling in patients with treated dilated cardiomyopathy

Abstract Background Enlargement of the mitral leaflets (MLs) adaptive to mechanical stress caused by dilated left ventricle (LV) was recognized, but their changes after the stimuli withdrawn remained unexplored. Aims To observe morphological changes in the MLs along with LV reverse remodeling (LVRR) occurred after standard care. Methods Patients with recent-onset dilated cardiomyopathy (RODCM) were prospectively enrolled (n=82), as well as a group of age, sex and body surface area matched normal controls (NC) (n=50). Two-dimensional transthoracic echocardiography was performed at baseline and 6-month follow-up with special interests in the length of anterior and posterior mitral leaflet (AML and PML), mitral annular dimension (MAD) and tenting height (TH). LVRR was measured as a reduction in the LV end-diastolic volume (LVEDV) of ≥15%. Results At the 6-month follow-up, LVRR was achieved in 69.5% patients and there were 26.9% patients who reported ≥1 grade reduction in secondary mitral regurgitation that related to LVRR. The AML (28±3 vs. 26±3mm, p=0.004) and PML (19±4 vs. 17±3mm, p&amp;lt;0.001) were decreased, as well as the MAD (31±5 vs. 28±5mm, p=0.001) and TH (10±3 vs. 8±2mm, p&amp;lt;0.001), but all remained larger than that of the NC group (all p&amp;lt;0.05). When compared with the control group, the AML and PML of the RODCM group was 16.7% and 35.7% longer at baseline, which remained 8.3% and 21.2% longer at the follow-up, respectively. The change in the AML (△AML) or PML (△PML) correlated moderately to the change in the LVEDV (△LVEDV) (r=0.487, p&amp;lt;0.001; r=0.516, p &amp;lt;0.001, respectively) (Figure 1). When compared between the subgroups stratified by LVRR, both the AML and PML decreased in the patients who had LVRR (+) (AML, 28±3 vs. 26±3, p=0.001; PML, 20±4 vs. 16±3, p&amp;lt;0.001), but remained the same length in those with LVRR (-) (AML, 27±4 vs. 28±4, p=0.318; PML, 17±3 vs. 17±3, p=0.790). The comparison in the △AML and △PML between the two subgroups is shown in Figure 2. Conclusion The enlarged MLs could retract with different behavior in the AML and PML, accompanied by LV reverse remodeling. This study conducted in patients with RODCM who received standard therapy provided the other facet of mitral leaflet plasticity adaptive to mechanical stretch.correlation between △MLs and △LVEDVCompare △MLs between LVRR subgroups

Anatomic suitability for transapical transcatheter mitral valve implantation using a tether-based device.

Transcatheter mitral valve implantation (TMVI) is a novel therapeutic option for treating symptomatic mitral valve disease. Evaluating patient anatomical suitability is a critical step in the TMVI screening process, but currently requires specialized software and computerized device models. This analysis sought to assess the effectiveness of simple and standardized multislice computed tomography (MSCT) anatomic measurements for their ability to discriminate between patients who passed anatomical screening for Tendyne™ TMVI. Subjects screened for the Tendyne Expanded Clinical Study from January 2016 through September 2019 were included. Core laboratory screening measurements included mitral annular (MA) dimensions at end-systole and end-diastole, simulated device implantation, and neo-left ventricular outflow tract (LVOT) area. Additionally, nine standard measurements of patient anatomy were assessed for their predictive value of patients passing the anatomic screening process. Out of 496 subjects screened for eligibility, 257 subjects met clinical eligibility criteria with MA dimensions within the manufacturer's suggested range: 153 (59.5%) underwent TMVI while 104 (40.5%) were excluded from the study for other anatomic reasons (76% due to risk of LVOT obstruction). CT-derived left ventricular end-systole diameter (LVESD) had the highest discriminatory power for predicting TMVI anatomical suitability (area under the curve of 0.908, p < 0.0001). The mitral inter-commissural (IC) dimension was best predictive of annular dimensions being within range, with dimensions <30 or >50 mm resulting in a negative predictive value of 94.4%. MSCT-derived mitral IC dimension and LVESD easily performed measures that are effective predictors of anatomical suitability or screen failure for this tether-based TMVI device.

Multimodality imaging assessment of mitral annulus disjunction in consecutive patients

Abstract Funding Acknowledgements Type of funding sources: None. Background Mitral annulus disjunction (MAD) has been investigated through trans-thoracic-echocardiography (TTE) and cardiac magnetic resonance (CMR) in different study cohorts and has been assumed either to represent a structural risk marker of sudden cardiac death or a benign, incidental finding. The imaging modality used to assess MAD might impact its prevalence and clinical significance. Purpose To assess the prevalence of MAD in consecutive patients undergoing TTE and CMR. Methods We retrospectively searched for MAD in consecutive patients undergoing TTE and CMR within six months, one from each other, at our center from March 2021 to April 2022. MAD was assessed in standard echocardiographic and CMR long-axis views and was defined as a ≥ 2 mm displacement between the left atrial wall-mitral valve leaflet junction hinge and the top of the left ventricular wall. Cases of pseudo-MAD and true-MAD were defined by MAD presence, respectively, during only systole and both systole and diastole. Results 124 patients (47 women; mean age: 59 years ± 17) were included. According to CMR, 38 patients (31%) presented with a structurally normal heart, and 37 (30%) presented with MAD. Patients with MAD presented more frequently MVP (27% vs. 1%; P&amp;lt;0.001), whereas patients without MAD were more frequently affected by non-ischemic cardiomyopathy (30% vs. 11%; p = 0.02). The two groups did not differ in age, sex, cardiac risk factors, symptoms, left ventricular volumes, ejection-fraction, pre-contrast T1- and T2-mapping, mitral annulus dimension and mitral regurgitation. MAD prevalence was higher by CMR than by TTE (30% vs. 8%; P=0.028). There was a low inter-modality agreement for the detection of MAD presence (Cohen's kappa=0.34) and a moderate agreement for MAD extent (ICC=0.71; 95% LOA 0.59, 0.8, p&amp;lt;0.05). Median MAD extent reported CMR and TTE were 2.6 mm (IQR 2.05–3.75 mm) and 4 mm (IQR 2.65–4.65 mm) respectively. All patients showing MAD at TTE demonstrated it at CMR too. Cases of true-MAD were observed at CMR (14% of the total cohort) but not at TTE. Conclusion In this cohort of consecutive patients, MAD was missed by TTE in more than 2 out of 3 patients exhibiting it at CMR. The high prevalence of MAD at CMR and the absence of significant association between this phenomenon and morpho-functional or structural alterations argue in favor of a benign finding at CMR. TTE detected MADs with higher extents compared to CMR. Further longitudinal studies are needed to evaluate the imaging-modality-related clinical relevance of MAD to improve patients’ risk stratification.

387 MITRAL VALVE MORPHO-FUNCTIONAL FEATURES DURING THE ACUTE AND RECOVERY PHASE IN PATIENTS WITH TAKOTSUBO SYNDROME

Abstract Background Acute mitral valve regurgitation is known to be associated with a severe prognosis in patients affected by Takotsubo syndrome (TTS). The mechanisms involved are different and related to various pathogenesis such as cordal or mitral anterior leaflet (LAM) systolic anterior motion (SAM) and tethering of the mitral valve. Aim of the study to compare mitral valve morpho-functional features and concomitant left ventricle (LV) abnormalities by transthoracic echocardiography in patients during the acute and recovery phase of Takotsubo syndrome. Methods 24 consecutive patients were enrolled from a multicenter prospective registry of TTS from July 2007 to February 2022. Through transthoracic echocardiography, LV ejection fraction, LV end-diastolic and end-systolic diameters and volumes, left atrium antero-posterior diameter and end-systolic volume, mitral anulus diameter, prevalence of mitral valve regurgitation, of LV outflow tract obstruction (LVOTO), coaptation depth and tenting area were collected during the acute and recovery phase of takotsubo syndrome. Results LVEF at admission was 39.6 ± 7.8% vs 60.5 ± 4% at functional recovery (p&amp;lt;0.001). LVEDV, LVESV and LVESVi were found to be higher during the acute phase when compared to the recovery phase (103.8 ± 28.9 vs 89.7 ± 23.4 ml, p=0.012; 59.8 ± 17.2 vs 35.1 ± 10.1 ml, p&amp;lt; 0.001; and 36.1 ± 9 vs 20.6 ± 5.4 ml/m2, p&amp;lt;0.001 respectively). No statistically significant differences were found between admission and recovery phase in term of mitral annular dimension (32.3 ± 4.6 vs 32.5 ± 4.1 mm, p=0.825), tenting area (2.3 ± 0.6 vs 2.2 ± 0.7 cm2, p=0.445), proximal thickness and length of both of the mitral leaflets, while coaptation depth was higher during the acute phase in comparison to functional recovery (1.1 ± 0.2 vs 1 ± 0.3 cm, p=0.018). 10 patients (41%) presented with moderate/ severe mitral insufficiency and 5 patients of them (20% of the general population) downgraded to mild at recovery. Among the patients with values of LVEDV higher than 104 mL, LVESV higher than 43 mL, LVESVi higher than 25 mL/m2 and coaptation depth higher than 1.1 cm during the acute phase, 4 out of 5 patients experienced a downgrade of the severity of mitral valve regurgitation. Conclusions Left ventricle end-diastolic volume and coaptation depth are statistically different during the acute and recovery phase. Among the patients who experienced a downgrading of the severity of mitral valve regurgitation, higher values of LVEDV, LVESV, LVESVi and coaptation depth during the acute phase were found.

Level of agreement between three-dimensional transthoracic and transesophageal echocardiography for mitral annulus evaluation: A feasibility and comparison study.

Mitral annulus assessment is of utmost importance for the management of patients with mitral valve (MV) abnormalities, as it helps to determine the decision for surgical or transcatheter treatment. Three-dimensional (3D) transesophageal echocardiography (TOE) has been the only reliable echocardiographic method for the evaluation of the mitral annulus by now. However, newer transthoracic echocardiography (TTE) 3D probes have enabled to provide accurate measurements as well and become a valuable tool when TOE is contraindicated. The aim of this study is to assess the feasibility of 3D TTE analysis of mitral annulus and the level of agreement with 3D TOE measurements. A total of 121 consecutive patients were assessed with 3D TTE and TOE. All mitral annulus parameters were retrospectively analyzed with the dedicated 4D autoMVQ application. Bland-Altman analysis and intraclass correlation coefficient were used for the comparison and agreement between the two methods. Half of our patients had normal mitral valves and served as control group, while the other half had various mitral valve pathologies. AutoMVQ analysis was not feasible in 11 out of 121 TTE examinations (91% feasibility) and in 4 out of 121 TOE examinations (96% feasibility). Mitral annular area and perimeter were slightly larger in TTE than those measured by TOE (12.7±3.6vs. 12.4±3.2 cm2 for area and 12.7±1.7vs. 12.5±1.6cm for perimeter), however still showing strong correlation (r=.942 and r=.922, respectively). The majority of mitral valve measurements (anterior-posterior, medial-lateral and commissural diameter, aorto-mitral angle and anterior leaflet length) were similar among the two methods with strong correlation (r>.80). Inter-trigonal distance, posterior leaflet length and tenting height showed weaker agreement between TTE and TOE (r=.687, r=.687, r=.634, respectively). Mitral annular dimensions (by 3D area) were found to be significantly larger in patients with MV pathology (13.5±3.5vs. 11±2.3 cm2 ), atrial fibrillation (14.4±3vs. 11.4±2.8 cm2 ), left ventricular (13.8±3.1vs. 11.7±3.1cm2 ) and left atrial dilatation (13±3.3vs. 10.6±2.3cm2 ) compared to the individuals in the control group (p<.001 for all comparisons). Assessment of the MV with 3D TTE with dedicated MVQ software is feasible and accurate, showing strong correlation and agreement with TOE measurements.

The mitral annulus in transposition of the great arteries late after Senning- and Mustard-procedures (Insights from the CSONGRAD Registry and MAGYAR-Path Study).

Dextro-transposition of the great arteries (dTGA) is a rare condition comprising 5-7% of all congenital heart diseases (CHD). Until 1990s, atrial switch operations were the method of choice for the treatment of dTGA. The aim of our present study was to evaluate the abnormalities of the mitral annulus (MA) by three-dimensional speckle-tracking echocardiography (3DSTE). Potential differences in MA dimensions and functional properties late after Senning- and Mustard-procedures were analyzed as well. This retrospective cohort study comprised 19 dTGA patients late after atrial switch operation, from which 7 subjects were not involved due to inferior image quality. The remaining dTGA patient group comprised 12 subjects (age: 30.7±8.6 years, 7 males). For comparisons, 32 age- and gender-matched healthy controls were evaluated (age: 34.4±12.3 years, 18 males). End-systolic and end-diastolic MA diameter (MAD), area and perimeter proved to be increased, while MA functional parameters [MA fractional area change (MAFAC) and fractional shortening (MAFS)] were reduced in all dTGA patients as compared to matched controls regardless of the atrial switch procedure used. However, MA morphological parameters were tendentiously lower, while MA functional parameters were tendentiously favorable in case of Senning-procedure compared to Mustard-procedure. dTGA is accompanied by MA dilation and its functional impairment late after Senning- and Mustard-procedures.

Automatic 3D mitral valve leaflet segmentation and validation of quantitative measurement

3D transesophageal echocardiography (TEE) is widely used in the diagnosis of mitral valve disease and is also well suited for guiding cardiac interventions. The aim of this work is to achieve patient-specific 3D TEE mitral valve leaflet segmentation without any user interaction and to assess the feasibility of 3D quantitative measurements on automatic segmentation model. We suggested a novel pre-training strategy to better implement automatic segmentation. The strategy refers to classify the diastolic and systolic states of the mitral valve through a 3D convolutional neural network architecture, and then use the pretrained weights obtained from the classification task to initialize the parameters of the 3D segmentation deep learning framework. To determine the accuracy of geometric parameters of segmentation model, the measurements of the segmentation model were compared with those obtained by the clinical software. Statistical analysis was performed by using Intraclass Correlation Coefficient and Bland–Altman method. Fourteen 3D volumes were used to evaluate the segmentation performance. The results show a Dice Similarity Coefficient (DSC) of 0.877±0.027 and an Average Surface Distance (ASD) of 0.925±0.392 mm. Twenty-eight 3D volumes were used for the quantitative measurement. The statistical results show that the mitral annular parameters have a good agreement between segmentation model and clinical software except for the annular height. We developed a fully automatic methodology to segment the mitral valve leaflet from 3D TEE and demonstrated the feasibility of improving segmentation performance with the proposed pre-training strategy. The automatic segmentation model was proved to be reliable for performing quantitative measurements of mitral valve annulus dimensions. The results indicate that the precision of the automatic segmentation methodology could pave the way for application in quantification, modeling and surgical planning tools.

Associations between Mitral Annular and Left Atrial Volume Changes in Healthy Adults-Detailed Analysis from the Three-Dimensional Speckle-Tracking Echocardiographic MAGYAR-Healthy Study.

Three-dimensional (3D) speckle-tracking echocardiography (3DSTE) is one of the newest development in non-invasive imaging offering simultaneous 3D evaluation of atria and valvular annuli. 3DSTE was used to analyze correlations between left atrial (LA) volume changes and mitral annular (MA) dimensions and functional properties in healthy adult subjects. A total of 297 healthy subjects were enrolled in this retrospective cohort study, from which insufficient quality of images was responsible for the exclusion of 98 cases (33%). The remaining study population consisted of 199 healthy adults without valvular regurgitation/stenosis in sinus rhythm (mean age: 33.5 12.7 years, 104 males, body mass index: 24.7 1.2 kg/ , systolic and diastolic blood pressure: 118.2 3.4 mmHg and 78.3 4.5 mmHg, respectively). Two-dimensional Doppler echocardiography and 3DSTE were performed in all cases. Larger LA volumes were associated with more dilated MA dimensions with its reduced function. Elevated LA stroke volumes could be demonstrated only in systole and end-diastole, while increased LA emptying fraction was present only in end-diastole. Reduced MA fractional area change was associated with larger diastolic LA volumes, smaller early diastolic LA stroke volume, in addition all LA emptying fractions were smaller as well. Correlations could be demonstrated between LA and MA parameters. 3DSTE is suitable not only for chamber quantifications, but also for the assessment of valvular annular dimensions. Strong relationship exists between LA volumes and MA dimensions and functional properties.

Mitral Annulus Geometry and Dynamic Motion Changes in Patients With Aortic Regurgitation: A Three-Dimensional Transesophageal Echocardiographic Study

The aim of the present study was to investigate the mitral annulus (MA) geometry and dynamic motion changes in patients with aortic regurgitation (AR) before and after aortic valve replacement (AVR). Moreover, the difference in the effect of the type of prosthetic aortic valve on MA was compared. Prospective observational study. Cardiac operating room at a single hospital. Eighty-two patients with isolated moderate-to-severe AR who underwent AVR. Forty patients with normal valves were enrolled as controls. None. The MA geometry and dynamic motion throughout the cardiac cycle were evaluated semiautomatically by three-dimensional transesophageal echocardiography. The severity of functional mitral regurgitation was intraoperatively evaluated. All patients were divided into 2 groups depending on the type of prosthetic valve (mechanical valve and bioprosthetic valve groups). Before AVR, compared with the control group without AR, the AR group demonstrated larger MA dimensions and the MA geometry was flatter. The contraction fraction of the MA area, perimeter, and height during the whole cardiac cycle were larger in the AR group (p < 0.05 for all). After AVR, most MA geometric and dynamic parameters decreased and functional mitral regurgitation also improved. In the postoperative subset analyses, the mechanical valve group showed a larger contraction fraction of the MA area and perimeter than the bioprosthetic valve group (p < 0.05 for both). The MA geometry and dynamic motion changed markedly in patients with AR. These spatial and dynamic changes were restored to a certain extent after surgical correction of the aortic valve. However, the effects produced by mechanical and bioprosthetic valves on MA were different.

C14 A PROMISING SURGICAL TECHNIQUE IN PATIENTS WITH ATRIAL FUNCTIONAL MITRAL REGURGITATION: HYPER–DOWN–SIZING ANNULOPLASTY

Abstract Objective Atrial functional mitral valve regurgitation is a less common form of functional mitral regurgitation with normal leaflet motion and morphology, preserved dimension and function of left ventricle, associated with atrial fibrillation ad/or left atrial dilatation. Several factors are involved into the etiology, such as mitral annular dilation and insufficient leaflet remodeling, atriogenic leaflet tethering, loss of annular saddle shape and contractility, changes in heart rate. Methods Eleven consecutive patients with atrial functional mitral regurgitation, mean age 65 ± 12 years, normal left ventricle dimension and ejection fraction greater than 50% underwent mitral valve repair via right mini–thoracotomy in case of isolated mitral and tricuspid valve surgery or via median sternotomy in case of combined procedures. Concomitant procedures include tricuspid valve repair in 1 patient and coronary artery bypass in 5 patients. All patients presented an increased dimension of left atrium (mean left atrial volume: 90 ± 23 ml); mitral annular dimension was investigated with trans–esophageal echocardiography before operation. In all patients was implanted a downsized complete rigid annuloplasty ring with asymmetrical design of two sizes smaller respect to measured intercommissural distance. Clinical outcomes of patients and echocardiographic findings related to mitral regurgitation recurrence and left ventricle function were followed in the time. Results At discharge, any patient present a residual mitral regurgitation greater than mild, mean trans–mitral gradient was 2.5 ±2.1 mmHg. During the follow–up period of 24 ± 5 months, the New York Heart Association functional class significantly improved from 2.5 ± 0.4 to 1.5 ± 2.1. In three patients occurred cardiac rhythm disturbances requiring hospital stay, only one patient developed a greater than mild mitral regurgitation, reoperation was not becessary in any case. Left atrial volume decreased from 90 ± 23 ml to 58 ± 30 ml. Conclusions Mitral annuloplasty with downsized ring is a safe and effective procedure in patient with atrial functional mitral regurgitation in the same way of patient with functional mitral regurgitation due to ventricular dilation and tethering. The comforting clinical and echocardiographic outcome in our small group of patient encourage future studies in this particular group of patients.

Computational estimates of annular diameter reveal genetic determinants of mitral valve function and disease.

The fibrous annulus of the mitral valve plays an important role in valvular function and cardiac physiology, while normal variation in the size of cardiovascular anatomy may share a genetic link with common and rare disease. We derived automated estimates of mitral valve annular diameter in the 4-chamber view from 32,220 MRI images from the UK Biobank at ventricular systole and diastole as the basis for GWAS. Mitral annular dimensions corresponded to previously described anatomical norms, and GWAS inclusive of 4 population strata identified 10 loci, including possibly novel loci (GOSR2, ERBB4, MCTP2, MCPH1) and genes related to cardiac contractility (BAG3, TTN, RBFOX1). ATAC-Seq of primary mitral valve tissue localized multiple variants to regions of open chromatin in biologically relevant cell types and rs17608766 to an algorithmically predicted enhancer element in GOSR2. We observed strong genetic correlation with measures of contractility and mitral valve disease and clinical correlations with heart failure, cerebrovascular disease, and ventricular arrhythmias. Polygenic scoring of mitral valve annular diameter in systole was predictive of risk mitral valve prolapse across 4 cohorts. In summary, genetic and clinical studies of mitral valve annular diameter revealed genetic determinants of mitral valve biology, while highlighting clinical associations. Polygenic determinants of mitral valve annular diameter may represent an independent risk factor for mitral prolapse. Overall, computationally estimated phenotypes derived at scale from medical imaging represent an important substrate for genetic discovery and clinical risk prediction.

Mitral regurgitation severity dynamic during acute decompensated heart failure treatment

Acute decompensated heart failure (ADHF) treatment leads to significant hemodynamic changes. The aim of our study was to quantitatively analyze the dynamics of mitral regurgitation (MR) severity (evaluated by transthoracic echocardiography) which occur during the treatment of ADHF and to correlate these changes with the clinical condition of patients as well as heart failure biochemical markers. The study included 27 consecutive adult patients (40.7% females, mean age 71.19 ± 11.2 years) who required hospitalization due to signs of acute HF. Echocardiographic assessment was performed upon admission and discharge together with clinical and laboratory evaluation. Significant reduction in dyspnea intensity [0–100 scale] (81.48 ± 9.07 vs. 45.00 ± 11.04 pts, p < 0.001), body weight (84.98 ± 18.52 vs. 79.77 ± 17.49 kg, p < 0.001), and NT-proBNP level (7520.56 ± 5288.62 vs. 4949.88 ± 3687.86 pg/ml, p = 0.001) was found. The severity of MR parameters decreased significantly (MR volume 44.92 ± 22.83 vs. 30.88 ± 18.77 ml, p < 0.001; EROA 0.37 ± 0.17 vs. 0.25 ± 0.16 cm2, p < 0.001; VC 6.21 ± 1.48 vs. 5.26 ± 1.61 mm, p < 0.001). Left atrial area (35.86 ± 9.11 vs. 32.47 ± 9.37, p < 0.001) and mitral annular diameter (42.33 ± 6.63 vs. 39.72 ± 5.05. p < 0.001) also underwent statistically significant reductions. An increase in LVEF was observed (34.73 ± 13.88 vs. 40.24 ± 13.19%, p < 0.001). In 40.7% of patients, a change in MR severity class (transition from a higher class to a lower one) was observed: 6/8 (75%) patients transitioned from severe to moderate and 6/18 (33.3%) patients transitioned from moderate to mild class. Treatment of ADHF leads to a significant reduction in MR severity, together with significant reductions in left atrial and mitral annular dimensions. Quantitative measurement of MR dynamics offer valuable assistance for ADHF management.

763 Feasibility and reliability of a comprehensive three-dimensional transesophageal echocardiography screening process for transcatheter mitral valve replacement

Abstract Aims The planning of transcatheter mitral valve replacement (TMVR) requires cardiac imaging assessment to establish patient eligibility according to mitral valve anatomy, device characteristics and risk of left ventricular outflow tract (LVOT) obstruction. In this setting, computed tomography (CT) is considered the reference method. Although recent studies demonstrated that three-dimensional transesophageal echocardiographic (3D-TEE) assessment of mitral anatomy presents a good agreement compared to CT, its potential role in the TMVR planning has never been fully evaluated. To test feasibility and reliability of a comprehensive 3D-TEE screening in candidates for TMVR. Methods We performed a single-centre retrospective observational study including 59 consecutive patients referred to our centre for TMVR due to high surgical risk, who performed a pre procedural CT and 3D-TEE screening. The measurements of mitral annulus (MA), native LVOT and predicted Neo-LVOT, assessed with CT and 3D-TEE were collected in order to evaluate their concordance in the assessment of TMVR eligibility. The final suitability decision was given by the valve manufacturer based on CT measurements and then compared with the screening results obtained with 3D-TEE evaluation. 3D-TEE measurements were obtained with a post processing analysis using a novel automated software platform (3mensio Structural Heart 10.1 - 3mSH, Pie Medical Imaging, Bilthoven, Netherlands). Results Excellent correlation was found between 3D-TEE and CT measurements for MA area (r =0.85), antero-posterior diameters (r= 0.81), native LVOT (r=0.82) and Neo-LVOT areas (r=0.95) (all P-values &amp;lt;0.0001). Among 59 patients screened, 17 did not undergo the intervention because were found ineligible due to small predicted neo-LVOT, too small or too large MA area. Among the 42 patients with a successful screening, 32 underwent TMVR and all of them showed a correct implantation and no LVOT obstruction at post procedural echocardiographic evaluation. An almost perfect agreement among CT and 3D-TEE was found in assessing the eligibility for TMVR implantation (Cohen kappa 0.82, P&amp;lt;0.001). Interobserver and intraobserver agreements were found excellent for the parameters appraised with ICCs &amp;gt;0.80. Conclusions 3D-TEE appraisements of MA dimensions, native LVOT and Neo-LVOT are feasible in patients candidate for TMVR, showing good correlations with CT measurements and high accuracy to predict TMVR screening success.

Transcatheter edge-to-edge mitral valve repair in atrial functional mitral regurgitation: insights from the multi-center MITRA-TUNE registry

BackgroundA-FMR is considered a specific sub-type of secondary MR in patients with atrial fibrillation (AF) and preserved left ventricle ejection fraction (LVEF). Aim of the study was to investigate the acute and mid-term outcomes of transcatheter edge-to-edge mitral valve repair (TMVr) with the MitraClip in atrial functional mitral regurgitation (A-FMR). MethodsThe study included patients with A-FMR and concomitant AF who underwent to the MitraClip at 7 Italian Centers. Aim of the study was to assess the safety, efficacy and mid-term cardiovascular outcomes. ResultsAfter reviewing 1153 patients with FMR treated with TMVr from 2009 to 2021, 87 patients (median age 81 years, 61% female) with A-FMR were identified. Technical success was achieved in 97%, 30-day device success in 83% and 30-day procedural success in 80%. All-cause death at 30-day was 5%. Estimated two-year freedom from all-cause death and cardiac death was 60% and 77%, respectively, whereas freedom from all-cause death/heart failure hospitalization was 55%. Residual MR ≤ 2+ was encountered in 89% (n = 47/53) and improvement in NYHA class I/II in 79% (n = 48/61). Post-procedural MR ≥ 2+ (HR 5.400, CI 1.371–21.268) and inter-commissural annular diameter ≥ 35 mm (HR 4.159, CI 1.057–16.363) were independent predictors of all-cause death/heart failure hospitalization during the follow-up. Positive reverse remodeling of left atrium and mitral annular dimensions occurred after TMVr during the follow-up. ConclusionsMitraClip resulted to be a safe and effective option to treat A-FMR in elderly patients.

Left atrial volumes changes are associated with changes in mitral annular dimensions and functional properties in healthy adults – a three-dimensional speckle-tracking echocardiographic study

Abstract Introduction Three-dimensional (3D) speckle-tracking echocardiography (3DSTE) is a novel echocardiographic method with capability of 3D assessment of heart chambers and valvular annuli making an opportunity to compare cyclic changes of left atrial (LA) volumes and mitral annular (MA) dimensions in physiological healthy circumstances. The present study was designed to examine correlations between LA volume changes and MA dimensions and functional properties in healthy adult subjects by 3DSTE. Methods The study population consisted of 199 healthy adults (mean age: 33.5±12.7 years, 104 males), who had no symptoms, conditions or diseases, which could affect results. None of subjects received any medication. The group of subjects was divided according to their maximum LA volume (Vmax) into three groups using 30 ml and 50 ml as cut-off values. All subjects underwent complete two-dimensional Doppler echocardiography extended with 3DSTE. Results All LA volumes and stroke volumes increased with end-systolic Vmax. Early diastolic passive atrial emptying fraction (PAEF) was significantly reduced in patients with Vmax&amp;gt;50 ml. End-systolic total atrial emptying fraction (TAEF) and late diastolic active atrial emptying fraction (AAEF) was not accompanied with increased end-systolic Vmax. Both end-diastolic and end-systolic MA dimensions were dilated in subjects with increased Vmax, which was accompanied with reduction of MA function. Only end-systolic MA dimensions showed further increase, when end-systolic Vmax was larger than 50 ml compared to cases with Vmax between 30 ml and 50 ml. When prognostic value of MA dimensions and functional properties were analyzed, several MA dimensions and MA fractional area change (MAFAC) were found to have prognostic value to predict Vmax&amp;gt;50 ml. The cut-off values for end-diastolic MA diameter (MAD-D), end-systolic MA diameter (MAD-S) and area, end-diastolic and end-systolic MA perimeter and MAFAC to predict Vmax&amp;gt;50 ml proved to be 2.3 cm, 1.5 cm, 3.4 cm2, 10.2 cm, 7.4 cm and 50.93%, respectively. While increased LA volumes were associated with both dilated MAD-D and MAD-S, only increased diastolic LA volumes were associated with reduced MAFAC. While dilated MAD-D was associated with increased total and active atrial stroke volumes, similar relationship with MAD-S could not be detected. Increased passive atrial stroke volume was associated with augmented MAFAC. While dilated MAD-D was associated with increased AAEF, dilated MAD-S was found to be related to reduced TAEF and PAEF. Increased MAFAC was associated with increased values regarding all emptying fractions. End-diastolic MA dimensions increased with dilation of end-systolic MA dimensions and vice versa. Increased MAFAC was associated with dilated MAD-D and reduced MAD-S. Conclusions Strong relationship exists between LA volumes and MA dimensions and functional properties in healthy subjects. Funding Acknowledgement Type of funding sources: None.

Novel computed-tomography derived prognostic markers in patients undergoing TAVI with a self-expanding valve

Abstract Introduction Transcatheter aortic valve implantation is the treatment of choice in a consistently expanding group of patients with severe aortic valve stenosis. Tricuspid and mitral annular dilatation with consequent valvular regurgitation are associated with adverse outcome. Computed tomography angiography (CTA) is routinely performed for preprocedural evaluation of vascular access and prosthesis sizing. Purpose To evaluate the impact of mitral and tricuspid annular dimensions in preprocedural CTA on prognosis of patients undergoing TAVI with a self-expanding valve. Methods CTAs of consecutive patients undergoing TAVI in a single high-volume center between 2016 and 2019 were retrospectively evaluated. Maximal septolateral tricuspid annular diameters (TAD) and mitral annular diameters (MAD) were obtained and measured from properly angulated three dimensional CTA datasets. Moreover, maximal pulmonary artery diameter perpendicular to the long axis was measured in every patient. Patients were followed up by clinical visits or telephone contacts. As clinical events were defined all-cause mortality, stroke and heart failure hospitalization. Results In total 123 patients were included in the study. The mean follow-up duration was 875±383 days and 21 clinical events were recorded. There was a moderate but statistical significant correlation between TAD and both pulmonary artery diameter (r=0.39, p&amp;lt;0.001) and pulmonary artery systolic pressure by echocardiography (r=0.23, p=0.015). In univariate logistic regression analysis pulmonary artery diameter and TAD were both associated with heart failure hospitalization (p=0.03 and 0.02 respectively). In addition, MAD was associated with total events (OR: 0.43, 95% CI 0.19–0.99, p=0.048). The relationship of MAD with events remained significant after adjustment for sex, age and tricuspid annular dimensions (OR: 0.28, 95% CI 0.1–0.79, p=0.02). Conclusions TAD and MAD were associated with heart failure rehospitalization and clinical events respectively in patients undergoing TAVI with a self-expanding valve. Further larger prospective studies are warranted to evaluate the prognostic value of these CTA markers. Funding Acknowledgement Type of funding sources: None.

Multiphase Assessment of Mitral Annular Dynamics in Consecutive Patients With Significant Mitral Valve Disease.

The aim of this study was to clarify the dynamics of the mitral annulus throughout the cardiac cycle and its relevance to transcatheter mitral valve replacement (TMVR) sizing and case selection. Limited data are available regarding the relevance of mitral annular (MA) and neo-left ventricular outflow tract (LVOT) dynamics in the overall population presenting with significant mitral valve disease. Patients attending a combined surgical-transcatheter heart valve clinic for severe symptomatic mitral valve disease were assessed using multiphase computed tomography. The relative influence of MA and neo-LVOT dynamics to TMVR case selection was studied. A total of 476 patients with significant mitral valve disease were evaluated. In 99 consecutive patients with severe mitral regurgitation, a 10-phase assessment showed that the mitral annulus was on average largest in late systole. On comparing maximal MA dimension with late systolic dimension, TMVR size assignment changed in 24.2% of patients. If the average MA perimeter was used to determine sizing, 48.5% were excluded because of MA dimension being too large; in a multiphase assessment of the neo-LVOT, an additional 16.2% were excluded on the basis of neo-LVOT dimension. In an expanded series of 312 consecutive patients, selection protocol influenced anatomical exclusion: a manufacturer-proposed early systolic approach excluded 69.2% of patients, whereas a late systolic approach excluded 82.7% of patients, the vast majority because of large mitral annuli. Contemporary TMVR can treat only a minority of patients with severe mitral regurgitation, principally because of limitations of large MA dimension.