Recurrent Mitral Regurgitation Research Articles

A RARE COMPLICATION OF MITRAL TEER PROCEDURE: CLIP LATE DETACHMENT AND EMBOLIZATION

Abstract Intraprocedural and late complications of MitraClip implantation have already been described. This report highlights the importance of conventional surgical options in the event of percutaneous treatment failure. An 85–year–old woman with a history of chronic anemia, and thalassemia Minor was referred to our clinic for severe mitral regurgitation (MR) due to a P2 flail with significant calcification of the posterior mitral annulus. During the Heart Team discussion, age and comorbidities led to consider the patient eligible for TEER with the MitraClip system (EuroSCORE II 9,34%; STS score 7,47%). TEER procedure was uneventful: one XTW was deployed at the level of the flail (A2–P2), a second XTW was then placed more lateral to treat a separate residual jet, and one NTW was finally placed between them. MR reduction was considered acceptable (moderate MR, mean grad 6 mmHg). After two months, symptoms worsened, and TTE showed severe MR (no device detachment) with increased sPAP and associated moderate TR. A couple of weeks later, the patient was hospitalized. Chest X–ray revealed clip embolization confirmed by coronary angiography that showed an XTW Clip embolized to the Right coronary sinus with partial occlusion of the ostium. Percutaneous clip retrieval is described in the literature, but the embolized device position and the presence of recurrent severe MR led us to prefer an urgent surgical intervention. Under CPB, the embolized XTW was easily retrieved through a small aortotomy; the intervention was completed by mitral valve replacement and tricuspid valve repair. The postoperative course was uneventful. Predischarge TTE showed normal mitral bioprosthesis function, mild AR, mild TR, and preserved LV function. DISCUSSION Clip embolization is a rare but potentially critical complication of TEER and can happen periprocedurally or on early follow–up. Single leaflet detachment is more common, but complete detachment and embolization can occur. Therapeutic options are represented by surgical or transcatheter approaches according to embolization sites and patient comorbidities. In our case, the risk of potential coronary obstruction or thrombosis and the concomitant need for MR treatment have led us to consider surgery as the first option. CONCLUSION TEER can be graved by acute or late complications. The best approach has to be tailored to each patient, and surgery can be an effective and safe option even for initially discarded high–risk patients.

Repeat Mitral Valve Interventions After Transcatheter Edge-to-Edge Repair: The COAPT Trial

The frequency and effectiveness of repeat mitral valve interventions (RMVI) after transcatheter edge-to-edge repair (TEER) for secondary mitral regurgitation (MR) are unknown. We aimed to examine the rate of and outcomes following RMVI after TEER in the COAPT trial.The COAPT tria randomized heart failure (HF) patients with severe secondary MR to TEER with the MitraClipTM device plus guideline-directed medical therapy (GDMT) versus GDMT alone. We evaluated the characteristics and outcomes of patients who had a RMVI during 4-year follow-up. A MitraClip implant was attempted in 293 patients randomized to TEER+GDMT, 10 of whom (underwent a RMVI procedure (9 repeat TEER and 1 surgical mitral valve replacement) after 4-years of follow-up (cumulative incidence 3.90%,95% CI 2.08-7.08; median 182 days after the initial procedure). Patients with RMVI had larger mitral annular diameters, fewer clips implanted and were more likely to have ≥3+ MR at discharge compared with those without RMVI. Reasons for RMVI included failed index procedure due to difficult transseptal puncture (n=2) or tamponade (n=1); residual or recurrent severe MR after an initially successful procedure (n=5); partial clip detachment (n=1); and site-assessed mitral stenosis (n=1). RMVI was successful in 8/10 (80%) patients. Patients who underwent RMVI had higher 4-year rates of HFH but similar mortality compared with those without RMVI. The annualized incidence rates of all HFH in patients who underwent RMVI were 234 events per 100 person years (95% CI 139-395) pre-RMVI and 46 per 100 person years (95% CI 25-86) post-RMVI as compared with 32 events per 100 patient years (95% CI 28-36) among patients not undergoing RMVI. The rate ratio of HFH was reduced after RMVI in patients undergoing RMVI (0.20, 95% CI 0.09-0.45).

Long-term Outcomes of Surgical Correction of Ischemic Mitral Regurgitation

Objective: To evaluate long-term outcomes of mitral valve annuloplasty using an autologous pericardial strip (“soft support ring” type) and a rigid support ring in combination with coronary artery bypass graft (CABG) in patients with ischemic mitral regurgitation.Materials and methods: We carried out retrospective and prospective analyses of the treatment outcomes in 90 patients with coronary heart disease (CHD) and ischemic mitral regurgitation. Ischemic mitral regurgitation (grade 2 or above) was an inclusion criterion for patients with CHD. Exclusion criteria were as follows: nonischemic mitral regurgitation, acute myocardial infarction, progressive angina pectoris, and repeated heart interventions. The patients were divided into 2 groups. Patients from group 1 underwent CABG with mitral regurgitation correction using a strip of glutaraldehyde-treated autologous pericardium (“soft support ring” type) according to our own method, whereas patients from group 2 underwent CABG with mitral regurgitation correction using a rigid support ring. The analysis revealed that the groups were comparable in all the studied parameters.Results: There was no statistically significant difference in the number of postoperative complications and hospital mortality between the groups. According to the analyzed data obtained at the time of discharge, all the patients had grade 0-1 mitral regurgitation, which shows a complete restoration of the mitral valve function after annuloplasty. In addition, there was a statistically significant decrease in the end-diastolic volume and an increase in ejection fraction, which is a sign of reverse left ventricular (LV) remodeling. The mean follow-up was 44±7.4 months. No deaths were reported during the follow-up. The results of the examination in the long-term period did not reveal negative dynamics in most patients compared with the findings in the early postoperative period. The LV size also did not change significantly, and the ejection fraction demonstrated an upward trend. One patient in each group had a recurrence of grade 3 mitral regurgitation.Conclusions: The immediate outcomes showed no recurrence of mitral regurgitation, a low number of intraoperative and postoperative complications, and pronounced reverse LV remodeling. We observed stable results in the long-term follow-up: only one patient in each group had a recurrence of mitral regurgitation. Reverse LV remodeling persisted throughout the follow-up. There were no significant differences between the groups in any parameter, which indicates that the developed annuloplasty method is not inferior to the traditional technique with a rigid support ring.

Restrictive annuloplasty or replacement on reverse remodeling for nonischemic dilated cardiomyopathy

BackgroundFor patients with nonischemic dilated cardiomyopathy (NIDCM), the indications for and results of mitral surgery remain controversial. We reviewed a strategy of mitral repair and replacement for clinically relevant secondary mitral regurgitation (MR) in patients with NIDCM.MethodsWe retrospectively reviewed 65 patients with advanced NIDCM (LVEF < 40%) who underwent mitral surgery. Of them, 47 (72%) underwent mitral annuloplasty and 18 (28%) replacement for secondary MR. The primary endpoint was postoperative reduction in indexed LV end-systolic volume (LVESVI).ResultsAt baseline, there was no intergroup difference in LVESVI (123 ± 47 vs. 147 ± 37 ml/m2, P = 0.055), LVEF (27 ± 8% vs. 25 ± 6%, P = 0.41), incidence of severe MR (57% (27/47) vs. 72% (13/18), P = 0.40), or EuroSCORE II score (6.2% vs. 7.6%, P = 0.90). At 6 months, the annuloplasty group reduced LVESVI to a greater degree than the replacement group (P < 0.001), yielding significantly smaller postoperative LVESVI (96 ± 59 vs. 154 ± 61 ml/m2, P < 0.001) and better LVEF (P < 0.001). The rates of moderate/severe recurrent MR were 17% (8/47) and 0%, respectively. Multivariable analysis demonstrated that mitral annuloplasty (OR 6.10, 95% CI 1.14–32.8, P = 0.035) was significantly associated with postoperative LV reverse remodeling. Cumulative survival was not different between the groups (P = 0.26).ConclusionsIn patients with NIDCM, mitral annuloplasty reduced LV volume to a greater degree than did mitral replacement. These findings may assist with surgical options for secondary MR associated with NIDCM.

Mitral valve surgery in patients with Marfan syndrome

ObjectiveTo review the pathology of the mitral valve (MV) and long-term outcomes of surgery in patients with Marfan syndrome (MFS). Patients and MethodsFrom 1988 through 2020, 60 patients with MFS had surgery to correct mitral regurgitation (MR): 19 had isolated MV surgery, 32 had combined MV and aortic root surgery, and 9 had MV surgery after aortic root surgery. Follow-up was complete for a median of 16.1 years. ResultsMV pathology was myxomatous degeneration in all patients and of advanced degree in 78.6% with bileaflet prolapse in 65.5%, mitral annulus disjunction in 57.5%, and mitral annulus calcification in 8.2% of patients. The MV was repaired in 47 patients and replaced in 13. Kaplan–Meier estimates of cumulative mortality at 20 years 21.3% for all patients, 6.7% after MV repair, and 57.8% after replacement (P < .001). MV reoperations were performed in 5 patients: 2 after repair and 3 after replacement. The cumulative incidence rate of reoperations on the MV was 3.8% at 10 years and 11.0% at 20 years in the entire cohort. Among 47 patients who had MV repair, moderate MR developed in 11 patients and severe in 2. Both patients with severe MR underwent MV reoperation. The cumulative incidence rate of recurrent moderate or severe MR after MV repair was 20.4% at 10 years, and 36.5% at 20 years. ConclusionsMV repair was associated with better survival than MV replacement, but recurrent MR after repair occurred in approximately one-third of the patients at 20 years after surgery.

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

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

Mitral valve repair for degenerative mitral regurgitation with Carpentier’s functional classification type II in elderly patients: a single center experience

ObjectiveMitral valve (MV) repair for Carpentier functional classification Type II (C-II) mitral regurgitation (MR) is widely accepted because of its efficacy. It is unclear whether MV repair has the same benefits in elderly patients as in younger patients because of their lower life expectancy. Herein, we examined the midterm results of MV repair for C-II mitral regurgitation, especially in patients aged ≧70 years.MethodA retrospective review was performed on 176 patients who underwent MV repair for C-II mitral regurgitation with a median age of 65 years; 55 (31%) patients were ≧70 years, and 124 were male (71%). Lesions of the mitral valve were isolated from the anterior leaflet (48 patients), posterior leaflet (113 patients), and both leaflets (15 patients), and included seven patients with Barlow’s disease. We compared the outcomes between patients aged ≧70 years (≧70 years; median age, 76 years) and those aged < 70 years (median age, 60 years).ResultsIn terms of the durability of MV repair in elderly patients, there were no significant differences in the rates of freedom from reoperation or MR recurrence at 5 years between patients aged < 70 years and those aged ≧70 years (reoperation:98% in < 70 years versus 89% in ≧70 years; P = 0.4053; MR recurrence:95% in < 70 years versus 81% in ≧70 years; P = 0.095). The mitral valve complexity was divided into two grades: Simple (isolated posterior mitral lesion) and Complex (isolated anterior lesion or both lesions). In patients aged < 70 years, there was no significant difference in the rate of freedom from MR recurrence at 5 years between the Simple and Complex groups (96% vs. 91%; P = 0.1029). In contrast, in patients aged ≧70 years, the MR recurrence rate at 3 years in Complex was significantly higher in the Complex group than in the Simple (100% vs. 80%; P = 0.0265).ConclusionsWe studied the outcomes of MV repair for C-II in MR. In elderly patients, MR recurrence was higher in complex lesions than in simple lesions. MV replacement may be considered for elderly patients with complex mitral valve lesions, if appropriately selected.

Remodeling on Lateral Side of Posterior Mitral Leaflet in Recurrent Mitral Regurgitation after Mitral Annuloplasty for Patients with Atrial Functional Mitral Regurgitation

Objective. The high recurrence rate of mitral regurgitation (MR) in patients with atrial functional mitral regurgitation (AFMR) who underwent mitral annuloplasty (MAP) is reported. However, the mechanism of recurrence is not fully understood and appropriate surgical intervention remains unknown. Herein, we reviewed patients with AFMR who underwent MAP at our institution and investigated the preoperative geometric characteristics of the mitral valve in terms of MR recurrence after surgery. Methods. We retrospectively evaluated 20 patients with AFMR who underwent MAP between 2010 and 2022. The mean follow-up period was 3.2 ± 2.3 years. Preoperative three-dimensional transesophageal echocardiography (3D TEE) was available for all patients, and geometric analysis of the mitral valve was performed using the Philips Q-Lab software. Results. MR recurred in six patients. The rates of freedom from MR recurrence were 79% and 57% at one and three years, respectively. The lateral portion of the posterior mitral leaflet (PML) in patients with recurrent MR was longer and thicker than that in patients without recurrent MR (length of P1; 10 ± 3 vs. 15 ± 5 mm, p&lt;0.01, length of P2; 11 ± 4 vs. 14 ± 4 mm, p=0.23, length of P3; 8 ± 3 vs. 10 ± 3 mm, p=0.13). Conclusions. Patients with remodeling of the lateral portion of PML tended to have recurrent MR after MAP. This factor could indicate progressive remodeling, and MAP alone may not be a sufficient intervention for these patients.

Impact of Recurrent Mitral Regurgitation on Left Ventricular Mass Regression and Cardiac Events following Mitral Valve Repair.

Mitral valve regurgitation results in volume overload, followed by left ventricular remodeling. Variation of reverse remodeling following mitral repair influences the clinical outcomes. We aimed to evaluate the association between recurrent mitral regurgitation and mass regression following mitral valve repair and the impact on major adverse cardiovascular events. A retrospective cohort study was conducted on 164 consecutive patients with severe mitral regurgitation who underwent elective mitral valve repair. Subgroups were classified based on the presence of recurrent mitral regurgitation exceeding moderate severity. The hemodynamic parameters were evaluated according to geometry, mass, and function with Doppler echocardiography before and after surgery. Cox regression analysis was performed to evaluate the association between hemodynamics and mass regression and clinical outcomes. The results for MR indicated 110 cases with non-recurrent MR and 54 with recurrent MR, along with 31 major adverse cardiovascular events. The tracked echocardiographic results revealed less reduction in dimension and volume, along with less mass regression in the recurrent MR subgroup. Significant differences were revealed in the relative change of the LV end-diastolic volume index and relative mass regression between subgroups. The relative change in the LVEDVI was proportionally correlated with relative mass regression. Cox regression analysis identified correlations with major adverse cardiovascular events, including suture annuloplasty, recurrent mitral regurgitation, tracked LV mass, relative LV mass regression, and systolic dysfunction. LV mass regression and relative change of the LV end-diastolic volume could be risk predictors of recurrent mitral regurgitation. The extent of LV mass regression is correlated with adverse cardiac events.

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.

Respect Versus Resect Approaches for Mitral Valve Repair: A Meta-Analysis of Reconstructed Time-to-Event Data

Mitral valve repair (MVr) has been associated with superior long-term survival and freedom from valve-related complications compared with mitral valve replacement for primary mitral regurgitation (MR). The 2 main approaches for MVr are chordal replacement ("respect approach") and leaflet resection ("resect approach"). We performed a systematic review and a meta-analysis using 3 search databases to compare the long-term end points between both approaches. The primary end point was long-term survival. The secondary end points were long-term MR recurrence and reoperation. After reconstruction of time-to-event data for the individual survival analysis, pooled Kaplan-Meier curves for the end points were generated. A total of 14 studies (5,565 patients) were included in the analysis. The respect approach was associated with superior survival compared with the resect approach in the overall sample (hazard ratio [HR] 0.73, 95% confidence interval [CI] 0.56 to 0.96, p=0.024, n=3,901 patients) but not in the risk-adjusted sample (HR 1.00, 95% CI 0.55 to 1.82, p=0.991, n=620 patients). There was no difference between the approaches in the rate of MR recurrence in the overall sample (HR 1.39, 95% CI 0.92 to 2.08, p=0.116, n=1,882 patients) or in the risk-adjusted sample (HR 1.62, 95% CI 0.76 to 3.47, p=0.211, n=288 patients). The data for reoperation were only available in the overall sample and did not reveal a difference (HR 0.92, 95% CI 0.62 to 1.35, p=0.663, n=3,505 patients). In conclusion, the current evidence suggests no difference in long-term mortality, MR recurrence, or reoperation between the resect and respect approaches for MVr after adjusting for patient risk factors. More long-term follow-up data are warranted.

Mitral regurgitation in atrial fibrillation: Is a simple repair enough to tackle a complex problem?

BackgroundClinical and echocardiographic results of valve repair for mitral regurgitation in the setting of atrial fibrillation are poorly studied. MethodsBetween January 2008 and December 2020, 89 patients underwent valve repair for mitral regurgitation in the setting of atrial fibrillation. Clinical and echocardiographic follow-up data were collected and studied. The primary composite endpoint consisted of all-cause mortality or hospitalization for heart failure. ResultsValve repair with true-sized annuloplasty was performed in 83 (93 %) and restrictive annuloplasty in 6 (7 %) patients. Early mortality occurred in 3 (3 %) and residual mitral regurgitation in 1 (1 %) patient. During a median follow-up of 5.4 years (interquartile range 3.4–9.5), 25 patients died, 6 due to end-stage heart failure. Ten patients were hospitalized for heart failure. The estimated event-free survival rate at 10 years was 48.2 % (95 % CI 33.5 %–62.9 %). Recurrent mitral regurgitation was observed in 14 patients and most often caused by leaflet tethering. When analyzed as a time-dependent variable, recurrent regurgitation was related to the occurrence of the primary endpoint (hazard ratio 3.192, 95 % CI 1.219–8.359, p = 0.018). On exploratory sub-analyses, no recurrent regurgitation was observed after restrictive annuloplasty or in patients with paroxysmal atrial fibrillation. Moreover, recurrent regurgitation was observed more often when signs of left ventricular impairment were present preoperatively. ConclusionsDespite good initial results, recurrent regurgitation was a frequent observation after valve repair for mitral regurgitation in atrial fibrillation and had an effect on heart failure related morbidity and mortality. Refinements in the timing of surgery and surgical technique might help improve outcomes.

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

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

Redo transcatheter edge-to-edge mitral valve repair: a single centre experience

Abstract Introduction: Mitral valve transcatheter edge-to-edge repair (TEER) has been established as a therapy for patients with severe symptomatic mitral regurgitation (MR) who are at high surgical risk. Failure to implant a TEER device and the occurrence of residual or recurrent MR ≥3+ are well documented but data regarding outcomes of redo-TEER following initial failure are sparse. Purpose To evaluate the safety and efficacy of redo-TEER following initial failed intervention. Methods We included 16 patients who underwent redo-TEER for symptomatic MR ≥3+ from July 2016 to December 2022. Acute results were assessed by echocardiography prior to discharge and safety was evaluated clinically, according to the occurrence of procedure-related adverse events. Mid- and long-term outcomes were evaluated at three months and one year respectively. Data were obtained retrospectively by chart review. Mortality data were drawn from the national death registry. Results Reasons for redo-TEER include device failure without detachment in nine (56%) patients, device failure due to single leaflet detachment in four (25%) patients and initial implantation failure in three (19%) patients. Median time from index procedure was 167 days (range: 19 – 1457 days). Technical (implantation of a TEER device) and procedural (MR ≤2+ at discharged) success were achieved in 94% and 87.5% of patients undergoing repeat intervention respectively. MR grade was reduced to 1+ in 71% of patients who had successful TEER. No intra-procedural mortality or life-threatening complications were noted. Mean post-TEER hospitalization length was 1.8 ± 1.3 days. No deaths were noted during the first year following redo-TEER. Echocardiography at three months and one year demonstrated MR ≤2+ for all patients in whom TEER was successful. At three months and one-year follow-up, respectively 67% and 50% of patients who underwent successful intervention were in New York Heart Association (NYHA) class I or II and only one had been hospitalized for heart failure. Conclusion Repeat mitral TEER following initial procedural failure is safe and has high acute and mid-term success rates. More research is needed to better characterise patients likely to benefit from repeated intervention.

Machine-learning-based prediction of survival and mitral regurgitation recurrence in patients undergoing mitral valve repair.

This study was conducted to assess long-term clinical outcomes after mitral valve repair using machine-learning techniques. We retrospectively evaluated 436 consecutive patients (mean age: 54.7 ± 15.4; 235 males) who underwent mitral valve repair between January 2000 and December 2017. Actuarial survival and freedom from significant (≥ moderate) mitral regurgitation (MR) were clinical end points. To evaluate the independent risk factors, random survival forest (RSF), extreme gradient boost (XGBoost), support vector machine, Cox proportional hazards model and general linear models with elastic net regularization were used. Concordance indices (C-indices) of each model were estimated. The operative mortality was 0.9% (N = 4). Reoperation was required in 15 patients (3.5%). In terms of C-index, the overall performance of the XGBoost (C-index 0.806) and RSF models (C-index 0.814) was better than that of the Cox model (C-index 0.733) in overall survival. For the recurrent MR, the C-index for XGBoost was 0.718, which was the highest among the 5 models. Compared to the Cox model (C-index 0.545), the C-indices of the XGBoost (C-index 0.718) and RSF models (C-index 0.692) were higher. Machine-learning techniques can be a useful tool for both prediction and interpretation in the survival and recurrent MR. From the machine-learning techniques examined here, the long-term clinical outcomes of mitral valve repair were excellent. The complexity of MV increased the risk of late mitral valve-related reoperation.

Recurrent mitral regurgitation and left atrial aneurysm in a pediatric patent: A complex case of infective endocarditis

ABSTRACT A 6-year-old boy with a history of infective endocarditis (IE) presented with recurrent disease manifesting as left hip arthritis and severe mitral regurgitation. He developed a rare complication – a left atrial pseudoaneurysm. Despite the absence of classic fever and systemic symptoms, imaging revealed the recurrence and guided surgical repair. This case highlights the complexities of recurrent IE in children and underscores the importance of high clinical suspicion and imaging modalities like echocardiography for diagnosis and management.

Residual or recurrent mitral regurgitation predicts mortality following transcatheter edge-to-edge mitral valve repair

ObjectiveAlthough regurgitant mitral valves can be repaired through surgical or transcatheter approaches, contemporary comparative outcomes are limited with the impact of residual and recurrent mitral regurgitation (MR) on clinical outcomes being poorly defined. We hypothesized that moderate (2+) or greater residual or recurrent (RR) MR—regardless of type of repair—predicts worse clinical outcomes. MethodsOur institutional experience of 660 consecutive patients undergoing mitral valve repair (2015-2021) consisting of 393 surgical mitral valve repair (SMVr) and 267 transcatheter edge-to-edge mitral valve repair (TEER) was studied. The echocardiographic impact of RRMR (2+) following both SMVr and TEER on death and reintervention was evaluated. ResultsPatients averaged 67.8 ± 14.2 years (SMVr = 63.8 ± 13.3 vs 73.6 ± 13.6, P < .0001) and 62.1% were male. Baseline clinical and demographic data were vastly different between the 2 groups. Residual or recurrent 2+ or greater MR developed in 25% (n = 68) of patients who received TEER compared with 6% (n = 25) of SMVr (P < .0001). Reintervention (9.3% vs 2.4%, P = .002) and death (37.9% vs 10.4%, P < .0001) rates at 3-years were greater among the TEER group versus SMVr group. Given the heterogeneity in baseline characteristics and difference in survival, each cohort was analyzed separately, stratified by RRMR, using multivariable modeling to identify predictors of repeat reintervention and death. There were too few events of RRMR in the SMVr cohort for evaluation. For the TEER subgroups, we observed greater long-term mortality, but not reintervention among those with RRMR., Hypertension was the strongest predictor of death and obesity was for reintervention. ConclusionsPatients undergoing SMVr and TEER are vastly different with respect to baseline patient characteristics and clinical outcomes, with patients who undergo TEER being much greater risk with poorer prognosis. Moderate or greater RRMR predicted worse long-term survival but not reintervention among patients who received TEER. Given the difference in survival among patients with RRMR following TEER, care must be taken to ensure that patients entering clinical trials and receiving TEER should have a high probability of achieving mild or less MR as seen in contemporary surgical results.

Discussion to: Residual or recurrent mitral regurgitation predicts mortality following transcatheter edge-to-edge mitral valve repair

Discussion to: Residual or recurrent mitral regurgitation predicts mortality following transcatheter edge-to-edge mitral valve repair

Simplified ELASTA-CLIP Before Transapical Mitral Valve Replacement

Residual and recurrent mitral regurgitation after transcatheter edge-to-edge repair are therapeutically challenging. In the present case report, we describe a simplified, transapical electrosurgical laceration and stabilization of clip procedure that represents an alternative and direct approach for electrosurgical laceration of mitral valve leaflets enabling transcatheter mitral valve replacement for recurrent mitral regurgitation after mitral valve transcatheter edge-to-edge repair.

Alfieri versus conventional repair for bileaflet mitral valve prolapse

ObjectiveMitral valve repair for bileaflet prolapse can be complex, involving multiple chords or resection. The Alfieri technique for bileaflet disease is simple but may be associated with mitral stenosis or recurrent mitral regurgitation. Outcomes of patients with bileaflet prolapse undergoing mitral valve repair using the Alfieri versus conventional chord/resection techniques were compared. MethodsAdults undergoing mitral valve repair for bileaflet prolapse for degenerative disease from 2017 to 2023 were stratified by repair technique. Outcomes including operative mortality and echocardiogram data were compared. Time to event analysis was used to characterize freedom from recurrent mitral regurgitation (moderate or greater mitral regurgitation). ResultsAmong 188 patients with bileaflet prolapse, 37% (70) were repaired with the Alfieri and the remaining patients were repaired with chords/resection. Compared with chords/resection, patients undergoing the Alfieri had shorter cardiopulmonary bypass and crossclamp times. Operative mortality (0% [0/70] vs 2% [2/118], P = .27) was similar between both techniques. The mean mitral gradient was low and similar for the Alfieri versus chords/resection (3 vs 3, P = .34). Development of recurrent mitral regurgitation at 2 years, incorporating the competing risk of death and mitral reintervention, was 4.3% (95% CI, 1.5%-9.3%) for the Alfieri technique and 5.8% (95% CI, 2.2%-11.8%) for chord/resection (P = .83). ConclusionsBoth the Alfieri and chord/resection techniques had low rates of recurrent mitral regurgitation at 2 years. The mitral valve gradient was low and similar regardless of technique; thus, those who received the Alfieri technique did not have an increased rate of mitral stenosis. The Alfieri may be an underused technique for bileaflet prolapse.