Etiology Of Mitral Regurgitation Research Articles

Cardiac chamber three-dimensional volumes and deformation predict clinical outcomes in chronic mitral regurgitation

Abstract Background In patients with mitral regurgitation (MR), cardiac remodeling assessed by two-dimensional (2D) echocardiographic linear indexes is highly variable and not suitable for individualized risk assessment. Purpose To evaluate whether measurements of myocardial strain and left atrial (LA), left ventricular (LV) and right ventricular (RV) three-dimensional (3D) volumes improve risk assessment in MR. Methods In the prospective 3D Echocardiography and Cardiovascular Prognosis in Mitral Regurgitation study (3D-PRIME), 176 patients with significant (moderate or greater) MR were investigated with 2D/3D echocardiography. Referral criteria for mitral intervention followed current guidelines. LA remodeling was assessed by the maximum and minimum 3D LA volume (3D-LAV), peak reservoir strain (LASr), and stiffness (i.e. the ratio: mitral peak E-wave divided by the annular e’ velocity (E/e´) / LASr). LV and RV were considered dilated in case of increased 3D end-diastolic (LV>=86/74 and RV>=87/74ml/m2 in men/women) and end-systolic volumes indexed for body surface area (LV>=41/33 and RV>=44/36ml/m2 in men/women). Peak global longitudinal strain was measured in the LV (LV-GLS) and the RV free wall (RV-FWS). The primary outcome was a composite of mitral valve surgery, percutaneous mitral edge-to-edge repair and death. Results During a 14 [8-24] months follow-up, the patients (70±13 years, 39% women) experienced 73 events including 14 deaths. In univariate survival analyses, LV and RV dilatation, but not LV-GLS and RV-FWS, were associated with the primary outcome (Figure) and had superior predictive value to 2D volumes and diameters (p<0.05). On contrary, both atrial size and function predicted outcome, with 3D-LAV (HR 1.01, 95% CI 1.00-1.01), LASr (HR 1.03, 95% CI 1.01-1.06) and increased LA stiffness (Figure) all significant predictors of events (p<0.05). In multivariate Cox analysis with adjustment for age, sex, body mass index and MR etiology, dilated LV (HR 2.6, 95% CI 1.5-4.4), dilated RV (HR 2.0, 95% CI 1.1-3.6) and increased LA stiffness ((HR 2.4, 95% CI 1.3-4.6) were independently associated with higher rate of events (p<0.05). Conclusion In patients with moderate or greater MR, increased cardiac chamber 3D volumes and LA stiffness, as well as impaired LA reservoir strain are associated with higher risk of disease progression towards mitral valve intervention and death. Our findings indicate that assessment of both cardiac chamber 3D size and LA deformation can contribute to increased diagnostic and prognostic precision in patients with MR.

Transcatheter mitral edge-to-edge repair in patients with prior cancer diagnosis

Abstract Background Transcatheter edge-to-edge repair (TEER) is a safe and effective therapy for mitral regurgitation (MR). Despite oncological patients have an increased risk of functional and organic MR due to cardiotoxic treatment exposure, the use of TEER in this setting remains underexplored. Purpose To evaluate the safety and efficacy of TEER in patients with MR and prior cancer diagnosis. Methods Observational, retrospective, multicenter study based on the Spanish national TEER registry. Patients from those centers providing oncological specific data were included in this analysis. Patients with and without history of cancer were propensity score matched (PSM) in a 1:1 ratio. The primary efficacy outcome was a composite of death from any cause or unplanned hospitalization for heart failure at 1 year. Results A total of 1237 patients with MR who underwent TEER between 2010 and 2022 across 14 centers in Spain were included. The mean age was 73 ± 11 years and 34% were female. MR etiology was functional in 58%, organic in 27% and mixed in 15%. Of them, 164 had a history of cancer. Baseline characteristics of the unmatched cohort are shown in Figure 1. Median time from cancer diagnosis to TEER was 7 (3-17) years and the most common cancer types were breast (20%), leukemia/lymphoma (19%) and colorectal (11%). PSM resulted in 163 pairs with a good balance of baseline characteristics (Figure 1). Procedural success rate was high and similar between the groups (93% vs 96%, p=0.217), as were periprocedural complication rates (Figure 2A). The primary efficacy endpoint occurred in 38 (23%) patients in the cancer group and 29 (18%) patients in the control group (Hazard ratio 1.36, CI 95% 0.84 to 2.20, p= 0.214) (Figure 2B). Conclusion In routine practice, a notable proportion of patients undergoing mitral TEER have a prior cancer diagnosis. Immediate and 1-year clinical outcomes appear comparable to those observed in non-cancer patients. These findings suggest that mitral TEER should not be withheld from this growing population.

The Critical Role of Mitral Regurgitation Etiology in TAVR

The Critical Role of Mitral Regurgitation Etiology in TAVR

Outcomes of mitral transcatheter edge to edge repair with MitraClip™ – An Indian single center experience

ObjectiveTo evaluate the outcomes of transcatheter edge-to-edge repair (TEER) with MitraClip™ (Abbott Vascular) in symptomatic high surgical risk Indian patients with significant mitral regurgitation (MR). MethodsPatients with moderately severe or severe primary or secondary MR and deemed high surgical risk were treated with MitraClip™. The data were collected retrospectively from medical records. The primary outcome was technical success, and secondary outcomes were ≤2+ MR reduction and improvement in functional capacity at 30 days. ResultsBetween November 2018 and August 2023, 64 patients were treated with MitraClipTM. The mean age was 70.0 ± 12.1 years and 64 % were males. The mean EuroScore II and STS score predicted mortality for mitral valve repair were 5.8 ± 4.5 % and 4.0 ± 3.8 % respectively. MR etiology was primary in 56.3 %, secondary in 40.6 % and mixed in 3.1 %. The device was implanted successfully in all but one patient with technical success rate of 98.4 %. The average number of clips per patient was 1.5 ± 0.6 and 42.2 % patients received more than one clip. The mean mitral valve gradient was 3.5 ± 1.6 mmHg. The MR severity of ≤2+ was achieved in 91.8 % of the subjects and similar proportion were in New York Heart Association Functional Class I or II at 30 days. ConclusionIn high-risk Indian patients with symptomatic significant MR, TEER with MitraClip™ was achieved with a high technical success rate. It was associated with significant reduction in MR severity and improvement in functional capacity in >90 % of the subjects.

Atrial Functional Mitral Regurgitation: From Diagnosis to Current Interventional Therapies.

Mitral regurgitation (MR) is one of the most common valvular pathologies worldwide, contributing to the morbidity and mortality of several cardiovascular pathologies, including heart failure (HF). Novel transcatheter treatment for MR has given the opportunity for a safe and feasible alternative, to surgery, in order to repair the valve and improve patient outcomes. However, after the results of early transcatheter edge-to-edge repair (TEER) trials, it has become evident that subcategorizing the mitral regurgitation etiology and the left ventricular function, in patients due to undergo TEER, is of the essence, in order to predict responsiveness to treatment and select the most appropriate patient phenotype. Thus, a novel MR phenotype, atrial functional MR (AFMR), has been recently recognized as a distinct pathophysiological entity, where the etiology of the regurgitation is secondary to annular dilatation, in a diseased left atrium, with preserved left ventricular function. Recent studies have evaluated and compared the outcomes of TEER in AFMR with ventricular functional MR (VFMR), with the results favoring the AFMR. In specific, TEER in this patient substrate has better echocardiographic and long-term outcomes. Thus, our review will provide a comprehensive pathogenesis and mechanistic overview of AFMR, insights into the echocardiographic approach of such patients and pre-procedural planning, discuss the most recent clinical trials and their implications for future treatment directions, as well as highlight future frontiers of research in the setting of TEER and transcatheter mitral valve replacement (TMVR) in AFMR patients.

The impact of transcatheter aortic valve implantation (TAVI) on mitral regurgitation - a single center study.

The coexistence of mitral regurgitation (MR) and severe aortic stenosis (AS) has been associated with worse outcomes in patients undergoing transcatheter aortic valve implantation (TAVI). Herein, the aim was to assess the etiology and degree of MR in an unselected TAVI population and investigate the impact of MR reduction at mid-term follow-up. Patients subjected to TAVI as a treatment for severe AS in a single center were retrospectively analyzed. The primary endpoint was the MR reduction after TAVI. The secondary endpoint was all-cause mortality and heart failure hospitalization at a 3-year follow-up. Patients undergoing TAVI (n = 283) in the years 2017-2019 were screened for the presence of hemodynamically significant MR. Sixty-nine subjects (24.4%) with severe (16, 23.2%) and moderate (53, 76.8%) MR were included. The primary MR was predominant (39 subjects, 56.5%). The median age of the patients was 82 years. MR improved in 25 patients (36.2%, p < 0.001). Baseline severe MR was more prone to reduce (8 subjects, 50%) than moderate (17 subjects, 32.1%, p = 0.04). The primary MR improved in 14 patients (35.9%), while secondary in 11 patients (36.7%, p = 1). Patients showing MR reduction had lower mortality (8 vs. 29.55%, p = 0.047) and were less frequently hospitalized (20 vs. 45.45%, p = 0.03) at 3-year follow-up. Hemodynamically significant MR improves after TAVI regardless of its etiology. Moreover, MR reduction after TAVI is associated with better clinical outcomes.

Early Outcomes of Two Large Mitral Valve Transcatheter Edge-to-Edge Repair Devices-A Propensity Score Matched Multicenter Comparison.

Background/Objectives: Previous trials reported comparable results with PASCAL and earlier MitraClip generations. Limited comparative data exist for more contemporary MitraClip generations, particularly the large MitraClip XT(R/W). We aimed to evaluate acute and 30-day outcomes in patients undergoing mitral valve transcatheter edge-to-edge repair (M-TEER) with one of the large devices, either PASCAL P10 or MitraClip XT(R/W) (3rd/4th generation). Methods: A total of 309 PASCAL-treated patients were matched by propensity score to 253 MitraClip-treated patients, resulting in 200 adequately balanced pairs. Procedural, clinical, and echocardiographic outcomes were collected for up to 30 days, including subgroup analysis for mitral regurgitation (MR) etiologies. Results: PASCAL and MitraClip patients were comparable regarding age (80 vs. 79 years), sex (female: 45.5% vs. 50.5%), and MR etiology (degenerative MR: n = 94, functional MR [FMR]: n = 96, mixed MR: n = 10 in each group). Technical success rates were comparable (96.5% vs. 96.0%; p > 0.999). At discharge, the mean gradient was higher (3.3 mmHg vs. 3.0 mmHg; p = 0.038), and the residual mitral valve orifice area was smaller in MitraClip patients (3.0 cm2 vs. 2.3 cm2; p < 0.001). At discharge, the reduction to MR ≤ 2+ was comparable (92.4% vs. 87.8%; p = 0.132). However, reduction to MR ≤ 1+ was more frequently observed in PASCAL patients (67.7% vs. 56.6%; p = 0.029), driven by the FMR subgroup (74.0% vs. 60.0%; p = 0.046). No difference was observed in 30-day mortality (p = 0.204) or reduction in NYHA-FC to ≤II (p > 0.999). Conclusions: Both M-TEER devices exhibited high and comparable rates of technical success and MR reduction to ≤2+. PASCAL may be advantageous in achieving MR reduction to ≤1+ in patients with FMR.

Outcomes of maze procedure and mitral valve surgery in atrial functional mitral regurgitation: a retrospective study

BackgroundAtrial functional mitral regurgitation (AFMR) is a newly discovered condition associated with longstanding atrial fibrillation. This retrospective study aimed to analyze the outcomes of the maze procedure and mitral regurgitation (MR) surgery in AFMR and atrial fibrillation in comparison with those in degenerative MR (DMR).MethodsPatients who underwent mitral valve repair/replacement with a maze procedure at a hospital (July 2012–August 2021) were included. We excluded patients aged below 18 years undergoing concomitant coronary artery bypass grafting or atrial septal defect repair and those with MR etiology other than ARMR or DMR.ResultsWe included 35 patients with AFMR and 50 patients with DMR. Patient characteristics and postoperative outcomes were not significantly different between the two groups. Long-term outcomes revealed no significant differences in the ratio of cardiac mortality, stroke, or hospital readmission. However, after the maze procedure, the sinus rhythm restoration rate was significantly lower (62% vs. 28.5%, p < 0.001), a junctional rhythm state (p < 0.001) and permanent pacemaker insertion for sick sinus syndrome (SSS) (p = 0.03) were significantly more common in AFMR than DMR. On postoperative transthoracic echocardiography (TTE), the pulmonary artery systolic pressure was significantly less decreased in the AFMR group than in the DMR group compared with that on preoperative TTE (p = 0.04).ConclusionsAFMR showed excellent mitral valve surgery outcomes, similar to DMR, but had a significantly higher risk of pacemaker insertion for SSS after the maze procedure.

Two-Year Clinical Outcomes of Staged Transcatheter Mitral Edge-to-Edge Repair After Transcatheter Aortic Valve Replacement

Residual significant mitral regurgitation (MR) can increase the risk of adverse events following transcatheter aortic valve replacement (TAVR). The clinical benefits of staged transcatheter edge-to-edge repair (TEER) post-TAVR remain underexplored. This study aimed to investigate the clinical outcomes of staged TEER for residual significant MR post-TAVR. This observational study included 314 consecutive patients with chronic residual grade 3+ or 4+ MR at 30 days follow-up post-TAVR, with 104 (33.1%) treated with staged TEER (TEER group) and 210 (66.9%) with medical therapy alone (MT group). The primary composite outcomes were all-cause mortality and heart failure (HF) hospitalization at 2 years. Additional analysis, including changes in MR grade and the New York Association (NYHA) functional classification, and subgroup outcome comparisons based on MR etiology were also conducted. In our study, the rate of primary composite outcome was lower in the TEER group than in the MT group (33.7% vs. 48.1%, p = 0.015). Significant improvement in MR grade and NYHA class was observed in the TEER group after 2 years. Subgroup analysis demonstrated that, among patients with degenerative MR, a lower incidence of composite outcome and HF hospitalization was observed in the TEER group (hazard ratio: 0.35; 95% confidence interval: 0.23–0.53, p < 0.001).In conclusion, staged TEER post-TAVR was associated with reduced MR and improved clinical outcomes. The clinical significance of MR post-TAVR should be carefully evaluated, and TEER should be considered for patients with significant residual MR, particularly those with degenerative MR.

Fact or Artifact: A prospective study on diagnostic value of a new echocardiographic parameter of Color Doppler Horizontal Splay width in assessment of mitral regurgitation severity

Objective. 1. To evaluate the diagnostic value of the echocardiographic parameter of Color Doppler Horizontal Splay width (CDHSW) in assessment the of mitral regurgitation (MR) severity.2. To determine the cut-off values of CDHSW for the diagnosis of severe MR.Material and methods. A prospective data collection of 81 patients with presence of CDHS on echocardiography was carried out. Transesophageal echocardiography was performed in all of them to clarify the etiology and severity of MR, and in addition, 33 (40%) patients underwent phase-contrast magnetic resonance imaging.Results. After multiparametric examination severe MR was found in 32 (39%) patients, moderate MR in 47 (58%) and mild MR in 2 (3%). Regurgitation jet was eccentric in 79 (98%) patients, and sharply eccentric in 58 (71%) of them. The values of CDHSW (measured in 4-chamber, 2-chamber view, and mean CDHSW values) were significantly higher in the group of severe MR in comparison with the group of moderate MR. A statistically significant strong correlation was revealed between the CDHSW (measured in the 4- and 2-chamber view, and mean CDHSW values) with the values of MR volume, regurgitant fraction, size of effective regurgitant orifice, and a moderate correlation with the values of vena contracta width, left ventricle end-diastolic velocity and left atrium volume. ROC analysis showed the highest diagnostic value (AUC 0,93 ± 0,5, p &lt; 0,001) of mean CDHSW in diagnosis of severe MR in comparison with CDHSW. Optimal cutoff value for mean CDHSW for severe MR diagnosis was &gt;30 mm with a sensitivity of 88% and specificity of 71%.Conclusions. 1. CDHSW is an echocardiographic parameter that provides additional opportunities in the diagnosis of latent moderate and severe eccentric MR.2. It is reasonable to use mean values for the increase of diagnostic sensitivity of CDHSW.3. The mean value of CDHSW &gt;30 mm is highly suggestive to severe MR.

Mitral Transcatheter Edge-to-Edge Repair in Nonagenarians

BackgroundThere are scarce data regarding mitral transcatheter edge-to-edge repair (TEER) in individuals aged 90 years and above. We aimed to evaluate patient characteristics, procedural aspects, and outcomes in this rapidly growing group. MethodsWe retrospectively studied a single-centre database of 967 isolated, first-time interventions, 103 (10.7%) of which were performed in nonagenarians. Outcomes included all-cause mortality, heart failure (HF) hospitalizations, and the persistence of significant mitral regurgitation (MR) or New York Heart Association functional class III/IV during the first postprocedural year. Analyses were repeated on a 204-patient, propensity score-matched subcohort, controlling for MitraScore elements, sex, race, MR etiology, functional status, atrial fibrillation/flutter, and procedural urgency. ResultsCompared with subjects below 90 years of age, nonagenarians were more likely to be white women of higher socioeconomic status; had a higher interventional risk, driven mainly by age and chronic kidney disease; presented more often with primary MR (71.8 vs 39.1%, P < 0.001); and exhibited less advanced biochemical/echocardiographic indices of cardiac remodelling. Further, their procedures were more commonly nonurgent and used fewer devices. A similarly high (> 97%) technical success rate was achieved in the 2 study groups. Likewise, no intergroup differences were observed in the rates or cumulative incidences of any of the explored endpoints, and neither of the outcomes’ risks was associated with age 90 and above. Comparable outcomes were also noted in the propensity score-matched subgroups. ConclusionsIn our experience, mitral TEER was equally feasible, safe, and efficacious in patients below and above 90 years of age.

Echocardiographic quantification of mitral apparatus morphology and dynamics in patients with dilated cardiomyopathy.

Mitral regurgitation is among the most common valvular heart diseases. Mitral regurgitation in patients with dilated cardiomyopathy is a complex pathology involving annular dilatation, papillary muscle displacement, systolic leaflet tethering, and left ventricular remodeling. Quantification of mitral apparatus damage in these patients is essential for successful interventional and surgical therapy. Mitral regurgitation in the presence of dilated cardiomyopathy is classified as Carpentier type IIIB, with restricted leaflet mobility as a standard feature. Echocardiography allows accurate evaluation of the complex anatomy and function of the mitral apparatus. Updated guidelines recommend two-dimensional followed by systematic three-dimensional echocardiographic evaluation in patients with mitral regurgitation. New three-dimensional echocardiographic software packages provide many parameters that help identify the precise morphology and function of the various components of the mitral apparatus, helping to determine the etiology of mitral regurgitation and evaluate disease severity. This review provides the first point-by-point approach to the assessment of all old and new echocardiographic methods, from the simplest to the most complex, used to examine the components of the mitral valve apparatus in patients with dilated cardiomyopathy. Although these parameters are still under research, this information will be helpful for establishing therapeutic procedures in a disease with a poor prognosis.

Pulmonary venous flow changes after Mitraclip implantation is predictor of mid-term right ventricular function improvement

Abstract Background Percutaneous mitral valve repair with Mitraclip has become an effective therapeutic alternative to mitral valve surgery in high-risk surgical patients with severe mitral regurgitation. Pulmonary venous flow assessment by pulsed Doppler is widely used to determine the severity of mitral regurgitation and apparently is the best method to evaluate mitral regurgitation after the procedure because device artifacts do not affect it. The main objective of this study was to assess the impact of pulmonary venous flow changes after Mitraclip implantation in right ventricular function in the follow up at 6 months after the procedure. Methods This single-center, retrospective study included all consecutive patients with mitral regurgitation ≥ III/IV undergoing percutaneous mitral valve repair with the MitraClip device at our institution between 2010 and 2023. We analyzed the changes in the systolic/diastolic flow velocity time integral ratio in pulmonary veins pre and postprocedure. The tricuspid annular plane systolic excursion (TAPSE) was the method used to assess the right ventricular function in the follow up. Results A total of 158 consecutive patients that underwent Mitraclip implantation at our institution were included. Men age was 77 years ±10.3, and 82 patients (52.5%) were women. The etiology of mitral regurgitation was degenerative in 70 patients (44.3%), functional in 60 patients (37.9%) and mixed in 28 patients (17.7%). Preprocedurally, tridimensional effective regurgitant orifice was 0.63 ±0.33cm2, left ventricular end-diastolic volume 145.19 ± 66.14 ml (indexed 80.33 ± 59.59 ml/m2), left ventricular ejection fraction 45.90 ± 15.99%, pulmonary artery systolic pressure (PASP) 48.79 ± 18.12 mmHg and TAPSE 18.59 ± 4.43mm. The change in the pulmonary venous flow assessed by the systolic/diastolic flow velocity time integral ratio, was predictor of a right ventricular function improvement at 6 months (y = -2.7169 + 3.0171 x, r= 0.45, p= 0,006 see figure 1). Conclusions Pulmonary venous flow changes after Mitraclip implantation assessed by the systolic/diastolic flow velocity time integral ratio is predictor of mid-term right ventricular function improvement.Figure 1

Early outcomes of the PASCAL P10 and the MitraClip XT transcatheter mitral leaflet approximation devices - A propensity score matched multicentre comparison

Abstract Background The edge-to-spacer PASCAL repair system was recently approved for percutaneous treatment of severe mitral regurgitation (MR). Comparative data with the MitraClip XT device which shows similar size and leaflet grasping features are lacking. Purpose Aim of this study was to compare the procedural and short-term safety and efficacy of two transcatheter mitral leaflet approximation devices, the PASCAL P10 and the MitraClip XT. Methods Overall, 566 patients underwent transcatheter mitral valve repair (TMVR) with PASCAL P10 (n=309) or MitraClip XT (n=257). The PASCAL P10 cohort included patients treated at 10 tertiary care centres in Germany between February and December 2019, while the MitraClip XT cohort consisted of patients treated at three of these 10 centres between May 2018 and September 2022. Propensity score (PS) matching based on the parameters gender, age, left ventricular ejection fraction, NYHA class, left ventricular end-diastolic diameter, left atrial volume index, vena contracta width, MR aetiology, and mean gradient resulted in 191 well balanced patient pairs. Primary efficacy endpoints were technical success, degree of residual MR at discharge and at 30-days as well as device success at 30-days. Primary safety endpoint was the rate of major adverse events (MAE) at 30-days. Results Technical success was 95.8% in the PASCAL group and 95.3% in the MitraClip group (P&amp;gt;0.99). An MR ≤2+ at discharge was numerically more frequent in the PASCAL than in the MitraClip group (PASCAL: 91.5% vs. MitraClip: 85.9%; P=0.101). An MR ≤1+ at discharge was achieved more frequently in the PASCAL group (PASCAL: 68.3% vs. MitraClip: 56.5%; P=0.025). This difference was sustained at 30-days with numerically more patients with residual MR ≤2+ (PASCAL: 89.7% vs. MitraClip: 82.4%; P=0.071) and significantly more patients with MR ≤1+ (PASCAL: 64.7% vs. MitraClip: 51.6%; P=0.021) in the PASCAL group than in the MitraClip group. At 30-days, the mean gradient was similar between the two groups (PASCAL: 3.0 [2.3–4.0] mmHg vs. MitraClip: 3.1 [2.7–4.2] mmHg], P=0.218). Device success at 30 days was achieved with an equal frequency in both groups (PASCAL: 78.8% vs MitraClip: 71.3%; P=0.129). At 30-days, MAE occurred more often in the MitraClip than in the PASCAL group (PASCAL: 3.7% vs. MitraClip: 12.6%; P=0.002). Conclusions In this PS-matched study comparing the PASCAL P10 with the MitraClip XT, safety and efficacy were comparable at 30-days.

Impact of anaemia and iron deficiency on long-term outcomes following transcatheter edge-to-edge repair in degenerative vs. secondary mitral regurgitation: results from a large single-center study

Abstract Background Transcatheter mitral valve edge-to-edge repair (TEER) is an established therapeutic option for significant mitral regurgitation (MR), as an alternative for patients at high risk for open heart surgery. While mitral valve reconstruction is the guideline-recommended treatment modality for degenerative mitral regurgitation (DMR), secondary mitral regurgitation (SMR) is more complex and requires a multifaceted approach. Anaemia and iron deficiency (ID) are both associated with unfavourable outcomes in patients with cardiovascular diseases, particularly in those with heart failure. In patients undergoing TEER, the prevalence of ID and anaemia is exceptionally high. However, data regarding the impact of anaemia and ID on outcomes are limited to short- and mid-term follow-up periods. Purpose This retrospective single center study, aimed to investigate effects of anaemia and ID on long-term outcomes following TEER for relevant MR, as well as to relate it to the underlying MR aetiology. Methods A total of 833 patients (mean age 76.1 ± 8.4 years, 40.7% female, 63.3% secondary MR) were treated by TEER between September 2008 and July 2019. Patients were stratified based on their anaemia status (anaemia was defined as hemoglobin &amp;lt;12 g/dL in females and &amp;lt;13 g/dL in males) or ID (defined according to current HF guidelines as a serum ferritin concentration of &amp;lt;100 ng/mL or 100–299 ng/mL and a transferrin saturation &amp;lt;20%). Clinical follow-up was conducted primarily through in-person visits or by structured telephone interviews at 6 and 12 months after intervention and annually thereafter. The median follow-up time was 5.5 years, with a maximum follow-up of 12.3 years. Results Anaemia and ID were prevalent among patients with 61.6% and 68.1%, respectively. Among all anaemic patients, 73.5% also had ID. Anaemic patients had a lower functional status at baseline and were less likely to show improvement after TEER. Additionally, anaemia was significantly associated with all-cause mortality (hazard ratio [HR]=1.68, 95%-confidence interval [CI]: 1.36-2.07, p&amp;lt;0.001) and the composite endpoint of death or heart failure rehospitalization (HR=1.30, 95%-CI: 1.10-1.54, p=0.002). Moreover, anaemia was found to be an independent predictor for all-cause mortality in patients with secondary MR, with a 5-year mortality rate of 69.9% in anaemic patients compared to 47.8% in non-anaemic patients (p&amp;lt;0.001). However, ID was not associated with an increased risk of all-cause mortality or the composite endpoint of death or heart failure rehospitalization for either degenerative or secondary MR. Conclusion The high prevalence of anaemia and ID in patients undergoing TEER is noteworthy. Anaemia was associated with poorer functional baseline status and less post-interventional improvement. Furthermore, and in contrast to ID, anaemia was linked to higher mortality rates and more heart failure rehospitalizations, particularly in patients with secondary MR.Kaplan Meier survival analysisPredictors for all-cause mortality

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.

Temporal trends in characteristics and outcomes in patients undergoing percutaneous mitral valve repair for secondary mitral regurgitation

Abstract Background and purpose Several studies have investigated the procedural and clinical outcomes of patients with secondary mitral regurgitation (MR) who underwent percutaneous mitral valve repair. However, temporal trend of patients’ characteristics and outcomes has not been studied in comparison with landmark studies. Thus, this systematic review investigated the temporal trend in patient characteristics and outcomes from observational studies over years in comparison with landmark studies in secondary MR. Methods The identified observational studies were grouped into two 5-year periods. The first 5-year period included 36 studies that started recruiting patients at any year between 2008 and 2012, whereas 25 studies in the second 5-year period started recruitment between 2012 and 2018. Pooled data of two every 5-year period were compared with the landmark studies. Multicenter studies with potential overlap in term of recruitment periods were excluded. Variables from observational studies were compared with those of landmark trials using a random-effects model for each variable. R software was used for non-comparative pooling of variables, and the RevMan software was used for the comparative meta-analysis. Results EVEREST versus observational studies: In first 5-year period, patients in EVERST program were more likely to have non-ischemic MR aetiology and less likely to be symptomatic at presentation (i.e., NYHA III/IV) or getting implanted cardiac device. They were less likely to have MR grade ≤2+ (OR 0.58, 95% CI:0.44-0.78) post procedure but maintained NYHA class I/II at 12-month follow-up (OR 1.74, 95% CI: 1.38-2.19) with no difference in mortality. In the subsequent 5-year period, there was no change from the former comparisons. COAPT versus observational studies: In the first period, COAPT patients were more likely to have renal insufficiency and receive beta-blockers and implanted device. They were less likely to present with severe heart failure symptoms or severe MR. There was no difference in post procedure outcomes, but they were more likely to maintain MR grade ≤2+ at follow-up (OR 3.98, 95% CI: 2.15-7.37). In the following period, COAPT patients were more likely to present with MR grade 3+ without a difference in procedural or clinical outcomes except for more chance to maintain procedural success at 12-mont follow-up (i.e., MR grade ≤2+; OR 2.41, 95% CI: 1.27-4.58). MITRA-FR versus observational studies: In the first period, MITRA-FR patients were less likely to have atrial fibrillation, renal insufficiency, or NYHA class III/IV. They were more likely receive beta-blockers and implanted device. However, there was no difference in post procedure and clinical outcomes. In the second period, there was no major change from the previous comparisons. Conclusion Although patients from landmark studies, namely COAPT and MITRA-FR, may have favourable characteristics, this did not translate into better outcome over time.

Multidetector Computed Tomography in Patients Who Underwent Transcatheter Mitral Edge-to-Edge Repair

Multidetector computed tomography (MDCT) can provide valuable information for mitral assessment, but its role in transcatheter mitral edge-to-edge repair (TEER) planning has been poorly elucidated. We aimed to compare MDCT with 3-dimensional transesophageal echocardiography (3D-TEE) for TEER preprocedural evaluation. We analyzed the preprocedural MDCT and 3D-TEE of 108 consecutive patients with mitral regurgitation (MR) who underwent MitraClip implantation. The levels of agreement for the etiology and mechanism of MR, mitral calcification, mitral annulus, and mitral valve orifice area (MVOA) measurements were compared between MDCT and 3D-TEE data. Receiver-operating-characteristic curves were generated for mitral annulus area and MVOA using a low mean transmitral pressure gradient at discharge (<5mm Hg) as the state variable, and the primary outcome of all-cause mortality or rehospitalization for heart failure at 1 year was compared between MDCT's and 3D-TEE's MVOA <4-cm2 cutoff. Good levels of agreement between MDCT and 3D-TEE were observed for determining the etiology (κ=0.81) and mechanism (κ=0.62) of MR but not for grading mitral calcification (κ=0.31 to 0.35). The correlations between MDCT and 3D-TEE measurements were strong for mitral annulus area (r=0.90) and good for MVOA (r=0.73). Furthermore, no significant differences in the area under the receiver-operating-characteristic curve to predict low transmitral pressure gradient at discharge or the primary outcome at 1 year were detected between MDCT- and 3D-TEE-derived parameters (all p >0.05). In conclusion, in patients who underwent TEER with MitraClip, a high degree of agreement for comprehensive evaluation of MR and prediction of clinical outcomes between MDCT and 3D-TEE was observed.

Outcomes After Transcatheter Mitral Valve Replacement According to Regurgitation Etiology

BackgroundWhether transcatheter mitral valve replacement (TMVR) devices perform similarly with respect to the underlying mitral regurgitation (MR) etiology remains unknown. The aim of the present analysis was to assess outcomes of TMVR according to the MR underlying etiology among the CHoice of OptImal transCatheter trEatment for Mitral Insufficiency (CHOICE-MI) registry. MethodsOf 746 patients, 229 patients (30.7%) underwent TMVR. The study population was subdivided according to primary, secondary, or mixed MR. Patients with mitral annular calcification were excluded. The primary study endpoint was a composite endpoint of all-cause mortality or hospitalization for heart failure at 1 year. Secondary study endpoints were all-cause and cardiovascular mortality at 1 year, New York Heart Association functional class, and residual MR, both at discharge and 1 year. ResultsThe predominant MR etiology was secondary MR (58.4%), followed by primary MR (28.7%) and mixed MR (12.9%). Technical success and procedural mortality were similar according to MR etiology. Discharge echocardiography revealed residual MR 2+ in 11.3%, 3.7%, and 5.3% of patients with primary, secondary, and mixed MR, respectively (P = .1). MR elimination was similar in all groups up to the 1-year follow-up. There was no difference in terms of primary combined outcome occurrence according to MR etiology. One-year all-cause mortality was reported in 28.8%, 24.2%, and 32.1% of patients with primary, secondary, and mixed MR, respectively (P = .07). ConclusionsIn our study we did not find differences in short-term and 1-year outcomes after TMVR according to MR etiology.

Restoration of Life Expectancy After Transcatheter Edge-to-Edge Mitral Valve Repair

BackgroundSurvival data after mitral transcatheter edge-to-edge repair (TEER) are scarce, and its impact on predicted life expectancy is unknown. ObjectivesThe aim of this study was to estimate the impact of TEER on postprocedural life expectancy among patients enrolled in the MitraSwiss registry through a relative survival (RS) analysis. MethodsConsecutive TEER patients 60 to 89 years of age enrolled between 2011 and 2018 (N = 1140) were evaluated. RS was defined as the ratio between post-TEER survival and expected survival in an age-, sex- and calendar period–matched group derived from the Swiss national 2011 to 2019 mortality tables. The primary aim was to assess 5-year survival and RS after TEER. The secondary aim was to assess RS according to the etiology of mitral regurgitation, age class and sustained procedural success over time. ResultsOverall, 5-year survival after TEER was 59.3% (95% CI: 54.9%-63.4%), whereas RS reached 80.5% (95% CI: 74.6%-86.0%). RS was 91.1% (95% CI: 82.5%-98.6%) in primary mitral regurgitation (PMR) and 71.5% (95% CI: 63.0%-79.3%) in secondary mitral regurgitation (SMR). Patients 80 to 89 years of age (n = 579) showed high 5-year RS (93.0%; 95% CI: 83.3%-101.9%). In this group, restoration of predicted life expectancy was achieved in PMR with a 5-year RS of 100% (95% CI: 87.9%-110.7%), whereas sustained procedural success increased the RS rate to 90.6% (95% CI: 71.3%-107.3%) in SMR. ConclusionsMitral TEER in patients 80 to 89 years of age is able to restore predicted life expectancy in PMR, whereas in SMR with sustained procedural success, high RS estimates were observed. Our analysis suggests that successful, sustained mitral regurgitation reduction is key to survival improvement, particularly in patients 80 to 89 years of age.