Mitral Regurgitation Research Articles

Background Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) are characterized by the abrupt onset of neuropsychiatric symptoms temporally linked to Group A β-hemolytic Streptococcus infection. The condition remains diagnostically challenging due to overlapping features with other autoimmune and psychiatric disorders, absence of definitive biomarkers, and variable infectious histories. Objective To describe a diagnostically complex case of PANDAS in a preadolescent girl presenting with concurrent choreiform movements, acute psychosis, and subclinical valvular changes. Case A 12-year-6-month-old previously healthy girl developed sudden-onset involuntary dance-like movements and acute psychiatric symptoms, including auditory hallucinations and bizarre delusions. Neurological examination revealed chorea without focal deficits. Echocardiography showed mild mitral and tricuspid regurgitation. Anti Streptolysin O (ASTO) test was positive, but other Laboratory markers of inflammation were normal. The temporal clustering of symptoms, subtle cardiac findings, positive ASTO test and exclusion of alternative diagnoses supported a working diagnosis of PANDAS. Management included antipsychotic, benzodiazepine, and anticonvulsant therapy, with referral for tertiary evaluation and potential immunomodulation. Conclusion This case emphasizes the importance of early recognition of PANDAS in children with abrupt neuropsychiatric and motor symptom onset, the necessity of thorough differential diagnosis, and the value of multidisciplinary care in optimizing outcomes.

In patients with ventricular functional mitral regurgitation (VFMR) undergoing transcatheter edge-to-edge repair (M-TEER), the prognostic significance of the ratio between mitral regurgitant volume and left atrial volume (LAV) remains unclear. This ratio may reflect the proportional or disproportionate burden of regurgitation on the left atrium. To address this gap, we aimed to investigate the association between the regurgitant volume (RVol)/LAV ratio and clinical outcomes in patients with VFMR, using data from a multicentre prospective registry. We calculated the RVol/LAV ratio from baseline transthoracic echocardiograms. The median value of the RVol/LAV ratio was 0.40. A total of 1830 patients who underwent M-TEER were allocated into two groups: the low RVol/LAV (RVol/LAV ratio <0.40) and high RVol/LAV (RVol/LAV ratio ≥0.40) groups. The primary endpoint was heart failure hospitalization.Eight hundred eighty-eight and 942 patients were included into the low RVol/LAV ratio and high RVol/LAV ratio groups, respectively. The median follow-up period was 508 days. At three years after repair, 215 (37.6%) and 187 (32.1%) patients in the low RVol/LAV and high RVol/LAV groups, respectively, were hospitalized for heart failure. The patients in the low RVol/LAV group demonstrated a significantly higher risk of heart failure hospitalization than did those in the high RVol/LAV group (hazards ratio, 1.25; 95%confidence interval, 1.03-1.52; p = 0.022). Furthermore, using multivariable Cox regression analysis, the low RVol/LAV was an independent predictor of the primary endpoint. The RVol/LAV ratio might serve as a valuable metric for improving risk stratification in patients with VFMR.

Background: Pulmonary hypertension is common in left-sided heart valve disease, with historical studies reporting mortality rates up to 31% in severe cases undergoing mitral valve surgery. This study evaluates the impact of severe pulmonary hypertension on outcomes of mechanical mitral valve replacement with posterior leaflet preservation by comparing results with patients having mild-to-moderate pulmonary hypertension. Methods: Prospective analysis of 86 patients with mitral valve disease undergoing mechanical valve replacement with posterior leaflet preservation from March 2015 to September 2016 was conducted. Patients were stratified by pulmonary artery pressure: severe (≥60 mmHg, n = 19) versus mild–moderate (35–59 mmHg, n = 67). Primary outcomes included mortality, complications, and functional recovery at 1, 6, and 12 months. Results: The cohort included 67 patients (77.9%) with mild–moderate pulmonary hypertension and 19 patients (22.1%) with severe pulmonary hypertension. Severe pulmonary hypertension patients demonstrated higher NYHA functional class (73.7% class III vs. 46.2%, p = 0.03), larger left atrial diameter (56.3 ± 9.8 vs. 49.5 ± 6.7 mm, p = 0.01), and higher mean pressure gradients (14.4 ± 5.3 vs. 11.3 ± 5.0 mmHg, p = 0.025). Mortality was 5.3% in the severe group versus 0% in the mild–moderate group (p = 0.331). Patients with severe pulmonary hypertension required longer ICU stays (6.3 ± 3.7 vs. 4.7 ± 2.2 days, p = 0.024) but showed no significant differences in ventilation time, reoperation rates, or major complications. At the 12-month follow-up, both groups achieved equivalent outcomes in pulmonary artery pressures, left ventricular function, and cardiac dimensions. Conclusion: In this study with a relatively small sample size, severe pulmonary hypertension was associated with significantly longer intensive care unit stay but not with higher mortality compared to mild–moderate pulmonary hypertension, with both groups attaining comparable functional and hemodynamic parameters at 12 months after mechanical mitral valve replacement with posterior leaflet preservation.

Background: Atrial fibrillation (AF) and mitral valve regurgitation (MVR) often co-occur in clinical settings, with the temporal sequence of their diagnoses potentially influencing cardiovascular outcomes. This study aimed to compare major cardiovascular event risks in patients diagnosed first with MVR followed by AF (MVR→AF) versus those with the reverse sequence (AF→MVR). Methods: A retrospective comparative outcomes analysis was conducted using the TriNetX Global Collaborative Network, encompassing data from 135 healthcare organizations. Two cohorts were defined post–propensity score matching using demographic, comorbidities, procedures and treatment: Cohort 1 (MVR→AF; n = 111,391) and Cohort 2 (AF→MVR; n = 111,391). Patients were balanced across demographics and comorbidities to isolate outcome differences. Cardiovascular outcomes were compared via later Cox models to obtain the hazard ratios (HRs) with 95% confidence intervals (CIs) (table 2). Results: Despite similar baseline characteristics, the MVR→AF group exhibited significantly higher incidence rates of all evaluated cardiovascular outcomes. Major Adverse Cardiovascular Events (MACE) occurred in 28.3% of MVR→AF patients compared to 21.0% in the AF→MVR cohort (HR 1.30; 95% CI: 1.28–1.33; p &lt; 0.0001) (Figure 1). This trend persisted across subcategories including ischemic heart disease (HR 1.18), heart failure (HR 1.38), myocardial infarction (HR 1.41), and cerebrovascular outcomes such as cerebral infarction (HR 1.35) and TIA (HR 1.31). The most notable disparity was observed in acute coronary disease (HR 1.65; p = 0.028). Cardiogenic shock and cardiac arrest, while elevated in the MVR→AF group, did not reach statistical significance (table 2). Conclusion: Patients with MVR preceding AF diagnosis are at significantly higher risk for adverse cardiovascular outcomes compared to those with AF diagnosed prior to MVR. These findings underscore the need for heightened surveillance and potential early intervention strategies in the MVR→AF population to mitigate downstream cardiovascular morbidity.

Background: Mitral annular calcification (MAC) is a chronic inflammatory condition that is associated with future cardiovascular events. There is limited data that explores how MAC impacts outcomes in patients with pre-existing mitral regurgitation (MR). Methods: This is a retrospective analysis using the TriNetX US Collaborative Network database. A database of hospitalized patients ≥50 years was queried using ICD-10 and TriNetX curated codes. We identified those given a discharge diagnosis of MR between 2020-2023, excluding patients with rheumatic mitral valve disease or ESRD. We then stratified by presence/absence of a new diagnosis of MAC (occurring after MR diagnosis). Cohorts were balanced for socio-demographics, body mass index, and common comorbidities including hypertension, hyperlipidemia, diabetes, and tobacco use, with a standard difference of &lt;0.1 considered to indicate adequate balancing. Hazard ratios were calculated for outcomes, with a P&lt;0.05 considered significant. Results: Our query yielded 11,462 patients in the MAC group and 450,474 patients in the no MAC group. Following propensity matching, each group had 11,462 patients. All targeted variables were adequately balanced. Average age was similar in both the MAC and no MAC groups (76 years vs 75.8 years). The populations were majority white (80.3% vs 81.2%) and female (56.8% vs 57.0%). BMI was also similar (29.2 vs 28.7). Among patients with pre-existing MR, subsequently diagnosed MAC was associated with increased 1-year risk of hospitalization (HR 1.22, 95%CI 1.180-1.262, p&lt;0.0001), ICU admission (HR 1.38, 95%CI 1.250-1.524, p&lt;0.0001), ischemic heart disease (HR 1.446, 95%CI 1.289-1.622, p&lt;0.0001), new onset HFpEF (HR 1.286, 95%CI 1.160-1.425, p&lt;0.0001), cerebrovascular disease (HR 1.341, 95%CI 1.190-1.512, p&lt;0.0001), prosthetic valve replacement (HR 2.126, 95%CI 1.786-2.530, p&lt;0.0001), and mitral stenosis (HR 3.16, 95%CI 2.490-5.234, p&lt;0.0001). There was not a significant difference between groups for HFrEF (HR 0.955, p=0.4377), cardiogenic shock (HR 1.188, p=0.1098), or cardiac arrest (HR 1.155, p=0.1979). Conclusions: In patients with previously diagnosed MR, a subsequent diagnosis of MAC was associated with increased 1-year risk of hospitalization, new onset ischemic heart disease or HFpEF, and a variety of other adverse cardiovascular outcomes.

Introduction: Standard echocardiographic measures of mitral regurgitation (MR) severity, such as vena contracta width (VCW) and effective regurgitant orifice area (EROA), are often unreliable after transcatheter mitral interventions due to altered valve anatomy. This case series highlights indirect echocardiographic parameters that collectively aid in assessing successful MR reduction after mitral interventions such as transcatheter edge-to-edge repair (TEER). Case Descriptions: Case 1: An 80-year-old woman with severe degenerative MR had a large, central MR jet occupying most of the left atrium (LA) and an LVOT stroke volume of 31 mL. Post-TEER, the MR jet resolved and LVOT stroke volume rose to 53 mL. Case 2: A 53-year-old man with severe functional MR had a dense, early-peaking with low-Vmax, triangular MR jet on spectral Doppler and a peak/mean iatrogenic atrial septal defect (ASD) gradient of 72/28 mm Hg. Post-TEER, the MR jet became parabolic with low Vmax and less dense, and the ASD gradient dropped to 16/9 mm Hg. Case 3: An 82-year-old woman with degenerative MR showed an E-wave dominant mitral inflow pattern with slow deceleration and pulmonary S wave reversal in the right upper pulmonary vein (RUPV). After TEER, the inflow pattern became A-wave dominant, and S wave reversal resolved. Case 4: A 54-year-old woman with chronic atrial fibrillation and severe MR after surgical valve replacement showed no spontaneous echo contrast (SEC) in the left atrial appendage (LAA). After valve-in-valve (ViV), there is now persistence of SEC. Discussion: Key echocardiographic indicators of resolved severe MR post-intervention include: (1) marked reduction in jet area on color Doppler, (2) increased LVOT stroke volume indicating improved forward flow, (3) transition from a dense, low-Vmax, triangular MR jet contour to a less dense, high Vmax, parabolic MR jet contour on spectral Doppler reflecting improved LA hemodynamics, (4) decreased transseptal pressure gradient across the iatrogenic ASD reflecting improved LA pressure, (5) shift from E-wave to A-wave dominant mitral inflow in the absence of significant mitral stenosis, (6) return of antegrade pulmonary S wave flow reflecting decreased LA pressure, and (7) reappearance of LAA SEC, as the MR jet no longer washes away the SEC seen in chronic atrial fibrillation. While no single measure is definitive, these findings support a multimodal approach to residual MR assessment and highlight the need for further validation.

Objective: The clinical trajectory of patients with moderate aortic stenosis (AS) complicated by concomitant mitral regurgitation (MR) remains poorly defined. While management strategies in severe AS are well established, patients with moderate AS and MR often fall below guideline-based thresholds for intervention despite symptoms and remodeling. We used cardiac magnetic resonance (CMR)—a robust modality for accurate valve quantification, particularly in mixed valvular disease— to assess the prognostic impact of MR in moderate AS and to compare the outcomes to patients with severe AS. Methods: We analyzed consecutive patients from the DeBakey CMR Registry (2008–2023) with ≥moderate AS on clinically indicated CMR. Exclusions included &gt;mild aortic regurgitation or mitral stenosis, subaortic obstruction, infiltrative cardiomyopathies, pre-capillary pulmonary hypertension, advanced malignancy, or unavailable follow-up. Patients were stratified by AS severity (moderate vs. severe) and MR grade (&lt;moderate vs. ≥moderate), with valve severity assessed per current CMR guidelines. The primary outcome was a composite of cardiovascular death or heart failure hospitalization. Statistical analysis was performed in R (Vienna, Austria), with significance defined as p&lt;0.05. Results: In a multivariate Cox regression analysis of 422 patients with moderate AS, both mitral regurgitant (MR) fraction on CMR (hazard ratio [HR] per 5% increase: 1.10; 95% CI: 1.04–1.16; P &lt; 0.001) and the presence of ≥ moderate MR (HR: 1.86; 95% CI: 1.31–2.65; P &lt; 0.001) were independently associated with the composite outcome (Table 1). In moderate AS, penalized spline regression analysis showed a statistically significant increase in risk with increasing MR fraction (P&lt;0.001 for linearity; P=0.028 for non-linearity; Figure 1). Kaplan-Meier curves demonstrated poorer 3-year event-free survival in patients with moderate AS and concomitant ≥moderate MR (33%) compared with both isolated severe AS (71%) and severe AS with ≥moderate MR (49%) (Figure 2). Conclusion: In moderate AS, concomitant MR is an independent predictor of adverse clinical composite outcomes. Patients with moderate AS and ≥moderate MR had worse composite outcomes than those with isolated severe AS, underscoring the additive risk of dual-valve pathology. These findings support more vigilant monitoring and may justify re-evaluation of treatment thresholds in this mixed valvular disease subgroup.

Background: Atrial fibrillation (AF) and mitral regurgitation (MR) are closely linked, and one may worsen the other. Objectives: To investigate the impact of baseline AF in patients with MR undergoing transcatheter edge-to-edge repair (M-TEER). Methods: One-hundred-fifty-six consecutive patients with symptomatic heart failure (HF) undergoing M-TEER for severe MR were studied. The primary endpoint was the composite outcome of death or HF hospitalization (HFH). Transthoracic echocardiograms were performed at baseline and follow-up. Results: Mean age was 80.8±8.8 years and 82 (52.6%) patients were female. MR etiology was primary in 69 (44.2%) and secondary in 87 (55.8%) patients. Atrial fibrillation or atrial flutter (AF) was present in 59 (37.8%) patients at baseline. M-TEER was successful (≤2+ MR) in 58 (98.3%) and 94 (96.9%) patients with and without AF respectively (p=0.59). During median 12.5 months follow-up, the primary endpoint occurred in 64 patients (2-year Kaplan-Meier estimated rate 41.0%), including death in 16 patients (10.3%) and HFH in 57 patients (36.5%). Baseline AF remained a significant independent predictor of death or HFH (aHR 2.03, 95% CI 1.12-3.69, p=0.02). Left ventricular end-diastolic volume, left atrial volume and right ventricular systolic pressure decreased during follow-up among patients in sinus rhythm but not among those in AF. AF was associated with an increased risk of severe MR recurrence (18.6% vs. 8.2%, p=0.05). Conclusion: In patients with HF and severe MR treated with M-TEER, baseline AF was associated with impaired right and left heart remodeling, more frequent MR recurrence, and more than doubling of the 2-year risk of death or HFH.

Background: Rheumatic heart disease (RHD) affects over 50 million people globally. Identifying latent RHD in asymptomatic children by echocardiography (echo) enables early secondary prophylaxis. The GOAL (Gwoko Adunu pa Lutino) trial demonstrated that monthly penicillin prevents disease progression in Ugandan children with screen-detected RHD. Recently a deep learning (DL) model trained on pediatric echo from GOAL with expert-adjudicated labels achieved strong performance compared to expert review (1). However, the performance of DL derived features against other emerging metrics such as left ventricular/left atrial strain has not been assessed. This study determined whether strain could provide additive value to assessment of RHD. Methods: Retrospective cohort analysis of completion studies from 435 children in GOAL trial (&lt;20 years of age). RHD status (latent or worse) was identified by expert clinicians. Mitral regurgitation (MR) features, including jet length, velocity and duration were extracted using the previously described DL model which was trained on pediatric echo images from high-quality standard portable echo with expert-adjudicated labels . Left atrial (LA), left ventricular (LV), and right ventricular (RV) strain parameters were manually quantified from apical views using Philips Ultrasound Workspace. Univariable and multivariable logistic regression were used to evaluate associations with RHD. Results: Two-hundred and forty-five children (56%) were identified to have RHD at study completion. Univariable logistic regression (Table 1) identified RHD associations with both DL-derived MR features and manual strain metrics, including maximum MR jet length (OR: 3.71, p &lt; 0.001), MR jet-to-LA atrium length ratio (OR: 2.87, p &lt; 0.001), MR duration (OR: 2.64, p &lt; 0.001), lower LV global longitudinal strain (OR: 0.79, p = 0.005), and lower LA global strain (OR: 0.79, p = 0.02). In multivariable stepwise regression (Table 1), three features remained independently associated: lower LV global longitudinal strain (OR: 0.76 [0.61–0.95], p = 0.016), greater MR jet length (OR: 3.06 [2.24–4.19], p &lt; 0.001), and longer normalized MR jet duration (OR: 1.63 [1.20–2.22], p = 0.016). Conclusions: Strain and DL-based classification of MR are independently associated with RHD. This study supports the biological validity of DL-driven RHD detection, also suggesting that strain measurements provides additive value in the assessment of RHD.

Background: Severe mitral regurgitation (MR) is typically associated with large V-waves on invasive hemodynamic monitoring. However, discrepancies often arise between echocardiographic assessments of MR severity using color Doppler and invasive hemodynamic measurements. These inconsistencies are largely influenced by left atrial (LA) compliance, which affects the magnitude of V-waves. We sought to identify non-invasive predictors of invasive LA compliance and V-wave response in patients undergoing transcatheter mitral valve therapies (TMVT). Hypothesis: Which echocardiographic and clinical factors are predictive of invasive LA compliance in patients undergoing TMVT for severe MR? Methods: Patients with severe MR who achieved MR resolution (≤1+ post-procedure) following TMVT by either transcatheter edge-to-edge repair (TEER) or transcatheter mitral valve replacement (TMVR) were included in the study. The compliant LA group consisted of patients with severe MR by color Doppler who had either a baseline LA mean pressure ≤12 mmHg or a concordant hemodynamic response, defined as ≥50% reduction in V-wave magnitude along with MR resolution. The non-compliant LA group included patients with a baseline LA mean pressure &gt;12 mmHg and a discordant response, defined as &lt;50% V-wave reduction despite MR resolution. Multivariable logistic regression was performed to identify independent predictors of LA compliance. Results: A total of 248 patients were included in the analysis, of whom 41 underwent TMVR and 207 underwent TEER. The mean age was 77.3 years, and 63% were male. Overall, 103 patients (41.5%) were classified as having a compliant LA, while 145 (58.5%) were classified as non-compliant. On multivariable logistic regression, two independent predictors of a non-compliant LA were identified: lower LA reservoir strain (OR 1.11; 95% CI, 1.04–1.19; p=0.002) and a history of prior atrial intervention; either atrial fibrillation intervention or left atrial appendage ligation (OR 0.28; 95% CI, 0.09-0.83; p=0.02) (Figure 1). Conclusion: Reduced LA reservoir strain and a history of atrial intervention are significantly associated with lower LA compliance and a blunted V-wave response following TMVT. These non-invasive markers may help identify patients with impaired LA mechanics and inform procedural planning and expectations.

Introduction: Continuous mitral regurgitation (MR) is a rare echocardiographic finding. Diastolic MR, although uncommon, is typically associated with atrioventricular (AV) dissociation such as complete heart block, bradycardia, or ventricular pacing. It may also occur when elevated left ventricular end-diastolic pressure (LVEDP) reverses the normal transmitral gradient. We present a case of a critically ill patient with acute embolic stroke, found to have multivalvular infective endocarditis with severe aortic regurgitation (AR) and continuous MR attributed to elevated LVEDP. Case Description: A 37-year-old male with a history of intravenous drug use, tricuspid valve endocarditis (2022), and hepatitis C presented as a Code Stroke after being found unresponsive with left sided weakness. Imaging revealed a large right middle cerebral artery infarct. Blood cultures grew Enterococcus faecalis. Transthoracic echocardiogram showed mild LV dilation with preserved EF (55–60%), a small vegetation on the mitral valve with mild-to-moderate MR, and multiple large vegetations on the aortic valve with leaflet prolapse causing severe AR. Notably, MR persisted into diastole despite sinus rhythm, with no AV dissociation on ECG or telemetry. He was admitted to the ICU for stabilization and surgical planning. Discussion: While diastolic MR typically results from AV dissociation, in this case, the diastolic component was due to markedly elevated LVEDP from acute-on-chronic severe AR. Chronic AR likely led to LV dilation, and acute worsening from valve destruction reversed the diastolic mitral pressure gradient, producing regurgitation during filling. Though previously described in isolated reports, continuous MR (with both systolic and diastolic components) is rarely documented in the setting of native valve endocarditis. This finding reflects critical hemodynamic compromise and carries implications for urgent surgical intervention. Conclusion: This case highlights continuous MR as a marker of elevated LVEDP in the absence of AV dissociation, occurring due to acute worsening of chronic AR in the setting of infective endocarditis. Recognizing this pattern is essential, as it signifies significant volume overload and impending decompensation.

Introduction: Studies have found significant familial clustering of mitral valve prolapse (MVP) and mitral valve regurgitation (MVR) in parent-child and sibling studies. However, genetic screening in MVP/MVR patients without syndromic presentation or in their family members is not recommended. Here we extend the familial clustering evidence beyond nuclear families and examine characteristics of MVP/MVR patients from high-risk MVP/MVR pedigrees. Methods: Transesophageal echocardiograms (ECHO) of patients seen at Intermountain Health from June 2006 to June 2024 were evaluated. Reported severity of MVP/MVR was used to categorize patients as severe, moderate, or mild (mild had to be reported on 2 or more ECHO). Patient characteristics were compared based on MVP/MVR ECHO severity. The Intermountain Genealogy Registry (IGR), a genealogy linked to Intermountain patients, was used to identify MVP/MVR cases from pedigrees. We compared MVP/MVR cases in pedigrees with high rates of MVP/MVR (relative rate &gt;5 times general patient population) to MVP/MVR cases in pedigrees with low rates of MVP/MVR. Finally, the IGR was used for large pedigree (≥3 generations) familial clustering analyses, based on genealogy familial index (GIF), which is the average kinship co-efficient for all case pairs. Results: A total of 751 MVP and 17,387 MVR patients were identified from 163,267 ECHOs. Those with severe MVP/MVR disease tended to male and have fewer comorbidities (Table 1). However, only males were significantly more likely to come from high-risk MVP/MVR pedigrees compared to low-risk MVP/MVR pedigrees (Table 2). MVP case pairs from large pedigrees had double the average relatedness (GIF ratio=2.1; Table 3), and while not significant, there was a trend toward different when compared to general patient pairs (p=0.07). However, the MVR case pairs from larger pedigrees did have a significant increase in relatedness (GIF ratio=1.4-1.7) compared to general patient pairs (p&lt;0.0001). Conclusions: There was no distinguishing patient characteristic, except for male sex, that indicated that an MVP/MVR patient was from a high-risk MVP/MVR pedigree. However, there was a trend toward significant familial clustering in large MVP pedigrees and a significant increase in relatedness for MVR. Examination of ECHO-specific parameters might help determine which ones are associated with MVP/MVR patients most likely from high-risk pedigrees and whose family members might be at higher risk.

Introduction: Transcatheter Edge to Edge Repair (TEER) of the mitral valve is offered to severely symptomatic patients with mitral regurgitation (MR) and high or prohibitive surgical risk. Chronic MR promotes atrial dilation and electrical remodelling, raising the risk of atrial fibrillation (AF). However, it remains unclear whether correcting MR via TEER reduces AF burden in patients who already have AF. Research Question: What is the effect of percutaneous repair of MR on AF burden and characteristics one year after the procedure in patients with AF undergoing TEER? Methods: We performed a retrospective single-center study where 73 patients were identified who had a diagnosis of AF and underwent TEER for MR between January 2021 and December 2023. The AF characteristics and burden are identified from chart review and reviewing EKG, Holter monitors, loop recorders, or already implanted device interrogations. A descriptive and comparative analysis of AF characteristics pre- and 1 year post-procedure is then performed. Result: The Mean age of this cohort was 79 + 6.6 years, with a 61% male and 89% white population. About 28.8% and 15% of patients had a pre-TEER history of cardioversion and ablation. Post procedure 68% (n=50) still had AF at least once during follow-up. A total of 20 patients had no AF noted since the procedure, corresponding to a 27.4 % relative risk reduction in AF persistence and an NNT of 4. About 22% of patients were noted to convert to sinus rhythm in 5.9 + 9 months and maintain it through the first year. During the follow-up, 5.5% and 4.1% underwent repeat cardioversion and ablation, respectively. New rhythm control agents were started in 6.8% of the total population. A total of 21 patients had quantified AF burden documented before and after the procedure. The burden numerically dropped from 32.45% to 27.58%, with a p=0.265. Conclusion: Our study indicates a possible numerical decrease in burden and shift in AF subtype distribution, which is comparable to the results of a prior study. This was not statistically significant given small sample size, retrospective nature. Although TEER alone would not reliably eliminate AF, it achieved a 27.4 % relative reduction in AF persistence (NNT = 4), suggesting a clinically meaningful benefit in reducing AF burden and promoting sinus rhythm. Prospective studies with larger cohorts and systematic rhythm monitoring are needed to clarify the true impact of MR correction on AF dynamics.

Background: Mitral valve prolapse (MVP) is associated with mitral regurgitation (MR), which can lead to adverse cardiac remodelling due to volume overload. In addition, mechanical stress from the prolapsing mitral valve may also induce replacement fibrosis. However, the type and extent of myocardial fibrosis across different MR severities remain poorly defined. Aim: To assess cardiovascular magnetic resonance (CMR) markers of myocardial fibrosis, including late gadolinium enhancement (LGE), indexed extracellular volume fraction (iECV), native T1, and native T2, in MVP patients stratified by MR severity. Methods: Patients with MVP undergoing 1.5T CMR at Karolinska University Hospital between February 2021–April 2025 were included. Imaging was performed to assess mitral annular disjunction, rule out primary cardiomyopathy, or as part of an ongoing CMR study involving MVP patients undergoing mitral valve surgery. Patients were excluded if they had ischemic heart disease, rheumatic mitral valve disease, mitral stenosis, previous mitral valve procedures, endocarditis or signs of primary cardiomyopathy. MR severity was defined by regurgitation fraction (RF) measured by CMR as mild (RF &lt; 20%), moderate (RF 20–39%), and severe (RF ≥ 40%). Native T1 and T2 maps were acquired at rest, and post-contrast T1 maps was used to derive ECV(%) maps. iECV was calculated by multiplying ECV% by left ventricular (LV) end-diastolic myocardial volume indexed to body surface area. Replacement fibrosis was assessed by LGE. Ordinal logistic regression was adjusted for age, sex, hypertension, and diabetes. Results: A total of 127 patients with MVP were included. Of these, 32 (25%) had mild MR, 57 (45%) moderate MR and 38 (30%) severe MR. Characteristics associated with increasing MR were older age, male sex, atrial fibrillation, pulmonary hypertension, higher LVEF, and LV dilatation. iECV, native T1 and LGE increased progressively with MR severity (ORs 1.43, 95% CI: 1.23-1.65; 1.02, 95% CI: 1.01-1.03 and 2.16, 95% CI 1.05-4.39, respectively) (Figures 1, 2 and 3). No significant differences were observed in native T2 between groups. Conclusion: Greater MR severity in patients with MVP was associated with more extensive myocardial abnormalities, including both diffuse and replacement fibrosis. Future studies are needed to determine whether CMR can guide optimal timing of mitral valve surgery to prevent irreversible remodelling and improve clinical outcomes.

Background: Transcatheter edge-to-edge repair (TEER) has emerged as an important therapeutic option for patients with severe mitral regurgitation (MR), even in the challenging context of cardiogenic shock (CS). However, real-world data on the outcomes of TEER in this high-risk population are limited. This study aimed to evaluate the incidence of mortality, procedural complications, and heart failure hospitalizations following TEER in patients with MR and CS. Methods: This retrospective cohort study used TriNetX, a federated health research network including data from 101 healthcare organizations across the U.S. Adult patients diagnosed with CS (ICD-10 R57.0) and nonrheumatic MR (ICD-10 I34.0) who underwent TEER (ICD-10-PCS 02UG3JZ) between 2005 and 2025 were included. Outcomes assessed up to one year post-procedure included all-cause mortality, heart failure hospitalizations, pacemaker implantation, stroke, valve thrombosis, recurrent MR, and mechanical complications. Statistical analyses included risk proportions, hazard ratios (HRs), and 95% confidence intervals (CIs). Results: Among 1,463 patients undergoing TEER for MR in the setting of CS, all-cause mortality at one year was 28.9% (n=424), reflecting the high-risk nature of this population (HR not available). Heart failure hospitalizations were documented in 11.2% (n=27/241 evaluable patients; HR not calculated due to limited cohort size). Pacemaker implantation occurred in 1.4% (n=20), stroke in 4.4% (n=58/1,314 evaluable patients; HR not available), valve thrombosis in 0.7% (n=10), recurrent MR in 0.9% (n=13), and mechanical complications in 1.0% (n=14). Kaplan-Meier survival analysis indicated a survival probability of 68.6% at one year post-TEER. Conclusions: In this large, real-world cohort of patients with cardiogenic shock undergoing TEER, nearly one-third experienced mortality within one year, underscoring the critical prognosis in this population. Although procedural complications such as valve thrombosis, device-related issues, and pacemaker implantation were infrequent, heart failure hospitalizations remained a notable concern. These findings highlight the need for careful patient selection and aggressive post-procedural management strategies to optimize outcomes in this high-risk group. Future studies should explore mechanisms of heart failure exacerbations and refine strategies to identify patients who may derive the greatest benefit from TEER in the setting of CS.

Background: Mitral valve prolapse (MVP) is frequently associated with mitral regurgitation (MR), which increases left ventricular (LV) preload and can lead to LV hypertrophy. In other disease states, elevated LV preload, has been associated with reduced coronary flow reserve due to increased resting coronary flow, resulting in impaired myocardial perfusion. However, myocardial perfusion at rest and under stress has not previously been characterized in patients with MVP and significant MR. Aim: To evaluate myocardial perfusion in patients with moderate or severe MR due to MVP compared with controls without MVP and MR, using cardiac magnetic resonance (CMR) imaging with adenosine stress perfusion mapping. Methods: Patients with MVP and moderate or severe MR referred for mitral valve surgery were prospectively enrolled in the MitraVT study (NCT06255457) and were compared to age- and sex-matched controls without MVP and primary MR. All participants underwent CMR at 1.5T (MAGNETOM Sola, Siemens Healthineers), including cine imaging and adenosine stress perfusion mapping. Exclusion criteria included coronary artery disease, rheumatic mitral disease, mitral stenosis, endocarditis, or primary cardiomyopathy. Myocardial perfusion was quantified for each of the 16 segments defined by the American Heart Association, both at rest and under stress. Global perfusion values were calculated as the mean across all segments. Clinical data were obtained from medical records. Results: In total, 20 patients and 20 controls were included (age 53.9±15.2 vs. 52.2±13.2 years, 55% vs. 55% female) with no differences in the prevalence of diabetes, hypertension, hyperlipidemia, or smoking status. Compared to controls, patients with primary MR had higher indexed end-diastolic LV volume, stroke volume index, and ejection fraction. Global myocardial perfusion was significantly reduced among patients with MVP and MR, both at rest (0.82±0.20 vs.1.04±0.32 ml/min/g, p=0.01) and at stress (2.46±0.45 vs. 3.44±0.71 ml/min/g, p&lt;0.001) (Figure 1). These differences remained significant when comparing the mean perfusion values across basal, midventricular, and apical levels. Conclusion: Patients with MVP and moderate or severe MR exhibited significantly reduced myocardial perfusion both at rest and at stress, indicative of coronary microvascular dysfunction. Future studies are needed to assess whether mitral valve surgery restores myocardial perfusion and improves symptom burden in this population.

Background Mitral valve prolapse (MVP) is a common valvular heart disease with potential for progression to mitral regurgitation (MR) and arrhythmias. While extensively studied in adults, its evolution from childhood remains underexplored. This study aimed to evaluate morphological changes in MVP from paediatric to adult age and their association with MR progression using transthoracic echocardiography (TTE). Methods This retrospective single-centre study included 53 patients with confirmed MVP diagnosed in childhood and followed up into adulthood (mean follow-up 9 ± 5 years). Each patient had at least two TTEs, and echocardiographic parameters were assessed and indexed for body surface area and height. The presence and progression of mitral annulus disjunction (MAD) were also analysed. Results At baseline, the mean age was 8.13 ± 3.25 years; at final follow-up, 18.45 ± 6 years. MAD was present in 60% of patients at both TTEs, while 13% developed MAD over time. Indexed MVP morphological parameters, including leaflet length, annular diameter, and MAD distance, remained stable from childhood to adulthood. However, the severity of MR increased over time and was associated with changes in multiple mitral valve parameters, rather than a single feature. No significant arrhythmic events or implantable cardioverter defibrillator (ICD) implantations were recorded. Conclusions MVP-related structural changes remain morphometrically stable when indexed for growth, yet MR severity can worsen due to a combination of morphological alterations. MAD can be identified in paediatric patients and may develop over time. These findings support the view that MVP may encompass different phenotypes and potentially represent a form of cardiomyopathy.

Background: Acute severe mitral regurgitation (MR) in patients with hypertrophic cardiomyopathy (HCM) is commonly caused by dynamic left ventricular outflow tract (LVOT) obstruction [systolic anterior motion (SAM)-dependent] with the remaining generally caused by spontaneous or secondary (degenerative valve disease, endocarditis). In both scenarios, hemodynamic forces play a significant role. We present a unique case of acute severe MR due to rapidly developing flail P3 segment of posterior mitral leaflet in a patient with obstructive HCM successfully treated with Mavacamten. Case Description: A 73-year-old female with symptomatic obstructive HCM and provoked LVOT gradients 92 (Valsalva) and 200 (exercise) mmHg and mild-moderate posteriorly directed MR was started on Mavacamten 5 mg daily (Figure, top row). No evidence of degenerative disease or prolapse was noted on baseline study. Within 3 months of treatment, she was free of symptoms and provoked LVOT gradient had decreased to &lt;20 mmHg. Eight months after treatment, she presented with acute onset severe dyspnea and transthoracic echocardiogram showed no significant LVOT obstruction but segmental posterior leaflet flail with anteriorly directed severe MR that was not seen on previous studies (including 2 months prior) [Figure, middle row]. Transesophageal echocardiography (Figure, bottom row) confirmed severe prolapse (aneurysmal) of P3 segment of posterior mitral valve leaflet and severe MR. No chordal rupture was detected by echocardiography or later at surgery (extended septal myectomy, mitral valve repair with P3 triangular resection, commissuroplasty of P3-A3, and placement of annuloplasty ring). She had significant improvement in symptoms, and there was no evidence of MR, SAM, or LVOT obstruction on intraoperative transesophageal echocardiography. Discussion: Acute severe MR in obstructive HCM is commonly dynamic and related to outflow tract obstruction due to SAM. Much less commonly, chordal rupture (either spontaneous or related to degenerative mitral valve disease or endocarditis) may result in acute severe MR. Isolated, rapidly developing severe leaflet prolapse without chordal rupture is a unique and previously not reported etiology of acute severe MR in obstructive HCM. Most unusual features of this presentation are the rapid development of marked prolapse while being treated with a potent negative inotrope and after elimination of LVOT gradients (markedly reduced intracavitary pressure).

Background: Percutaneous Transvenous Mitral Commissurotomy (PTMC) is the preferred treatment for severe mitral stenosis (MS) in patients with favorable valve morphology. Mitral Annular Calcification (MAC) may adversely affect procedural success and increase post-procedural mitral regurgitation (MR). Objective: To evaluate the impact of Mitral Annular Calcification on post-PTMC outcomes. Methodology: This mixed retrospective and prospective study was conducted at Peshawar Institute of Cardiology from April 2021 to December 2024. A total of 303 patients with severe MS (MVA ≤1.0 cm², mean gradient &gt;10 mmHg) were included. Echocardiographic parameters including Wilkins and commissural scores were assessed. Procedural success was defined as post-PTMC MVA &gt;1.5 cm², ≥50% increase in MVA, and absence of severe MR or major complications. Data were analyzed using SPSS 26. Results: Mean age was 38.88±11.38 years; 80.9% were females. Wilkins score ≤8 was observed in 82.8%, and 63% had no commissural calcium. Mean MVA increased from 0.92±0.16 cm² to 1.8±0.31 cm²; 91.7% achieved procedural success. Severe MR occurred in 11.2%, with one mortality. Commissural score correlated positively with MR (r=0.475, p&lt;0.001) and negatively with MVA (r=–0.398, p&lt;0.001). Patients with commissural score 2 had a 5.24-fold higher risk of severe MR (p=0.027). Conclusion: PTMC is a safe and effective intervention for severe MS; however, Mitral Annular Calcification significantly reduces procedural success and increases MR risk. Pre-procedural commissural scoring enhances patient selection and outcome prediction. Keywords: Commissural Score, Mitral Annular Calcification, Mitral Regurgitation, Mitral Valve Area, PTMC.

Background: There is little evidence regarding mitral transcatheter edge-to-edge repair (TEER) in the setting of severe pulmonary hypertension (PH), defined by an estimated pulmonary arterial systolic pressure (PASP) &gt;70 mmHg on echocardiography. Objectives: To explore the prevalence of, and correlates and postprocedural outcomes associated with, severe PH in patients undergoing mitral TEER. Methods: We retrospectively evaluated a single-center registry of isolated, first-time interventions as a function of severe PH presence at baseline. Outcomes included all-cause mortality, heart failure (HF) hospitalizations, and the persistence of significant mitral regurgitation (MR) and functional impairment during the first postprocedural year. Results: A total of 1,182 individuals qualified for analysis. Of them, 100 (8.5%) had severe PH, demonstrating a median PASP of 78 (IQR, 75-85) mmHg. Compared to subjects free of severe PH, those with it exhibited a higher interventional risk, greater comorbidities, and more severe MR and cardiac dysfunction, and were more likely to undergo an urgent procedure. General interventional features were unaffected by severe PH status, leading in both study groups to a high (&gt;97%) technical success rate and, ultimately, significant improvement in PASP, MR grade and functional capacity. Severe PH was associated with worse residual MR in the total cohort – but not within a 187-patient, propensity score matched sub-cohort. In either, it did not impact the rate, cumulative incidence, and risk of mortality and/or HF hospitalizations. Conclusions: Mitral TEER in patients with severe PH should, in the hands of experienced interventionalists, prove feasible, safe, and efficacious.