Moderate Functional Mitral Regurgitation Research Articles

Relationship between the severity of functional mitral regurgitation at admission and one-year outcomes in patients hospitalized for acute heart failure with mildly reduced ejection fraction

BackgroundThe epidemiological distribution of functional mitral regurgitation (FMR) in heart failure (HF) and mildly reduced ejection fraction (HFmrEF) patients and its impact on outcomes remains unclear. We attempt to investigate the prognosis of FMR in patients with HFmrEF.MethodsThe HF center registry study is a prospective, single, observational study conducted at the Second Affiliated Hospital of Shenzhen University, where 2330 patients with acute HF (AHF) were enrolled and 890 HFmrEF patients were included in the analysis. The patients were stratified into three categories based on the severity of FMR: none/mild, moderate, and moderate-to-severe/severe groups. Subsequently, a comparison of the clinical characteristics among these groups was conducted, along with an assessment of the incidence of the primary endpoint (comprising all-cause mortality and readmission for HF) during a one-year follow-up period.ResultsThe one-year follow-up results indicated that the primary composite endpoint occurrence rates in the three groups were 23.5%, 32.9%, and 36.5%, respectively. The all-cause mortality rates in the three groups were 9.3%, 13.7%, and 16.4% respectively. Survival analysis demonstrated a statistically significant difference in the occurrence rates of the primary composite endpoint and all-cause mortality among the three groups (P < 0.05). Multifactor Cox regression revealed that moderate FMR and moderate-to-severe/severe FMR were independent risk factors for adverse clinical prognosis in HFmrEF patients, with hazard ratios and 95% confidence intervals of 1.382 (1.020–1.872, P = 0.037) and 1.546 (1.092–2.190, P = 0.014) respectively.ConclusionsModerate FMR and moderate-to-severe/severe FMR independently predict an unfavorable prognosis in patients with HFmrEF.

Moderate functional mitral regurgitation: difference between atrial and ventricular mechanism of the regurgitation

Abstract Background/Introduction In severe functional mitral regurgitation (MR), further distinction of the mechanism of MR in atrial functional MR (aFMR) and ventricular functional MR (vFMR) has shown prognostic importance. However, no data are available on moderate functional MR, whose characteristics and prognosis are largely unknown. Purpose To assess clinical and echocardiographic characteristics of patients with moderate aFMR and vFMR and their potential difference in outcome. Methods Patients with moderate functional MR were retrospectively included. aFMR was defined as isolated mitral annulus dilatation in combination with preserved left ventricular ejection fraction (LVEF≥50%) without ischemic heart disease or LV dilatation. Patients were classified as vFMR when LVEF was reduced, LV was dilated and/or wall motion abnormalities were present. Mitral valve intervention and all-cause mortality were used as combined endpoint. Results In total 474 patients with moderate functional MR (mean age 67 ±12, 57% male) were evaluated, of which 136 (29%) had aFMR and 338 (71%) had vFMR as underlying mechanism. Among the clinical variables, patients with aFMR had more atrial fibrillation (77% vs. 35%; p&amp;lt;0.001), were less symptomatic (NYHA class ≥ III: 6% vs. 18%; p&amp;lt;0.001) and had better renal function (eGFR 73 ±23 ml/min/1,73m2 vs. 65 ±23 ml/min/1,73m2; p=0.005) as compared to vFMR. In the vFMR group, 49% of patients had ischemic heart disease. Among the echocardiographic variables, as expected in aFMR, LVEF was higher (42 ±14% vs. 55 ±13%; p&amp;lt;0.001), while LV volumes (LV end-diastolic volume index 55 ±13 mL/m2 vs. 82 ±38 mL/m2; p&amp;lt;0.001) and E/E’ ratio were smaller (10 ±4 vs. 15 ±4; p&amp;lt;0.001) as compared to vFMR. However left atrial (LA) volume index was similar between both groups (43 ±14 mL/m2 vs. 41 ±18 mL/m2; p=0.271). For the echocardiographic measures of the right heart, significant difference was observed only for TAPSE which was higher for the aFMR group (22 ±4mm vs. 20 ±5mm; p&amp;lt;0.001). During a median follow-up of 74 months [IQR: 46.8-107.0], 132 (30%) patients died and 30 (6%) underwent mitral valve intervention. Event-free survival analysis for the combined endpoint was significantly better for aFMR patients (Figure 1). Based on significant variables from the univariable Cox regression analysis, multivariable Cox regression analysis showed that the mechanism of functional MR (with aFMR being protective as compared to vFMR), age, male gender, impaired renal function, NYHA class, severe LA dilatation and TAPSE were independently associated with the combined endpoint (Table 1). Conclusion In patients with moderate functional MR, aFMR is independently associated with better event-free survival as compared to vFMR. Therefore, clear identification of the mechanism of MR implies a better risk stratification and may be helpful for the management of patients with moderate MR.

Prognostic Power of Quantitative Assessment of Functional Mitral Regurgitation and Myocardial Scar Quantification by Cardiac Magnetic Resonance.

The severity classification of functional mitral regurgitation (FMR) remains controversial despite adverse prognosis and rapidly evolving interventions. Furthermore, it is unclear if quantitative assessment with cardiac magnetic resonance can provide incremental risk stratification for patients with ischemic cardiomyopathy (ICM) or non-ICM (NICM) in terms of FMR and late gadolinium enhancement (LGE). We evaluated the impact of quantitative cardiac magnetic resonance parameters on event-free survival separately for ICM and NICM, to assess prognostic FMR thresholds and interactions with LGE quantification. Patients (n=1414) undergoing cardiac magnetic resonance for cardiomyopathy (ejection fraction<50%) assessment from April 1, 2001 to December 31, 2017 were evaluated. The primary end point was all-cause death, heart transplant, or left ventricular assist device implantation during follow-up. Multivariable Cox analyses were conducted to determine the impact of FMR, LGE, and their interactions with event-free survival. There were 510 primary end points, 395/782 (50.5%) in ICM and 114/632 (18.0%) in NICM. Mitral regurgitation-fraction per 5% increase was independently associated with the primary end point, hazards ratios (95% CIs) of 1.04 (1.01-1.07; P=0.034) in ICM and 1.09 (1.02-1.16; P=0.011) in NICM. Optimal mitral regurgitation-fraction threshold for moderate and severe FMR were ≥20% and ≥35%, respectively, in both ICM and NICM, based on the prediction of the primary outcome. Similarly, optimal LGE thresholds were ≥5% in ICM and ≥2% in NICM. Mitral regurgitation-fraction×LGE emerged as a significant interaction for the primary end point in ICM (P=0.006), but not in NICM (P=0.971). Mitral regurgitation-fraction and LGE are key quantitative cardiac magnetic resonance biomarkers with differential associations with adverse outcomes in ICM and NICM. Optimal prognostic thresholds may provide important clinical risk prognostication and may further facilitate the ability to derive selection criteria to guide therapeutic decision-making.

Prognostics of Feasibility of Mitral Valve Ring Annuloplasty for Moderate Functional Mitral Regurgitation Associated with Severe Aortic Valve Disease

Prognostics of Feasibility of Mitral Valve Ring Annuloplasty for Moderate Functional Mitral Regurgitation Associated with Severe Aortic Valve Disease

Results of aortic valve replacement in aortic stenosis and moderate functional mitral regurgitation.

Referral and admission echocardiography (ECHO) in patients scheduled for aortic valve replacement (AVR) with aortic stenosis (AS) may differ in the assessment of moderate functional mitral regurgitation (FMR). Our study aimed to determine truly moderate FMR and evaluate its impact on survival. We conducted an observational study of patients referred for AVR with AS and no, mild, or moderate FMR between 2014 and 2019. Patients were assigned into three groups: (1) no/mild (N-FMR); (2) moderate-FMR on one ECHO (either at referral or on admission) termed incidental (I-FMR); (3) moderate FMR in two studies (both at referral and on admission) termed permanent (PM-FMR). The referral and admission assessment were performed median 35 days apart. Of the 679 elective patients who underwent elective isolated AVR, 516 patients had N-FMR, 102 patients had I-FMR, and 61 patients had PM-FMR. Median follow-up was 46 months (22.5-58.5); max 73.3. Thirty-day mortality was 2.5% vs. 1% vs. 8.2% (N-FMR vs. I-FMR vs. PM-FMR, respectively; P = 0.01). Five-year survival was 84.1% in N-FMR vs. 88.5% in I-FMR vs. 60.6% in the PM-FMR group, where it was the lowest (P < 0.001). In multivariable modeling, PM-FMR increased mortality (hazard ratio [HR], 1.88 [1.05-3.37]; P = 0.03). I-FMR had no effect on mortality (HR, 0.67 [0.32-1.37]; P = 0.28). Five-year survival after excluding 30-day mortality was 86.3% vs. 89.4% vs. 66.0%; (N-FMR vs. I-FMR vs. PM-FMR, respectively; P = 0.02). PM-FMR increased late mortality (HR, 2.17 [1.14-4.15]; P = 0.01). In patients undergoing isolated AVR for AS, the presence of permanent moderate FMR significantly impacts 30-day and mid-term survival.

Outcomes and predictors of patients with moderate or severe functional mitral regurgitation and nonischemic dilated cardiomyopathy.

Patients with functional mitral regurgitation (FMR) and nonischemic dilated cardiomyopathy (DCM) are associated with high mortality. Our study aimed to compare the clinical outcomes between different treatment strategies and identify predictors associated with the adverse outcomes. A total of 112 patients with moderate or severe FMR and nonischaemic DCM were included in our study. The primary composite outcome was all-cause death or unplanned hospitalization for heart failure. The secondary outcomes were individual components of the primary outcome and the cardiovascular death. In this study, the primary composite outcome occurred in 26 patients (44.8%) in mitral valve repair (MVr) group and 37 patients (68.5%) in medical group (hazard ratio [HR], 0.28; 95% confidence interval [CI], 0.14-0.55; p < .001). The 1-, 3-, and 5-year survival rates for patients with MVr were 96.6%, 91.8%, and 77.4%, respectively, which were significantly higher than that of medical group: 81.2%, 71.9%, and 65.1%, respectively (HR, 0.32; 95% CI, 0.12-0.87; p = .03). Left ventricular ejection fraction (LVEF) < 41.5% (p < .001) and atrial fibrillation (p = .02) were independently associated with the primary outcome. LVEF < 41.5% (p = .007), renal insufficiency (p = .003), and left ventricular end-diastolic diameter > 66.5 mm (p < .001) were independently associated with heightened risk for all-cause death. Compared with medical therapy, MVr was associated with a better prognosis in patients with moderate or severe FMR and nonischemic DCM. We observed that LVEF < 41.5% was the only independent predictor of the primary outcome and all individual components of secondary outcomes.

Impact of concomitant mitral valve surgery on the clinical outcomes of patients with moderate functional mitral regurgitation and HFpEF undergoing aortic valve replacement: a cohort study

BackgroundFunctional mitral regurgitation (FMR) worsens the prognosis of patients with heart failure with preserved ejection fraction (HFpEF). While concomitant mitral valve surgery (MVS) is recommended for severe FMR during aortic valve replacement (AVR), the optimal treatment of moderate FMR, especially in those with HFpEF, remains unclear. This study aimed to evaluate the effect of MVS in patients with moderate FMR and HFpEF undergoing AVR.MethodsA total of 212 consecutive patients (AVR: 34.0%, AVR-MVS: 66.0%) during 2010 and 2019 were enrolled. Survival outcomes were compared. Inverse probability treatment weighting (IPTW) was used to balance the baseline characteristics. Kaplan-Meier curve and log-rank test were applied to compare the survival outcomes. The primary endpoint was the overall mortality.ResultsThe mean age was 58.9 pm 11.9 years, and 27.8% of them were female. During a median follow-up of 16.4 months, AVR-MVS did not reduce the risk of mid-term MACCE (hazard ratio [HR]: 1.53, 95% confidence interval [CI]: 0.57–4.17, Plog-rank = 0.396), while it showed a tendency toward higher MACCE risk in the IPTW analysis (HR: 2.62, 95% CI: 0.84–8.16, Plog-rank = 0.096). In addition, AVR-MVS increased the risk of mortality as compared to isolated AVR (0 vs. 10%, Plog-rank = 0.016), which was sustained in the IPTW analysis (0 vs. 9.9%, Plog-rank<0.001).ConclusionIn patients with moderate FMR and HFpEF, isolated AVR might be more reasonable than AVR-MVS.

Treatment of Moderate Functional Mitral Regurgitation during Aortic Valve Replacement: A Cohort Study.

Treatment of moderate functional mitral regurgitation (FMR) during aortic valve replacement (AVR) is controversial. This study aimed to evaluate the effect of different surgical strategies in patients with moderate FMR undergoing AVR. A total of 468 patients with moderate FMR undergoing AVR from January 2010 to December 2019 were retrospectively studied comparing 3 different surgical strategies, namely isolated AVR, AVR + mitral valve repair (MVr) and AVR + mitral valve replacement (MVR). Survival was estimated using the Kaplan-Meier method and compared with the log-rank test, followed by inverse probability treatment weighting (IPTW) analysis to adjust the between-group imbalances. The primary outcome was overall mortality. Patients underwent isolated AVR (35.3%), AVR + MVr (30.3%), or AVR + MVR (34.4%). The median follow-up was 27.1 months. AVR + MVR was associated with better improvement of FMR during the early and follow-up period compared to isolated AVR and AVR + MVr (p 0.001). Compared to isolated AVR, AVR + MVR increased the risk of mid-term mortality (hazard ratio [HR]: 2.13, 95% confidence interval [CI]: 1.01-4.48, p = 0.046), which was sustained in the IPTW analysis (HR: 4.15, 95% CI: 1.69-10.15, p = 0.002). In contrast, AVR + MVr showed only a tendency to increase the risk of follow-up mortality (HR: 1.63, 95% CI: 0.72-3.67, p = 0.239), which was more apparent in the IPTW analysis (HR: 2.54, 95% CI: 0.98-6.56, p = 0.054). In patients with severe aortic valve disease and moderate FMR, isolated AVR might be more reasonable than AVR + MVr or AVR + MVR.

Abstract 15499: Adjunctive Papillary Muscle Approximation With Undersizing Mitral Annuloplasty Improves Mitral Valve Mobility and Biomechanics to Repair Functional Mitral Regurgitation

Introduction: Undersizing mitral annuloplasty (UMA) to repair functional mitral regurgitation (FMR) has failed to achieve durable results. Though FMR recurrence rates of 60% at 2 years are often cited, even at 30 days, nearly 30% of the patients had moderate or greater FMR in the CTSN trial. We previously demonstrated experimentally that adjunctive papillary muscle approximation (PMA) can improve valve function, with or without UMA. In this modeling study, we used patient specific mitral valve geometries to investigate the effects of UMA and UMA+PMA on mitral valve biomechanics. Methods: 3D ultrasound was obtained in 3 pigs with chronic heart failure and moderate or severe FMR. Each 3D echo was segmented, and computational valve models were developed. UMA was mimicked with ring sizes of 36, 32, and 28 mm ( Fig A ). PMA was then added to each ring size, and the outcomes were reassessed ( Fig B ). In each simulation, leaflet stresses and chordal forces, coaptation area, and tenting parameters were computed. Results: Compared to pre-repair, UMA increased coaptation area by 178.3% with 36 mm, 279.1% with 32 mm, and 356.7% with 28 mm ring ( Fig C ). With 36 mm ring, leaflet stresses increased by 4.3%, while smaller rings reduced stresses by 24.3% (32 mm) and 33.8% (28 mm) ( Fig D ). Chordal forces after UMA decreased by 37.6%, 50.6%, and 55.2% ( Fig E ). Leaflet mobility was improved, as tenting area decreased by 46.1%, 57.9%, and 67.5% ( Fig F ). Adding PMA, achieved better valve closure and coaptation without the need for excessive annular downsizing: tenting area decreased by 76.5%, 85.2%, and 92%, and coaptation area increased by 190.6%, 309.8%, and 386.4%. In addition, leaflet stresses were reduced by 17.4%, 38.5%, and 44.9%, and chordal forces by 48.1%, 63.7%, and 72.9%. Conclusions: Adjunctive addition of PMA repaired FMR and restored physiological mitral valve mobility even at 36 mm annular size, reducing the need for excessive annular undersizing and potentially resulting in a durable repair.

Abstract 15663: Trasapical Mitral Valve and Left Ventricular Reshaping to Repair Functional Mitral Regurgitation in a Dilated Ventricle

Background: The COAPT trial demonstrated that repair of functional mitral regurgitation (FMR) in heart failure (HF) improves prognosis, only when the LV end diastolic diameter is &lt;65mm. A significant need exists for a new therapy that can address both FMR and the LV in patients with LV EDD&gt;65mm. In this study, we report a novel beating heart transapical device that can address FMR by beating heart papillary muscle approximation (PMA), and reduces the LV size and sphericity as well. Preclinical efficacy of this novel device in a swine HF/FMR model is reported. Methods: The device was prototyped using biocompatible 3D printed parts (Fig A), and a delivery catheter was custom designed for beating heart deployment (Fig B). In 7 healthy pigs, and 4 pigs induced with chronic post-myocardial infarction HF, with moderate or greater FMR, the device was implanted via a transapical access. The device was adjusted in steps - (step 1) reduce the inter-PM distance to an extent that FMR is mild or less; and (step 2) reshape the LV to achieve a 30% reduction in LV EDV and 25% reduction in sphericity index (SI). Echocardiography was used to assess mitral valve function and LV geometry, and LV function was assessed with invasive hemodynamics. Pigs were survived thereafter. Results: With this new device, MR was consistently reduced from moderate levels to none/mild. Mitral valve coaptation length increased from 3.49 ± 0.42 to 6.45± 1.13 mm (p=.019) and tenting area decreased from 158.09± 33 to 116.4± 16.7mm 2 (p=.05). LV EDV was reduced from 142.8± 29.6 to 97.5± 19.6ml (p=.025), SI was decreased from 0.67± 0.04 to 0.49± 0.07 (p=.0497) and IPMD was reduced from 23.5± 5.7 to 12.76± 3.0mm (p=.032). The device did not adversely impact cardiac output (6.59± 1.3 to 4.83± 1.6 LPM, p=.067) or E/A wave ratio (1.40± 0.23 to 1.35±0.29, p=.60). Conclusion: This novel transapical beating heart MV and LV reshaping device, significantly reduced FMR and reshaped the LV in this swine model.

Analysis of changes in “mitral valve reserve” after coronary artery bypass grafts in patients with functional mitral regurgitation

IntroductionThe treatment of moderate functionalmitral regurgitation (FMR) during coronary artery bypass grafting (CABG) is still debated. Our primary end point was to assess the improvement of “mitral valve reserve” (MVR) after CABG alone as a clinical demonstration of left ventricular (LV) recovery.Materials and methodsBetween June 2019 and June 2021, we prospectively enrolled 104 consecutive patients undergoing CABG with moderate FMR. Inclusion criteria were inferior-posterior-lateral wall hypokinesia and revascularization of the circumflex or right coronary artery. MVR was calculated as the ratio between anterior and posterior leaflets’ straight length. All patients were followed for 1 year. The improvement of MVR has been considered as a reduction of the ratio between anterior and posterior leaflets straight length.ResultsCompared to baseline, mean MVR was significantly reduced both at 6 (2.24 ± 0.95 vs. 1,91 ± 0.6; p = 0,047) and 12 months follow-up (2.24 ± 0.95 vs. 1,69 ± 0.49; p = 0,006). Left ventricular (LV) reverse remodeling, meant as improvement of LV ejection fraction and reduction of LV end-systolic volume index and mitral anulus diameter were evaluated at 6 months and 1 year. Mitral regurgitation grade were also significantly reduced at 6 months (p < .001).ConclusionThe benefits of myocardial revascularization in term of improvement of mitral regurgitation’s degree can be explained by the changes of MVR. The patients with FMR, who could have more advantages from CABG alone, should be the ones who have LVESVi just moderately increased.

Surgical treatment of patients with aortic valve disease complicated with moderate functional mitral regurgitation and heart failure with midrange ejection fraction: a cohort study.

Background Controversies exist on the treatment of moderate functional mitral regurgitation (FMR) in patients with severe aortic valve disease undergoing the aortic valve replacement (AVR). While a substantial proportion of these patients can be complicated with heart failure with midrange ejection fraction (HFmrEF), established studies show that the latter might compromise the patient outcome. This study was aimed to evaluate the prognostic value of concomitant mitral valve surgery during AVR in patients with severe aortic valve disease followed by moderate FMR and HFmrEF.MethodsA total of 78 consecutive patients were retrospectively recruited. Patients were divided into control (isolated AVR) and treatment (AVR + mitral valve surgery) groups. Follow-up outcomes were compared by Kaplan-Meier method, followed by multiple adjustment with inverse probability treatment weighting (IPTW) analysis. The primary outcome was the occurrence of major adverse cardiovascular and cerebrovascular events (MACCE).ResultsThirty-six patients received isolated AVR, while 42 received AVR with mitral valve repair or replacement. The median follow-up time was 28.7 months. Unadjusted analysis showed that there was no significant difference in the rate of MACCE between the two groups [hazard ratio (HR): 1.14, 95% confidence interval (CI): 0.48–2.69, Plogrank=0.770], which was sustained in IPTW analysis (HR: 1.64, 95% CI: 0.59–4.55, Plogrank=0.342). In addition, while concomitant mitral valve surgery improved follow-up FMR more completely (P=0.026) in the IPTW analysis, the ejection fraction was comparable between the two groups (P=0.276). Furthermore, IPTW analysis also showed that mitral valve surgery was associated with the increased risk of postoperative acute kidney injury (P=0.007).ConclusionsIn patients with aortic valve disease followed by moderate FMR and HFmrEF, mitral valve surgery concomitant to AVR may not bring extra benefit in the MACCE-free survival and the improvement of HFmrEF. However, while concomitant mitral valve surgery has priority on the complete improvement of FMR, it might increase the risk of postoperative acute kidney injury.

Effect of Impella 5.5 on Preexisting Functional Mitral Regurgitation in Patients with Heart Failure–Related Cardiogenic Shock

BackgroundHeart failure–related cardiogenic shock (HF-CS) is increasingly common. Moderate/severe functional mitral regurgitation (FMR) is commonly seen in patients presenting with decompensated heart failure and is associated with worse outcomes. Percutaneous mechanical circulatory support devices are increasingly used to provide hemodynamic support for ongoing CS. There is no description of the impact of Impella device on hemodynamic response when used in combination with preexisting FMR. MethodsRetrospective review of patients aged ≥18 years, who underwent Impella 5.5 implant for HF-CS, and who had a transthoracic echocardiogram performed pre- and post-Impella. ResultsOf 24 patients, 33% had moderate-to-severe/severe FMR, 38% had mild-moderate/moderate FMR, and 29% had trace/mild FMR on pre-Impella transthoracic echocardiogram. Additional right ventricular assist device was simultaneously inserted in 3 patients, of whom 1 had severe, 1 had moderate, and another had mild FMR pre-Impella. Despite maximally tolerated Impella unloading, 6 patients (25%) had persistent moderate-severe/severe FMR, and 9 (37.5%) patients had persistent moderate FMR. Overall, however, there was a decrease in central venous pressure, pulmonary artery diastolic pressure, serum lactate, and vasoactive-inotrope score at 24 ​hours post-Impella, and survival was high at 83%. ConclusionsIn a retrospective cohort of patients admitted with HF-CS who underwent Impella 5.5 implant for hemodynamic support, Impella did not seem to acutely ameliorate FMR severity. Despite this, there was a significant improvement in hemodynamic response at 24 ​hours post-Impella. In carefully selected patients, especially those with isolated left ventricular failure, Impella 5.5 may provide adequate hemodynamic support even in the presence of higher severity FMR.

Interaction between secondary mitral regurgitation and left atrial function and their prognostic implications after cardiac resynchronization therapy.

Left atrial (LA) function is a strong prognostic marker in patients with heart failure and functional mitral regurgitation (MR). Although cardiac resynchronization therapy (CRT) has shown to improve MR severity, the interaction between a reduction in MR severity and an increase in LA function, as well as its association with outcomes, has not been investigated. LA reservoir strain (RS) was evaluated with speckle tracking echocardiography in patients with at least moderate functional MR undergoing CRT implantation. MR improvement was defined as at least 1 grade improvement in MR severity at 6 months after CRT implantation. The primary endpoint was all-cause mortality. A total of 340 patients (mean age 66 ± 10 years, 73% male) were included, of whom 200 (59%) showed MR improvement at 6 months follow-up. On multivariable analysis, an improvement in MR severity was independently associated with an increase in LARS (odds ratio 1.008; 95% confidence interval 1.003-1.013; P = 0.002). After multivariable adjustment, including baseline and follow-up variables, an increase in LARS was significantly associated with lower mortality. MR improvers showing LARS increasement had the lowest mortality rate, whereas outcomes were not significantly different between MR non-improvers and MR improvers showing no LARS increasement (P = 0.236). A significant reduction in MR severity at 6 months after CRT implantation is independently associated with an increase in LARS. In addition, an increase in LARS is independently associated with lower all-cause mortality in patients with heart failure and significant functional MR.

Effect of β-blocker on patients with moderate functional mitral regurgitation undergoing surgical aortic valve replacement.

The optimal treatment for severe aortic valve disease complicated with moderate function mitral regurgitation (FMR) remains controversial. Although isolated surgical aortic valve replacement (SAVR) is reasonable, previous studies also show that moderate FMR might deteriorate after surgical treatment and result in poorer prognosis. Because the left ventricular remodelling plays a critical role in the development of FMR, these patients might potentially benefit from the administration of β-blocker (BB). Unfortunately, relevant clinical evidence is lacking. This study aimed to investigate the impact of post-operative administration of BB on the outcomes of moderate FMR patients undergoing isolated SAVR. In this single-centre cohort study, patients who underwent isolated SAVR and complicated with pre-operative moderate FMR during 2010 and 2019 at our centre were retrospectively recruited. Patients were divided into two groups according to postoperative administration of BB (BB group vs. control group). The cumulative survival rates were calculated using the Kaplan-Meier method and tested by the log-rank test, followed by inverse probability treatment weighting (IPTW) analysis to further control the between-group imbalances. The primary outcome was the major adverse cardiovascular and cerebrovascular events (MACCE), a composite endpoint of all-cause death, repeat heart valve surgery, non-fatal myocardial infarction, stroke, and hospitalization for heart failure. A total of 165 patients were enrolled, 57 (34.6%) of whom were female, and the mean age was 59.2±12.2years. Eighty (48.5%) patients received post-operative BB therapy. The median follow-up time was 18.4months. The administration of BB was not associated with lower risk of MACCE [hazard ratio (HR): 0.68, 95% confidence interval (CI): 0.29-1.62, P=0.388] or all-cause death (HR: 1.03, 95% CI: 0.30-0.56, P=0.967). In the IPTW dataset, the total number of patients were 326.89, and the outcomes regarding the risk of MACCE (HR: 0.79, 95% CI: 0.31-1.97, P=0.607) and all-cause death (HR: 1.33, 95% CI:0.35-5.05, P=0.674) were in line with the unmatched analysis. The follow-up echocardiographic results were available for 72.2% of the overall cohort, and the use of BB was observed to be associated with higher improvement rate of follow-up FMR according to the IPTW analysis (92.2% vs. 98.3%, P=0.033). The administration of BB after SAVR was not associated with lower risk of MACCE for patients of severe aortic valve disease complicated with moderate FMR, but was potentially beneficial for improving FMR.

Myocardial Contractile Mechanics in Ischemic Mitral Regurgitation: Multicenter Data Using Stress Perfusion Cardiovascular Magnetic Resonance

BackgroundLeft ventricular (LV) ischemia has been variably associated with functional mitral regurgitation (FMR). Determinants of FMR in patients with ischemia are poorly understood. ObjectivesThis study sought to test whether contractile mechanics in ischemic myocardium underlying the mitral valve have an impact on likelihood of FMR. MethodsVasodilator stress perfusion cardiac magnetic resonance was performed in patients with coronary artery disease (CAD) at multiple centers. FMR severity was confirmed quantitatively via core lab analysis. To test relationship of contractile mechanics with ischemic FMR, regional wall motion and strain were assessed in patients with inducible ischemia and minimal (≤5% LV myocardium, nontransmural) infarction. ResultsA total of 2,647 patients with CAD were studied; 34% had FMR (7% moderate or greater). FMR severity increased with presence (P < 0.001) and extent (P = 0.01) of subpapillary ischemia: patients with moderate or greater FMR had more subpapillary ischemia (odds ratio [OR]: 1.13 per 10% LV; 95% CI: 1.05-1.21; P = 0.001) independent of ischemia in remote regions (P = NS); moderate or greater FMR prevalence increased stepwise with extent of ischemia and infarction in subpapillary myocardium (P < 0.001); stronger associations between FMR and infarction paralleled greater wall motion scores in infarct-affected territories. Among patients with inducible ischemia and minimal infarction (n = 532), wall motion and radial strain analysis showed impaired subpapillary contractile mechanics to associate with moderate or greater FMR (P < 0.05) independent of remote regions (P = NS). Conversely, subpapillary ischemia without contractile dysfunction did not augment FMR likelihood. Mitral and interpapillary dimensions increased with subpapillary radial strain impairment; each remodeling parameter associated with impaired subpapillary strain (P < 0.05) independent of remote strain (P = NS). Subpapillary radial strain (OR: 1.13 per 5% [95% CI: 1.02-1.25]; P = 0.02) and mitral tenting area (OR: 1.05 per 10 mm2 [95% CI: 1.00-1.10]; P = 0.04) were associated with moderate or greater FMR controlling for global remodeling represented by LV end-systolic volume (P = NS): when substituting sphericity for LV volume, moderate or greater FMR remained independently associated with subpapillary radial strain impairment (OR: 1.22 per 5% [95% CI: 1.02-1.47]; P = 0.03). ConclusionsAmong patients with CAD and ischemia, FMR severity and adverse mitral apparatus remodeling increase in proportion to contractile dysfunction underlying the mitral valve.

Severity Of Functional Mitral Regurgitation On Admission For Acute Decompensated Heart Failure Predicts Long-Term Outcomes-A Modifiable Interaction?

<h3>Background</h3> Functional mitral regurgitation (FMR) has emerged as a therapeutic target in patients with chronic heart failure and left ventricular systolic dysfunction (LVSD). The significance of FMR in acute decompensated heart failure (ADHF) remains obscure. We systematically investigated the prevalence and clinical significance of FMR on admission in patients admitted with ADHF and LVSD. <h3>Methods</h3> Single center, retrospective review of patients admitted with ADHF and LVSD between 2012 and 2017. Patients were divided into three groups of FMR: none/mild, moderate and moderate-to-severe/severe FMR. The primary outcome was 1-year post discharge all-cause mortality. We also compared these groups for 6-month heart failure hospitalization (HFH) rates. <h3>Results</h3> Of 2303 patients, 39% (896) were females. Median left ventricular ejection fraction was 25%. Four hundred and fifty three (20%) patients had moderate-to-severe/severe FMR, which was independently associated with 1-year all-cause mortality. Moderate or worse FMR was found in 1210 (53%) patients and was independently associated with 6-month HFH. Female sex was independently associated with higher severity of FMR. <h3>Conclusions</h3> More than half of patients hospitalized with ADHF and LVSD had at least moderate FMR, which was associated with increased readmission rates and mortality. Intensified post discharge follow-up should be undertaken to eliminate FMR amenable to pharmacological therapy and enable timely and appropriate intervention for persistent FMR. Further studies are needed to examine sex-related disparities in FMR.

Concomitant Mitral Regurgitation in Patients Undergoing Surgical Aortic Valve Replacement for Aortic Stenosis: A Systematic Review.

Background: Concomitant mitral regurgitation (MR) is frequently seen in patients undergoing surgical aortic valve replacement (AVR) for severe aortic stenosis (AS). When the severity of MR is moderate or less, the decision to undertake simultaneous mitral valve intervention can be challenging.Methods: A systematic search of Medline, PubMed (NCBI), Embase and Cochrane Library was conducted to qualitatively assess the current evidence for concomitant mitral valve intervention for MR in patients with AS undergoing AVR. The primary outcome for this systematic review was the postoperative change in the severity of MR and other outcomes of interest included factors that predict improvement or persistence of MR and long-term impacts of residual MR.Results: A total of 17 studies were included. The percentage of patients demonstrating improvement in MR severity following AVR ranged from 17.2% to 72%; the studies that exclusively included patients with moderate functional MR and reported longer term echocardiographic follow-up of greater than 12 months demonstrated an improvement in MR severity of 45% to 72%.Conclusion: This systematic review demonstrates that a proportion of patients can exhibit an improvement in MR following isolated surgical AVR, but whether this confers any long-term morbidity and mortality benefit remains unclear.

416 A very severe aortic stenosis secondary to radiation therapy for Hodgkin lymphoma: a case report

Abstract Aims Hodgkin lymphoma is a highly curable disease, with survival rates around 85% at 5 years, thanks to its treatment, mainly based on radiation therapy alone or in association with chemotherapy. However, radiation therapy carries the risk of long-term complications, mainly represented by secondary malignancies or cardiovascular diseases. Indeed, patients treated with radiation remain at increased risk of coronary artery disease, congestive heart failure, valve disease, pericardial disease and sudden death. In particular, radiation-induced valve disease has been reported in approximately 10% of treated patients, with the most common being aortic or mitral regurgitation, followed by aortic stenosis. We describe the case of a very severe aortic valve stenosis developed 35 years after radiotherapy for Hodgkin Lymphoma. Methods A 60-years-old woman with history of Hodgkin Lymphoma treated with radiotherapy 35 years ago, no cardiovascular risk factors, complained progressive fatigue and worsening dyspnoea. She was referred to our centre from a spoke centre for congestive heart failure caused by aortic stenosis. At her arrival, we performed a transthoracic echocardiography finding a very-severe aortic stenosis (mean gradient 97 mmHg, AVA 0.3 cm2), a moderate functional mitral regurgitation and an important hypertrophy suspected of infiltrative pattern. No coronary artery disease was found at coronary angiography. Furthermore, she underwent a cardiac magnetic resonance showing a moderate left ventricular dilatation and hypertrophy with areas of non-ischaemic late gadolinium enhancement, significant for myocardial fibrosis with no specific pattern of infiltration. She was treated with surgical aortic valve replacement with biological prosthesis (Inspiris Resilia 21) with good results at the discharge echocardiography. Discussion Cardiovascular toxicity is nowadays the most common non-malignancy cause of death in radio-treated cancer survivors. At the level of the valvular apparatus, radiation damage is expressed with fibrosis of the myocardium and of the valvular endothelium, leading to thickening and calcification especially of the left-sided valves. Radio-treated patients have a 50% cumulative incidence of cardiovascular diseases at 40 years after treatment, and a clinically-relevant valve disease is found in approximately 6% of radio-treated patients at 20 years. Conclusions Thus, an early identification of the disease in a subclinical state is crucial. Nevertheless, there is still no consensus on the timing and the modality of cardiovascular screening after radiation therapy. Moreover, an elevated cardiovascular risk profile was found to be directly related to cardiotoxicity; this underlines the importance of identification and aggressive treatment of cardiovascular risk factors. Radiation dose reduction and the use of shields may further reduce the incidence of late cardiovascular complications in these patients.

Abstract 11227: Ischemia Mediated Contractile Dysfunction Modulates Functional Mitral Regurgitation - Multiparametric Strain and Tissue Characterization Data from the Society of Cardiovascular Magnetic Resonance (scmr) Registry

Introduction: LV ischemia has been linked to functional mitral regurgitation (FMR) but ischemia is present many pts without FMR. CMR concomitantly assesses MR, ischemia and LV function but has not been used to test factors modifying impact of ischemia on FMR. Methods: Vasodilator stress CMR was performed in CAD pts in a multicenter registry, in whom advanced (≥moderate) FMR was confirmed by core lab. LV ischemia was categorized by subpapillary involvement (subtending mitral apparatus). To test mechanism by which ischemia impacts FMR, LV strain was measured in pts with ischemia and &lt;5% LV infarct, with and without (1:2) FMR, matched for ischemia extent/distribution. Followup was done for mortality. Results: 2639 pts were studied; 7% had advanced FMR. While FMR pts had more ischemia in subpapillary (21.8 ± 28.3 vs 13.4 ± 21.9%) and nonpapillary (19.2 ± 25.5 vs 13.0 ± 22.2%) regions (p&lt;0.001), multivariate analysis showed only subpapillary ischemia (OR 1.13 per 5% LV [1.05, 1.21] p=0.001) to be associated with FMR (nonpapillary p=NS). Wall motion scores in ischemic subpapillary segments were higher in pts with FMR (1.7±0.9 vs 0.8±0.9, p&lt;0.001) paralleling strain subgroup data (n=114): FMR prevalence increased stepwise with impaired radial and circumferential strain ( Figure ). Adverse mitral remodeling associated with impaired strain; mitral tenting area (OR -0.01 per % [-0.02, -0.004] p&lt;0.01) and papillary fractional shortening (OR 0.36 per % [0.26, 0.47] p&lt;0.001) each associated with subpapillary radial strain controlling for nonpapillary strain (p=NS). On follow up (median 4.7 [2.2, 7.7] yr), FMR, age, subpapillary ischemia and infarction each independently predicted death (p&lt;0.001): When categorized as dysfunctional or non-dysfunctional, only ischemic/dysfunctional myocardium (HR 1.15 per 5% LV [1.05, 1.14] p&lt;0.001) associated with death. Conclusions: Ischemia mediated LV dysfunction on multiparametric CMR modulates likelihood of FMR and adverse prognosis.