Mitral Disease Research Articles

Secondary Mitral Regurgitation: Diagnosis and Management

Secondary mitral regurgitation is one of the most common valve diseases. The disease is a result of left atrial or left ventricular dysfunction. It is generally classified into stages based on its severity. While surgical intervention does not confer improved survival in this subset of mitral disease, recent advances in transcatheter interventions have resulted in improved survival and symptomatology in carefully selected patients. In this review, the multimodality imaging evaluation of the mitral valve and secondary mitral regurgitation is discussed. Commercially available and investigational transcatheter interventions for secondary mitral regurgitation management are also reviewed.

Comparison of maternal and fetal outcomes in mothers with non-congenital mitral valve stenosis and healthy control

BackgroundPhysiological changes during pregnancy cause complications in mothers with mitral stenosis and their infants. This study was designed to assess maternal and fetal pregnancy outcomes in women with rheumatic mitral valve stenosis and compare them with the control group. Materials and methodsThis study is a case-control study on 153 pregnant women, including 51 with mitral stenosis (MS) and 102 without MS as the control group, between 2007–2022. For each studied patient, two control participants were selected and matched in residence, age, and year of pregnancy. SPSS version 22 was used for data analysis. ResultsThe mean age was 31.7 ± 4.6 years in cases and 31.6 ± 4.7 in the healthy controls. Demographic variables were not significantly different between the case and control groups. The rate of stillbirth (5.9% vs. 0.0%), %), NICU admission (13.7% vs. 2.0%), and IUGR (5.9% vs. 0.0%) were higher in the fetal case group compared with the control group. On the other hand, maternal outcomes, including pulmonary edema (13.7% vs. 0.0%), ICU admission (23.5% vs. 0.0%), limb edema (15.7% vs. 0.0%), dyspnea (37.3% vs. 0.0%), pulmonary hypertension (9.8% vs. 0.0%), palpitations (21.1% vs. 0.0%) and hospital admission during pregnancy (37.2% vs. 4.9%) were statistically more common in the case groups. ConclusionsPregnancy is associated with significant fetomaternal morbidities in women with mitral valve heart disease. So they need a multidisciplinary approach in preconception and antenatal care.

Isolated dextrocardia and rheumatoid arthritis with mitral stenosis with pulmonary hypertension with atrial fibrillation: A rare association

This case presents a rare occurrence of rheumatoid arthritis (RA) in a 50-year-old woman with concurrent mitral valvular disease and dextrocardia. Diagnosed with seropositive RA 5 years earlier, the patient exhibited fever, cough, and progressive dyspnea. Clinical examination revealed irregular tachycardia, elevated jugular venous pressure, and signs of heart failure. Laboratory results confirmed seropositive RA, anemia, and elevated inflammatory markers. Electrocardiogram and echocardiogram indicated dextrocardia, atrial fibrillation, and moderate mitral stenosis. This case highlights the unusual association of RA with valvular heart disease and the added complexity of dextrocardia. Recognizing diverse cardiac manifestations in RA is crucial, contributing to the growing evidence linking autoimmune disorders to cardiovascular complications. Further research is essential to understand the intricate relationship between RA and unique cardiac abnormalities.

Mitral Annular Calcification-Related Valvular Disease: A Challenging Entity

Mitral valve annular calcification-related valvular disease is increasingly common due to the rising prevalence of age-related mitral annular calcifications. Mitral annular calcification alters the structure and function of the mitral valve annulus, which in turn causes mitral valve regurgitation, stenosis, or both. As it frequently coexists with comorbid conditions and overlapping symptoms, mitral annular calcification-related valvular disease poses significant diagnostic and therapeutic challenges. For instance, left ventricular diastolic dysfunction hinders the assessment of mitral valvular disease. Detection of mitral annular calcifications and assessment of related mitral valve disease hinge on two-dimensional echocardiography. Comprehensive assessment of mitral annular calcifications and related mitral valve disease may require multidetector computed tomography and three-dimensional echocardiography. Invasive hemodynamic testing with exercise helps identify the cause of symptoms in patients with comorbid conditions, and transcatheter interventions have emerged as a viable therapeutic option for older patients. After an outline of the normal mitral annulus, we examine how mitral annular calcifications lead to mitral valve disease and how to accurately assess mitral regurgitation and stenosis. Lastly, we review surgical and transcatheter approaches to the management of mitral annular calcification-related mitral valve regurgitation, stenosis, or both.

Scoring model based on cardiac CT and clinical factors to predict early good mitral valverepair in rheumatic mitral disease.

We aimed to evaluate the mitral valve calcification and mitral structure detected by cardiac computed tomography (cardiac CT) and establish a scoring model based on cardiac CT and clinical factors to predict early good mitral valve repair (EGMR) and guide surgical strategy in rheumatic mitral disease (RMD). This is a retrospective bi-center cohort study. Based on cardiac CT, mitral valve calcification and mitral structure in RMD were quantified and evaluated. The primary outcome was EGMR. A logical regression algorithm was applied to the scoring model. A total of 579 patients were enrolled in our study from January 1, 2019, to August 31, 2022. Of these, 443 had baseline cardiac CT scans of adequate quality. The calcification quality score, calcification and thinnest part of the anterior leaflet clean zone, and papillary muscle symmetry were the independent CT factors of EGMR. Coronary artery disease and pulmonary artery pressure were the independent clinical factors of EGMR. Based on the above six factors, a scoring model was established. Sensitivity = 95% and specificity = 95% were presented with a cutoff value of 0.85 and 0.30 respectively. The area under the receiver operating characteristic of external validation set was 0.84 (95% confidence interval [CI] 0.73-0.93). Mitral valve repair is recommended when the scoring model value > 0.85 and mitral valve replacement is prior when the scoring model value < 0.30. This model could assist in guiding surgical strategies for RMD. The model established in this study can serve as a reference indicator for surgical repair in rheumatic mitral valve disease. • Cardiac CT can reflect the mitral structure in detail, especially for valve calcification. • A model based on cardiac CT and clinical factors for predicting early good mitral valverepair was established. • The developed model can help cardiac surgeons formulate appropriate surgical strategies.

Insights into malignant mitral valve degenerative disease from a sudden cardiac death cohort highlighting significant measurement differences from normal.

Mitral valve prolapse (MVP) is an accepted cause of sudden cardiac death (SCD) in most autopsy series. Diagnosis at autopsy relies upon subjective assessment with no established objective pathological criteria. This study set out to establish objective measurements to help pathologists dealing with SCD. We diagnosed 120 (1.5%) cases of MVP in 8108 cases of SCD. We measured the mitral annulus, anterior and posterior leaflets, rough zone and mitral annular disjunction (MAD) in 27 MVP cases and compared them to 54 age- and sex-matched normal mitral valves. Age of death was 39 ± 16 years, with 59 females and 61 males. History of mild MV disease was present in 19 (16%). Eleven (9%) died associated with exertion. Left ventricular hypertrophy was present in nine (15%) females and 10 (16%) males. Both MV leaflets showed thickening and ballooning in all individuals. MVP showed highly significantly increased annular circumference, elongation and thickening of both leaflets as well as increased MAD (all P < 0.001). Left ventricular fibrosis was present in 108 (90%), with interstitial fibrosis in the posterolateral wall and papillary muscle in 88 (81%) and coexisting replacement fibrosis in 40 (37%). This is the largest MVP associated with SCD series highlighting a young cohort with equal representation of males and females. There is involvement of both leaflets with significant annular dilatation, elongation and thickening of both leaflets with MAD. Left ventricular fibrosis explains arrhythmia. Our quantitative measurements should serve as a reference for pathologists assessing post-mortem hearts for MVP.

Transcatheter Aortic Valve Replacement as a bridge to minimally invasive endoscopic mitral valve surgery in Elderly Patients in the era of ERAS and Fast Track TAVI concepts.

In this bicentric study, we report the outcomes of combined transcatheter aortic valve replacement combined with minimally invasive mitral valve surgery. We included a cohort of six patients (79.6 ± 3.2 years, 83% women) with high-risk profiles and deemed to be non-operable with combined mitral and aortic valvular disease. All patients had unsuitable anatomies for transcatheter mitral valve edge-to-edge repair (TEER). Moreover, most of the patients (5/6) suffered a combined aortic valve lesion, which complicates the efficiency of cardioplegia in the case of CBP through minimally invasive incisions. The first stage was implanting a TAVI valve to achieve aortic valve competency and hence facilitate the infusion of cardioplegia after clamping the aorta during endoscopic mitral valve surgery. After one week, we performed the minimally invasive mitral valve repair. Most patients (n = 5; 83%) underwent successful endoscopic mitral valve repair. Intraoperatively, the mean ischemic time was 42 min, and the total bypass time was 72 min. Postoperatively, the mean intubation time was 0 h. Postoperative complications included reoperation for bleeding in one patient (16.7%) and a new heart block requiring pacemaker implantation in one patient (16.7%). There was neither in-hospital mortality nor 1-year mortality.

Impacts of Left Atrial Appendage Treatments on Mitral Valve Diseases during Surgical Ablations.

Left atrial appendages (LAAs) play an important role in regulating left atrial function, and much evidence supports the possibility that changes in left atrial structure may cause or worsen mitral regurgitation. This study intended to investigate the outcomes of patients with mitral regurgitation who underwent left atrial appendage closure (resection or endocardial closure) during isolated surgical ablations. Patients with mild or moderate mitral regurgitation who received isolated surgical ablations for atrial fibrillation (AF) in our center from 2013 to 2022 were referred. During follow-up, each clinical visit was composed of medical interrogation, a 24 h Holter, and echocardiographic evaluation. Death, atrial fibrillation, worsening of mitral regurgitation, and stroke were evaluated as outcomes. Freedom from outcomes whose results were adjusted by inverse probability of treatment weighting for causal effects after acquiring propensity scores. A total of 456 patients were enrolled in this study. During a median follow-up of 48 months, 30 deaths and 11 cases of stroke were observed. After adjustments, no significant differences in terms of death or stroke were observed among the three groups. Patients who underwent resection or endocardial closure during surgical ablations had a higher risk of mitral regurgitation worsening during follow-up (p 0.05). During the whole follow-up, patients who underwent left atrial appendage interventions showed significantly larger left atrial and mitral annular diameters, as well as lower tethering height than those who had left atrial appendage preserved (all p 0.05). Mitral regurgitation was more likely to get worse when patients with fundamental mitral diseases underwent LAA interventions during isolated surgical AF ablations. In the absence of LAA, the dilation of the left atrium and mitral annulus may ultimately lead to worsening of regurgitation.

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.

Midterm Outcome of Valve Repair for Rheumatic Mitral Stenosis: 6-year Experience in a Single Mid-Volume Cardiac Center

Previous studies have reported satisfactory long-term results of mitral valve (MV) repair for rheumatic mitral disease. However, the effects of this procedure in isolated rheumatic mitral stenosis remain unclear. In addition, protective effects of MV repair on cardiac function have not been verified in rheumatic MV disease. This study retrospectively evaluated early mortality and mid-term results of MV repair for isolated rheumatic mitral stenosis in a mid-volume cardiac centre, and explored the effects of this procedure on cardiac function. Between January 2015 and May 2021, 360 patients with isolated rheumatic mitral stenosis and combined (concomitant) atrial fibrillation (AF) underwent MV repair (100 patients) or MV replacement (260 patients). Perioperative characteristics were compared between the two groups and a regression analysis for early mortality and mid-term left ventricular ejection fraction was conducted. In addition, mid-term survival was compared between the two groups. Baseline characteristics of the two groups were balanced after matching. Compared with patients in the replacement group, patients with MV repair had a lower occurrence of postoperative hypotension and AF. There was no difference in early mortality or mid-term survival between the two groups. However, MV repair was associated with a higher mid-term left ventricular ejection fraction. During follow-up, four thromboembolic events and four haemorrhagic events occurred in the replacement group. No blood coagulation-related complications occurred in the repair group. Mitral valve repair for isolated rheumatic mitral stenosis and concomitant AF was feasible in a mid-volume cardiac centre, with satisfactory perioperative results and mid-term outcomes. Furthermore, this procedure preserved mid-term left ventricular systolic function.

Concomitant Tricuspid Valve Surgery Is Not Associated With Increased Operative Risk During Robotic Mitral Valve Surgery.

The aim of this study was to investigate the outcomes of robotic mitral valve surgery with and without concomitant tricuspid valve surgery. Patients who underwent robotic mitral surgery between March 2010 and September 2022 were included. Patients were grouped according to the presence of concomitant tricuspid interventions. The groups were compared for baseline factors, operative parameters, and early postoperative outcomes. Age- and gender-matched groups were also compared for outcomes. The study included 285 robotic mitral surgery patients. There were 59 patients who underwent concomitant tricuspid interventions. In the concomitant tricuspid surgery group, cardiopulmonary bypass time (150.1 vs 128.4 min, P < 0.001) and cross-clamp time (99.2 vs 82.4 min, P < 0.001) were longer. Prolonged intubation was more frequent in the concomitant tricuspid intervention group (5.2% vs 0.5%, P = 0.029). The groups did not differ in terms of mortality, permanent pacemaker (PPM) requirement, or other morbidities. Perioperative outcomes were similar after matched group analysis. Operative mortality and early adverse outcomes did not increase with the addition of tricuspid intervention in our cohort of robotic mitral surgery patients. The robotic approach for mitral disease and coexisting tricuspid disease may offer safe results without an increased risk of postoperative PPM requirement.

Outcomes of Mitral Valve Repair for Degenerative Mitral Disease: A Single-Centre 10-Year Experience

To evaluate the long-term outcomes of degenerative mitral valve (MV) repair. This study analysed 1,069 patients who underwent MV repair due to degenerative MV disease at Beijing Anzhen Hospital from January 2010 to December 2019. All patients were clinically followed until December 2019, with an average follow-up period of 4.7 years. Perioperative complications, 30-day mortality, long-term outcomes, and risk factors of all-cause death and recurrent mitral regurgitation (MR) were summarised. Ten patients died in the hospital and 33 died during the follow-up period. Recurrent MR occurred in 113 patients. Fourteen patients underwent re-operation. Rates of long-term survival, absence of recurrent MR, and no re-operation were 94.0% (91.6%-96.6%), 81.2% (77.3%-85.3%), and 98.2% (97.2%-99.3%), respectively. The risk factors for long-term all-cause death included age and an ejection fraction (EF) <60%. The risk factors for recurrent MR included age, female sex, E-wave velocity, anterior prolapse, residual 1+MR postoperatively, and lower body mass index. Mitral valve repair is an effective treatment for degenerative MV disease that, in an experienced heart centre, can be performed with low mortality, recurrence, and re-operation rates. Advanced age and an EF <60% were risk factors for long-term all-cause death. Age, female sex, residual 1+MR postoperatively, lower body mass index, higher peak E-wave velocity, and anterior prolapse were risk factors for recurrent MR.

Concomitant Tricuspid Valve Surgery With Mitral Valve Surgery for Moderate Tricuspid Regurgitation

BackgroundTricuspid valve surgical procedures (TVS) concomitant with mitral valve (MV) surgical procedures for less than severe tricuspid regurgitation (TR) remains controversial. This study examined the long-term outcomes of patients with moderate or mild to moderate TR undergoing MV surgical procedures with or without TVS. MethodsPatients with moderate or mild to moderate TR undergoing MV replacement or repair between January 2002 and June 2021 were included. Primary outcomes of reoperation and long-term survival were compared for patients undergoing MV replacement or repair with or without TVS before and after stratifying by mitral disease cause. ResultsThe study included 505 patients. Mean age was 69 ± 12.7 years. The Society of Thoracic Surgeons Predicted Risk of Mortality for MV replacement (3.71 vs 4.39; P = .34) and repair (1.73 vs 1.67; P = .84) was similar for patients who did and did not undergo TVS. Operative mortality was similar for replacement (4.2% vs 6.1%; P = .77) or repair (0% vs 0%) with or without TVS. Patients undergoing MV replacement or repair with or without TVS had similar 10-year survival (67.1% vs 73.2% [P = .37]; 68.7% vs 78.8% [P = .052]) and rates of reoperation (2.1% vs 0.8% [P = .69]; 4.9% vs 4.6% [P = .99]). Cox proportional hazards modeling confirmed that TVS did not decrease the risk of death after MV replacement (hazard ratio, 0.839 [0.479-1.467]) or repair (hazard ratio, 0.852 [0.516-1.408]). The findings were unchanged after stratifying by MV disease cause or restricting the analysis to patients with moderate TR only, with no differences in survival or reoperation (all P > .05). ConclusionsConcomitant TVS for moderate or mild to moderate TR did not improve survival or decrease reoperation. Parameters beyond the degree of TR may aid in surgical decision-making.

Female Gender in Cardiac Surgery: Is it Still a Significant Risk? A Retrospective Study in Saudi Arabia.

Female sex is considered an independent predictor for mortality and morbidity following cardiac surgery. This study is to review the outcomes of adult cardiac surgery between males and females in a Saudi tertiary referral hospital. This was a retrospective study for 925 adult patients operated on for ischemic coronary artery disease and acquired aortic and mitral valvular heart disease from 2015 to August 2023. We analyzed patient characteristics, intraoperative data, and postoperative results to compare outcomes between males and females. Preoperative risk factors were not significantly different in both groups. Postoperative outcomes showed gender-based differences. In univariable analysis, females, compared to males, had significantly greater odds of prolonged postoperative ventilation (>24 hours), 32.8% of females compared to 20.7% of males (p < 0.001). Also, sternal wound infection was notably higher among females (13.3%) (p < 0.001). Mortality also exhibited a significant association, with 14.2% of females experiencing mortality compared to 9.4% of males (p = 0.049). In the multivariable analysis for elevated postoperative troponin, the use of pre-operative intra-aortic balloon pump, urgent/emergent surgery, elevated pre-operative troponin and combined bypass grafting with valve surgery, were also predictive of higher post-operative troponin concentrations (beta = 0.43, 95% CI: 0.25 to 0.62, p < 0.001). Females in Saudi Arabia have an increased risk of short-term morbidity and mortality after cardiac surgery compared to males. Vague and delayed presentation and then the late diagnosis and referral are likely the main contributing factors. This highlights the need to implement preoperative measures to improve early diagnosis and referral to eliminate gender bias.

Epidemiological Investigation of Rheumatic Heart Disease in the Emergency Department in Dakar: A Descriptive Analysis

Background: Rheumatic Heart Disease (RHD), also known as "Bouillaud's disease", is a post-streptococcal non-suppurative inflammatory disease complicating an upper airway infection with group A β-hemolytic streptococcus. Although RHD has almost disappeared in developed countries, it is still a major public health problem in low- and middle-income countries, as it remains the most frequent cause of cardiovascular mortality and morbidity in children. The objective was to describe the epidemiological and evolutionary aspects of rheumatic heart disease admitted to the emergency room of the Albert Royer National Children's Hospital in Dakar.&#x0D; Methods: We conducted a retrospective, descriptive study over a 12-month period (January 1 to December 31, 2021) of children aged 3 to 18 years hospitalized for rheumatic heart disease in the emergency department during the study period.&#x0D; Results: The prevalence was 3.73% (37/993) with a mean age of 11.35 +/- 3 years and a majority between 10 and 15 years. Males predominated - sex ratio 1.3. The majority came from disadvantaged areas (91.9%) with low incomes for the most part (83.8%). The reasons for consultation were dominated by dyspnea (86.5%), fever (75.7%) and poly-arthralgia (35.1%). General and physical signs were tachycardia (86.5%), orthopnea (24.3%), hypoxia (40.5%), congestive heart failure (83.7%). Cardiac involvement was dominated by mitral and aortic polyvalvular disease in more than half (57%). Management included diuretics (97.3%), oxygen therapy (90%), corticosteroids (31%) and antibiotics (81%). Three cases of death were noted. Conclusion: RHD is still frequent in our countries with an often poor prognosis due to delayed management. Prevention policies are necessary to eradicate this scourge.

The impact of calcium and vitamin D supplement intake on survival in patients with concomitant moderate aortic and mitral valve disease

Abstract Background Calcium and vitamin D supplement intake has increased among the elderly population, who are prone to deficiency. We sought to assess the association between calcium and vitamin D supplementation and the long-term outcomes in patients diagnosed with concomitant moderate aortic and mitral valve disease. Methods We included 3257 patients (aged 71.7 ± 12.9 years; 55.2% male; 83.1% white), who presented to the Cleveland Clinic between 2010 and 2018, diagnosed with concomitant moderate aortic and mitral valves disease. The patients were followed up with a mean period of 21.8 months (range 1-155.8). Patients were stratified based on the supplementation with calcium and vitamin D. Focusing on the aortic component of the concomitant valvular disease, patients were further subdivided into two groups; Aortic Stenosis (AS) with either Mitral Regurgitation (MR) or Stenosis (MS)(group 1), and Aortic Regurgitation (AR) with either MR or MS(group 2). The primary endpoints were death and heart failure hospitalization. The data was analyzed using Kaplan Meier survival analysis on SPSS. Results Of the total 3257 patients included in this study, 2273 (70%) were not supplemented, and 984 (30%) were supplemented with calcium and vitamin D. Supplementation with calcium and vitamin D was significantly associated with a higher risk of all-cause mortality (HR=1.114, 95% CI [1.003-1.237]; p=0.043) (Figure 1). However, no significant association with heart failure hospitalization was noted (HR=1.003, 95% CI [0.884-1.139]; p=0.958). On further sub-group analysis of the aortic component, 1045 (32%) patients in group 1 and 2212 (68%) patients in group 2 were assessed. In group 1, 701 (67%) patients were not supplemented, and 344 (33%) were supplemented. Calcium and vitamin D supplementation was associated with a significantly higher risk of all-cause mortality in patients with AS (HR=1.203, 95% CI [1.017-1.425]; p=0.031). Conversely in patients with AR (group 2), 1572 (71%) patients were not supplemented, and 640 (29%) were supplemented, and no significant association was exhibited in this group (HR=1.044, 95% CI [0.913-1.193]; p=0.531) (Figure 2). Conclusion In our cohort of patients with concomitant moderate aortic and mitral valve disease, the intake of calcium and vitamin D supplements was associated with higher mortality specifically in patients with aortic stenosis.Figure 1Figure 2

Aortic stenosis drives the differential in survival in patients with concomitant moderate aortic and mitral valves diseases

Abstract Background Valvular heart diseases are common causes of morbidity and mortality worldwide. In this study we sought to assess the long-term outcomes of patients diagnosed with concomitant moderate aortic and mitral valves diseases at a tertiary center. Methods All 3257 patients (aged 71.7 ± 12.9 years old, 55.2% male, 83.1% white) who presented to the Cleveland Clinic between 1/2010 and 1/2018 and were diagnosed with concomitant moderate aortic and mitral valves diseases were included in this study. The patients were categorized into groups on the basis of aortic and mitral stenosis/regurgitation (AS/AR and MS/MR). The primary endpoint of the study was the composite event defined as heart failure hospitalization or all-cause mortality. The data was analyzed via Kaplan Meier and Cox proportional hazards regression analysis on SPSS. Results The median follow-up period was 21.8 months (range 1-155.8). All-causes mortality occurred in 1611 patients (49.5%), heart failure hospitalization in 1119 (34.4%) and the composite event in 1926 patients (59.1%). AR/MR was the most frequent group with 2090 patients (64.2%) followed by AS/MR with 866 (26.6%), AS/MS with 179 (5.5%) and AR/MS with 122 (3.7%). As presented in figure 1, patients with AS/MR had the worst outcome followed by AS/MS, AR/MR and finally AR/MS (p-value &amp;lt;0.001). However, when dividing the comparison on the basis of one valve only, and even after adjusting for aortic and mitral valve interventions, no significance difference in outcomes is noted between MR and MS (p=0.755) while AS had significantly poorer outcome than AR with p&amp;lt;0.001. Conclusion In our cohort, patients with concomitant moderate aortic and mitral valves diseases had an overall high rate of death and heart failure hospitalization. Patients with AS had significantly poorer outcomes than patients with AR but no difference was noted when comparing MS to MR.Figure 1Figure 2

Predictors of long-term outcomes of patients with concomitant moderate aortic and mitral valves diseases: a single tertiary care center experience 2010-2018

Abstract Background To date, moderate concomitant valvular heart diseases have been scarcely studied. This study aimed to further define predictors of long-term outcomes in patients diagnosed with concomitant moderate aortic and mitral valve disease at a tertiary center. Methods In this cohort we included 3257 patients (aged 71.7 ± 12.9 years; 55.2% male; 83.1% white) diagnosed with concomitant moderate aortic and mitral valves diseases who presented to the Cleveland Clinic between 2010 and 2018. The patients’ demographic, clinical and echocardiographic variables were collected. The primary endpoint of the study was the long-term composite outcome defined as heart failure hospitalization or all-cause mortality. We then conducted a univariate and multivariate cox proportional hazard survival analysis for the primary endpoint. Results The patients were followed up for 21.8 months. Baseline demographic characteristics are presented in table 1. Multiple demographic, clinical, and echo variables were evaluated. Using a univariate Cox proportional hazard survival analysis, older Age, history of smoking, Diabetes, Hypertension, Chronic Kidney Disease (CKD), Coronary Artery Disease (CAD), Atrial Fibrillation (Afib), Dyslipidemia, higher Right Ventricular Systolic Pressure (RVSP), higher New York Heart Association (NYHA) class, and lower Left Ventricular Ejection Fraction (LVEF) were associated with worse long-term outcomes. Additionally, patients who underwent an aortic (39.1%) or a mitral valve intervention (29.4%) were associated with better long-term outcomes (HR, 0.710, 0.708; respectively). In comparison, on Multivariable Cox analysis, female sex was significantly associated with worse survival (HR of 1.151, p-value=0.019). However, older Age, history of smoking, Diabetes, CKD, higher RVSP, NYHA class 2, 3, and 4, and lower LVEF remained significantly associated with worse long-term (table 2). Aortic valve intervention remained significantly associated with better survival (HR, 0.861, P-value=0.021). Compared to the Aortic Stenosis/ Mitral Stenosis (AS/MS) group, univariate analysis showed that patients in the Aortic Regurgitation/Mitral Regurgitation (AR/MR), and the AR/MS groups were significantly associated with better long term outcomes (HR, 0.738, HR, 0.575; respectively). Conversely, on Multivariate Cox analysis, AR/MR and AS/MR groups were significantly associated with better survival compared to AS/MS group (HR, 0.580, HR, 0.716; respectively). Conclusion In patients diagnosed with concomitant moderate aortic and mitral valve diseases, female sex, older age, history of smoking, diabetes, CKD, RVSP, NYHA class, LVEF and aortic valve intervention are independent predictors of the composite endpoint of heart failure hospitalization or all-cause mortality.Table 1Table 2

Prevalence and incidence of diastolic dysfunction in new-onset atrial fibrillation: implications for clinical and preclinical HFpEF

Abstract Background Atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF) are closely associated diseases that frequently coexist. However, due to the overlapping symptoms, the diagnosis of HFpEF can be overlooked with symptoms being attributed to AF. Purpose We aimed to investigate the prevalence of diastolic dysfunction (DD) in patients with new-onset AF compared to sinus rhythm (SR), study changes in diastolic function parameters over time in the two groups and compare the incidence of DD at follow-up. Methods Adults with new diagnosis of AF and adults in SR were identified. Patients with previous cardiac surgeries, congenital heart disease, hypertrophic or infiltrative cardiomyopathy, primary mitral disease, left-sided valve disease, low ejection fraction, enlarged left ventricle, or with no 6-month follow-up echocardiogram were excluded. Diastolic function was assessed through 4 components: mitral medial e’ &amp;lt;0.07 m/sec, mitral medial E/e’ &amp;gt;15 in SR and &amp;gt;11 in AF, TR velocity &amp;gt;2.80 m/sec, and left atrial volume index &amp;gt;34 ml/m2, with severe DD (SDD) defined by ≥3/4 findings and moderate DD (MDD) by ≥2/4 abnormal diastolic function parameters. Annualized changes were calculated as the difference between follow-up and baseline values divided by years in between. In a secondary analysis, patients with new-onset AF were propensity score-matched to patients with SR in a 3:1 ratio based on age, sex, body mass index, and comorbidities. Results Overall, 1,747 patients with incident AF (median age 67 years; 34% females) and 29,623 in SR (median age 59 years; 51% females) were included. New-onset AF was independently associated with the presence of SDD vs SR (8% vs 2%) and MDD (25% vs 11%, p&amp;lt;.001 for both in adjusted analysis). Over median follow-up of 3.2 (IQR 1.6-5.8) years, annualized severity progression in each of the 4 diastolic function parameters was greater in the AF group (p&amp;lt;.001 for all), Table. The incidence rates of SDD and MDD were 3.7 and 8.8 per 100-person year, respectively, in AF versus 1.1 and 3.6 per 100-person years, respectively, in SR (p&amp;lt;.001 for both at univariate and multivariable analysis), Figure. Results were similar in the propensity-score matched analysis. Conclusions Patients with new-onset AF more commonly have moderate or severe diastolic dysfunction that indicates the presence of potentially overlooked clinical HFpEF (when symptoms exist) or preclinical HFpEF (when symptoms are absent) compared to patients in SR. In long-term follow-up, patients with AF display accelerated progression in DD; suggesting that therapies to prevent progression to symptomatic HFpEF may be highest value in this patient population.

Degenerative or rheumatic: after all, what is the most prevalent etiology of mitral regurgitation in developing countries?

Abstract Introduction Mitral regurgitation (MR) is the most prevalent valve disease in Europe, mostly degenerative. In Brazil, on the other hand, there are few recent epidemiological data and previous studies show a higher prevalence of rheumatic disease. However, a change in the epidemiological profile of valve disease has recently been observed, largely due to the increase in life expectancy and decrease in the incidence of rheumatic fever. This study aims to evaluate patients with MR in a tertiary hospital in Brazil, emphasizing the etiological analysis. Methods Patients with moderate or severe MR on echocardiogram performed between 07/01/2018 and 06/30/2020 in a Brazilian Cardiology hospital were retrospectively evaluated, including 2,017 cases. Clinical data (age, sex, symptoms and comorbidities) were analyzed, in addition to complementary tests, such as electrocardiogram and echocardiogram. Results A total of 2,017 cases were included, of which 1,966 (97.5%) had severe MR. The mean age was 65 years and 52% were female. In this cohort, 924 patients (45.8%) had primary MR, while 1093 (54.2%) had secondary causes. Among the primary etiologies (N=1093), degenerative was the most prevalent, responding to 51.3% (n=474), followed by rheumatic disease, present in 34.5% of the patients (n=319). The other primary etiologies observed were calcific (94 patients = 4.7%), infective endocarditis (15 patients = 0.7%) and congenital (10 patients = 0.5%). In the comparative analysis between degenerative and rheumatic MR, a statistically significant difference was observed in age and gender. Patients diagnosed with rheumatic MR were younger - mean age: 58 years (standard deviation 49-68) compared to 67 years in patients with degenerative mitral disease (standard deviation 58-76 years). Most patients with rheumatic disease were female (N=255, 79.9%), with percentages almost twice as high as those observed in degenerative MR (N=192 - 40.5%). Secondary causes (N=1,093) were composed of dilated etiology in 859 patients (78.6%), ischemic (140 patients - 12.8%) and atrial functional (55 patients - 5%). Conclusion In agreement with the current epidemiological change in valvular heart disease, we could also observe an important change in the etiology of MR in Brazil, with a reduction in the burden of rheumatic disease and greater expressiveness of mitral prolapse.