Moderate-severe Functional Mitral Regurgitation Research Articles

P245 IMPLICATIONS IN PHARMACOLOGICAL AND ELECTRICAL OPTIMIZATION IN HEART FAILURE: A EMBLEMATIC CASE

Abstract We describe the case of an 82–year–old man with permanent atrial fibrillation in oral anticoagulation therapy. Former smoker. Diabetes mellitus. In 2009, subacute MI with PTCA/DES of anterior descending artery and obtuse marginal branch, critical stenosis of circumflex artery, right coronary artery occluded. Infrarenal aorta occlusion. Echocardiography TT mild–moderate mitral regurgitation. Ejection fraction (EF) preserved. Inferior wall akinesia. In 2019 hospitalization for heart failure due to severe bradyarrhythmia in atrial fibrillation. In therapy with bisoprolol 10 mg/day Echocardiography FE 35%, moderate–severe functional mitral regurgitation, PAPs 55 mmHg. Arterial pressure 100/85 Sat 2O 90% Treatment at discharge: furosemide 75 mg/day, bisoprolol 7,5 mg/day, Metformina 500 mg/day, potassium canrenoate 50 mg/day atorvastatin 40 mgday and warfarin,Ramipril 2.5 mg/day, allopurinol 150 mg/day. In 2020 new hospitalization for heart failure. NYHA III–IV; BNP 1890 pg/ml. Beta–blocker therapy reduced to bisoprolol 3.75 day for pulmonary hypertension and bradycardia, furosemide increased to 100 mg/day, possibly further titratable on the basis of renal function, blood electrolytes and clinical response, maintaining restriction of daily liquids at about 1000 cc. Initiated Sacubitril/Valsartan 24/26 mgx 2 /day. Coronary angiography was not possible due to occlusion of the abdominal aorta and right radial artery (1,2,3). CT CORO performed with relief of the interventricular branch occluded in the middle section; patent obtuse marginal branch stent; right coronary artery occluded. Abdominal aorta occluded at the level of the renal arteries. The patient was submitted to CRT–D implant for bradycardia and wide QRS like left bundle branch block. Glyphozine associated with Metformin. Echocardiography TT LVEF 40%, moderate functional MR, PAPS 35 mmHg. NYHA II. Edema resolution No hospitalizations for decompensation. titrated ARNI at 49/51 mg x 2/day, and the beta blocker Cardicor 5mg/day. At remote monitoring decreased ventricular catheter impedance. What does the case tell us? The combination of Sacubitril/Valsartan and Glifozine determined an inverse remodeling of the heart. The combination of Sacubitril/Valsartan and Glifozine improved cardiac compensation and clinically stabilized the patient.

Right ventricular dysfunction and tricuspid regurgitation in functional mitral regurgitation

AimThe objective of this study was to investigate the prognostic importance of right ventricular dysfunction (RVD) and tricuspid regurgitation (TR) in patients with moderate–severe functional mitral regurgitation (FMR) receiving MitraClip procedure. RVD and TR grade are associated with cardiovascular mortality in the general population and other cardiovascular diseases. However, there are limited data from observational studies on the prognostic significance of RVD and TR in FMR receiving MitraClip procedure.Methods and resultsA systemic review and meta‐analysis were performed using MEDLINE, Scopus, and Embase to assess the prognostic value of RVD and TR grade for mortality in patients with functional mitral regurgitation (FMR) receiving MitraClip procedure. Hazard ratios were extracted from multivariate models reporting on the association of RVD and TR with mortality and described as pooled estimates with 95% confidence intervals. A total of eight non‐randomized studies met the inclusion criteria with seven studies having at least 12 months follow‐up with a mean follow‐up of 20.9 months. Among the aforementioned studies, a total of 1112 patients (71.5% being male) were eligible for being included in our meta‐analysis with an overall mortality rate of 28.4% (n = 316). Of the enrolled patients, RVD was present in 46.1% and moderate–severe TR in 29.2%. RVD was significantly associated with mortality compared to normal RV function (HR, 1.79, 95% CI, 1.39–2.31, P < 0.001, I 2 = 0). Patients with moderate–severe TR showed increased risk of mortality compared with those in the none‐mild TR group (HR, 1.61. 95% CI, 1.11–2.33, P = 0.01, I 2 = 14).ConclusionsThis meta‐analysis demonstrates the prognostic importance of RVD and TR grade in predicting all‐cause mortality in patients with significant FMR. RV function and TR parameters may therefore be useful in the risk stratification of patients with significant FMR undergoing MitraClip procedure.

Left Atrial Volumetric/Mechanical Coupling Index: A Novel Predictor of Outcome in Heart Failure With Reduced Ejection Fraction.

Left atrial assessment is complex, particularly in heart failure with reduced ejection fraction due to interactions with functional mitral regurgitation (FMR). Pilot data suggest that left atrial volumetric/mechanical coupling index (LACI) may be useful, but large outcome data are lacking. We enrolled a comprehensively characterized cohort of patients in sinus rhythm with heart failure with reduced ejection fraction diagnosis at Mayo Clinic from 2007 to 2011. Routinely measured left atrial volume index and tissue-doppler-imaging a' allowed LACI calculation as (left atrial volume index)/(tissue-doppler-imaging a'). Survival was the outcome measured. The cohort's 4196 patients (69 [58-77] years, ejection fraction 40 [31-45]%) had mild FMR in 1505 and moderate-severe FMR in 1068. LACI was overall 5.06 (3.50-8.10) and increased with each FMR grade (3.86 [2.94-5.29] without FMR, 5.38 [3.80-8.02] with mild, 5.45 [1.49-8.07] with moderate/severe FMR; P<0.0001). At diagnosis, higher LACI was independently determined by more severe FMR and by higher left ventricular mass index, lower ejection fraction, higher E/e', and lower glomerular filtration rate (all P<0.0001). During follow-up 1588 (38%) patients died. In spline modeling, excess mortality appeared around LACI=6 and steeply increased thereafter (5-year survival 72±1% with LACI<6 and 49±2% with LACI ≥6, P<0.0001). Multivariable comprehensive adjustment showed LACI strong association with excess mortality (adjusted hazard ratio, 1.41 [1.23-1.61], P<0.0001 for LACI ≥6). Independent link to mortality persistent across FMR grades (adjusted hazard ratio, 1.45 [1.13-1.86], P=0.004 without FMR, 1.42 [1.16-1.77], P=0.0008 with mild FMR, and 1.38 [1.01-1.66], P=0.04 with moderate/severe FMR) without interaction (P=0.3). LACI independent impact on outcome was incremental to that of left atrial volume index, tissue-doppler-imaging a', or any other characteristic including the Meta-Analysis Global Group in Chronic-score (least significant P=0.02). In this large cohort, left atrial volumetric/mechanical coupling measured by LACI in routine practice integrates the influence of several morphological/hemodynamic determinants but displays progressive deterioration with increasing FMR severity in heart failure with reduced ejection fraction. About outcome, higher LACI is strongly, independently, and incrementally associated with excess mortality, irrespective of FMR grade and in all subsets. Hence, LACI is a novel and critical measure in heart failure with reduced ejection fraction, quantifiable in routine practice, which should be integrated in prognostication and decision-making.

Degenerative mitral regurgitation predicts worse outcomes in patients undergoing transcatheter aortic valve replacement

To evaluate the role mitral regurgitation (MR) etiology and severity play in outcomes for patients undergoing transcatheter aortic valve replacement (TAVR). Multiple prior studies have investigated the influence of MR severity on outcomes for patients undergoing TAVR. Less has been published regarding the effects of MR etiology on outcomes, including its impact on heart failure hospitalization. Two hundred and seventy patients undergoing TAVR at 2 hospitals were enrolled. Each patient had a baseline and follow-up (within 30 days of TAVR) echocardiogram that was analyzed. MR was graded as none, mild, moderate, or severe, as well as functional or degenerative. We compared patient outcomes, including death and heart failure hospitalization, among none-mild MR, moderate-severe functional MR, and moderate-severe degenerative MR groups. Two hundred and seventy patients underwent TAVR, reducing mean aortic valve gradients from 45 ± 15 mm Hg to 9 ± 4 mm Hg. On multivariable analysis, only patients with moderate-severe degenerative MR had decreased survival free of death or CHF hospitalization compared to those with none-mild MR (P = .011). Subanalysis showed patients with moderate-severe degenerative MR were more likely to be hospitalized for heart failure at 2 years compared to those with moderate-severe functional MR (P = .02). Patients with moderate-severe degenerative MR were also less likely to have improvement in MR severity at follow up (P = .01). Special consideration should be given to patients with moderate-severe degenerative MR undergoing TAVR. As transcatheter approaches for mitral valve repair and replacement continue to evolve, moderate-severe degenerative MR patients may benefit from consideration of double valve intervention.

Impact and evolution of right ventricular dysfunction after successful MitraClip implantation in patients with functional mitral regurgitation

BackgroundRight ventricular dysfunction (RVdysf) is a predictor of poor outcome in patients with heart failure and valvular disease. The aim of this study was to evaluate the evolution and the impact of RVdysf in patients with moderate–severe functional mitral regurgitation (FMR) successfully treated with MitraClip. Methods and resultsFrom October 2008 to July 2014, 60 consecutive high surgical risk FMR patients were evaluated and stratified into two groups: RVdysf group (TAPSE<16mm and/or S′TDI <10cm/s, 21 patients) and No-RVdysf group (38 patients). The overall mean age of patients was 73±8 (83% male). Ischemic FMR etiology was present in 67%. Mean LVEF was 30±10%. Overall mean time follow-up was 565±310days. The only significant difference between the two groups was a greater prevalence of stroke, ICD and use of aldosterone antagonist in RVdysf group. Acute procedural success was achieved in 90% of patients. At 6-month echo-matched analysis significant RV function improvement was observed in patients with baseline RVdysf (TAPSE 15±3.0 vs. 19±4.5, p=0.007; S′TDI 7±1.2 vs. 11±2.8, p<0.0001; baseline vs. 6-month, respectively). The mean improvement in the 6-min walking test was significant in both groups (120 and 143m, RVdysf and No-RVdysf groups, respectively). At Kaplan–Meier analysis, the presence of RVdysf did not affect the outcome in terms of freedom from composite efficacy endpoint. ConclusionsThis study shows that successful MitraClip implantation in patients with FMR and concomitant right ventricular dysfunction yields significant improvement of RV function at mid-term follow-up. Further data on larger population will be required to confirm our observations.

TCT-713 Impact And Evolution Of Right Ventricular Dysfunction After MitraClip In High Risk Patients With Functional Mitral Regurgitation

Right ventricular dysfunction (RVdisf) is predictor of poor outcome in patients with heart failure and valvular disease. The aim of this study was to evaluate the impact and the evolution of RVdisf in patients with moderate-severe functional mitral regurgitation (FMR) after MitraClip. From October

Three-dimensional changes in mitral valve annulus geometry in organic and functional mitral regurgitation: insights for mitral valve repair

Background: Assessment of changes in mitral valve annulus (MVA) geometry according to mitral regurgitation (MR) etiology is key to select most effective annulus reshape for MV repair. Objectives: Study purpose was to assess MVA changes in organic and functional MR in comparison to normal (N) subjects, by transthoracic 3D echocardiography (3DE). Methods: 30 pts with moderate-severe organic MR (OMR) due to MV prolapse (57±14 yrs, 21 men) and 29 pts with moderate-severe functional MR (FMR) (61±13 yrs, 21 men) were compared to 30 N age-, gender- and body size-matched. Subjects underwent 3D full-volume acquisition of MV. MVA geometry was analyzed at mid-systole with prototype dedicated software (TomTec MV assessment 2.0). Results: Compared to N, both OMR and FMR pts had larger MVA and leaflet size (Table). MVA was more ellipsoidal in OMR pts than in N, due to larger increase in anterolateral-posteromedial (AL-PM) diameter than in antero-posterior (A-P) diameter (sphericity index (SI) correlated inversely to AL-PM diameter: r=-0.45, p=0.013); even though enlarged, FMR had no significant change in sphericity. MVA non-planarity angle and angle between MVA and aortic annulus (Ao-AP) were similar in N vs OMR, but significantly wider in FMR. Tenting height and volume were similar to N in OMR, and significantly higher in FMR. View this table: MVA comparison in N, OMR and FMR Conclusion: Quantitative analysis by 3DE revealed significant differences in MVA between OMR and FMR. While MVA shape is preserved in organic MR, it is severely affected in functional MR.

Cardiac Resynchronization Therapy as a Therapeutic Option in Patients With Moderate-Severe Functional Mitral Regurgitation and High Operative Risk

Cardiac Resynchronization Therapy as a Therapeutic Option in Patients With Moderate-Severe Functional Mitral Regurgitation and High Operative Risk

Cardiac Resynchronization Therapy as a Therapeutic Option in Patients With Moderate-Severe Functional Mitral Regurgitation and High Operative Risk

Cardiac Resynchronization Therapy as a Therapeutic Option in Patients With Moderate-Severe Functional Mitral Regurgitation and High Operative Risk

Cardiac Resynchronization Therapy as a Therapeutic Option in Patients With Moderate-Severe Functional Mitral Regurgitation and High Operative Risk

Functional mitral regurgitation (MR) is a common finding in heart failure patients with dilated cardiomyopathy and has important prognostic implications. However, the increased operative risk of these patients may result in low referral or high denial rate for mitral valve surgery. Cardiac resynchronization therapy (CRT) has been shown to have a favorable effect on MR. Aims of this study were to (1) evaluate CRT as a therapeutic option in heart failure patients with functional MR and high operative risk and (2) investigate the effect of MR improvement after CRT on prognosis. A total of 98 consecutive patients with moderate-severe functional MR and high operative risk underwent CRT according to current guidelines. Echocardiography was performed at baseline and 6-month follow-up; severity of MR was graded according to a multiparametric approach. Significant improvement of MR was defined as a reduction ≥ 1 grade. All-cause mortality was assessed during follow-up (median 32 [range 6.0 to 116] months). Thirteen patients (13%) died before 6-months follow-up. In the remaining 85 patients, significant reduction in MR was observed in all evaluated parameters. In particular, 42 patients (49%) improved ≥ 1 grade of MR and were considered MR improvers. Survival was superior in MR improvers compared to MR nonimprovers (log rank P<0.001). Mitral regurgitation improvement was an independent prognostic factor for survival (hazard ratio 0.35, confidence interval 0.13 to 0.94; P=0.043). Cardiac resynchronization therapy is a potential therapeutic option in heart failure patients with moderate-severe functional MR and high risk for surgery. Improvement in MR results in superior survival after CRT.