Moderate-severe Mitral Regurgitation Research Articles

Isolated congenital cleft mitral valve: a rare cause of mitral regurgitation presented as poor weight gain in children

The anterior mitral leaflet cleft is very rare congenital lesion often encountered in association with other congenital heart defects. The isolated anterior leaflet cleft is a rare anomaly and is usually the cause of mitral valve regurgitation which is correctable. Children with poor feeding exhibit weight loss, growth retardation and sometimes heart failure. Clinically echocardiography is the first investigation of choice for evaluation of mitral valve disease providing useful information about valve anatomy and hemodynamic parameters. A case of 6-month-old male child with chief complaint of poor feeding and difficulty in breathing especially in early morning is being presented in this case report. A pan-systolic murmur of grade 4/6 heard on apex and back side of chest wall. Echocardiography revealed an isolated anterior mitral leaflet cleft producing moderate-severe mitral regurgitation. Isolated cleft of mitral valve is a very rare defect that has to be identified and diagnosed. All children presented with poor weight gain or failure to thrive should be screened with TTE to rule out congenital heart diseases.

In-hospital evolution of secondary mitral regurgitation in acutely decompensated heart failure.

Secondary mitral regurgitation (MR) negatively affects prognosis in acutely decompensated heart failure (ADHF), but can be rapidly sensitive to changes in volume status and medical interventions. We sought to assess the evolution of secondary MR in patients hospitalized for ADHF and its prognostic implications. We retrospectively enrolled 782 patients admitted for ADHF with at least two in-hospital echocardiographic evaluations of MR. We classified MR severity as none-mild or moderate-severe. Based on MR evolution, patients were divided into 'persistent moderate-severe MR', 'improved MR' (from moderate-severe to none-mild) and 'persistent none-mild MR'. Four hundred and forty patients (56%) had moderate-severe MR at first evaluation, of whom 144 (33% of patients with baseline moderate-severe MR) had 'improved MR', while 296 (67%) had 'persistent moderate-severe MR'. Patients with improved MR had better clinical, laboratory and echocardiographic parameters of decongestion at discharge compared with those with persistent moderate-severe MR and showed a higher up-titration of recommended therapies. Left ventricular volume, ejection fraction and serum urea were the predictors of improved MR at multivariable analysis. After adjustment, no differences in 5-years survival (primary outcome) were observed according to baseline MR severity. When patients were stratified according to the in-hospital changes in MR severity, improved MR was associated with lower risk of 5-years mortality, compared with both persistent none-mild MR [hazard ratio (HR) = 0.505, P = 0.032] and persistent moderate-severe MR (HR = 0.556, P = 0.040). The severity of MR frequently improved during hospitalization for ADHF; the extent and the changes in MR severity during the in-hospital stay identified distinct patient phenotypes, and seemed to portend different long-term outcomes, with higher 5-years survival associated with improvement in MR.

ECHOCARDIOGRAPHIC PREDICTORS OF RESIDUAL MR ≥ 2+ AND CLINICAL OUTCOMES ONE YEAR AFTER MITRACLIP IMPLANTATION

Abstract Introduction The extent of residual mitral regurgitation (MR) (1+ vs ≥ 2+) has a notable impact on the outcome of MitraClip (MC) repair of significant functional MR. Aim The aim of the study was to analyze the one–year results in our series of patients with functional MR treated with MC. Materials and Methods Between 2020 and 2022, 58 consecutive patients underwent percutaneous mitral valve repair with MC technology. All patients had moderate–severe MR on a functional basis. Results At one year 10 patients died (mortality 17.2%). The remaining 48 patients had complete follow–up for up to one year and were included in the statistical analysis: The incidence of new hospitalizations was 8.3%; The incidence of grade 1+ and ≥ 2+ MR was 54.1% (26) and 45.9% (22), respectively; In patients with MR ≥ 2+ the clinical and instrumental outcomes were worse than in patients with MR 1+; Posterior leaflet height and extent of immediate postprocedural MR were independent predictors of MR ≥ 2+. In multivariable analysis, preprocedural posterior leaflet height (PLH) (OR 0.16, p = 0.02) and immediate postprocedural MR degree (IPOMR) (OR 12.4, p = 0.03) were predictive; preprocedural Ejection Fraction (EF) was almost significant (OR 0.87, p = 0.08) (Figure 1). Conclusions Percutaneous repair with MC of moderate/severe functional MR has favorable one–year outcomes in terms of mortality and rehospitalizations. The best results are obtained in cases with residual MR 1+. Echocardiographic parameters are independent predictors of residual MR ≥ 2+.

2-Year Clinical and Echocardiography Follow-Up of Transcatheter Mitral Valve Replacement With the Transapical Intrepid System

BackgroundThirty-day outcomes with the investigational Intrepid transapical (TA) transcatheter mitral valve replacement (TMVR) system have previously demonstrated good technical success, but longer-term outcomes in larger cohorts need to be evaluated. ObjectivesThe authors sought to evaluate the 2-year safety and performance of the Intrepid TA-TMVR system in patients with symptomatic, ≥moderate-severe mitral regurgitation (MR) and high surgical risk. MethodsPatient eligibility was determined by local heart teams and approved by a central screening committee. Clinical events were adjudicated by an independent clinical events committee. Echocardiography was evaluated by an independent core laboratory. ResultsThe cohort included 252 patients that were enrolled at 58 international sites before February 2021 as part of the global Pilot Study (n = 95) or APOLLO trial (primary cohort noneligible + TA roll-ins, n = 157). Mean age was 74.2 years, mean STS-PROM was 6.3%, 60.3% were male, and 80.6% were in NYHA functional class III/IV. Most presented with secondary MR (70.1%), and nearly all had ≥moderate-severe MR (98.4%). All-cause mortality was 13.1% (30-day), 27.3% (1-year), and 36.2% (2-year). The 30-day ≥major bleeding event rate was 22.3%. Heart failure rehospitalization was 9.6% (30-day) and 36.2% (2-year). At 2 years, >50% of patients were alive with improvement in NYHA functional class (82.1%, class I/II), and all patients with available echocardiograms had ≤mild MR. ConclusionsThis analysis represents the largest reported TA-TMVR experience with the longest follow-up in high-risk ≥moderate-severe MR patients. Early mortality and heart failure rehospitalizations were significant, exacerbated by early TA-related bleeding events; however, meaningful improvements in clinical outcomes and marked reductions in MR severity were observed through 2 years.

Assessing right ventricular peak strain in myocardial infarction patients with mitral regurgitation by cardiac magnetic resonance feature tracking.

Although it is known that mitral regurgitation (MR) in patients with myocardial infarction (MI) may increase the right ventricular (RV) afterload, leading to RV dysfunction, the exact detrimental effects on RV function and myocardial peak strain remain unresolved. In this study, we assessed the impact of MR on the impairment of RV myocardial deformation in patients with MI and explored the independent influential factors of RV peak strain. A total of 199 MI participants without or with MR were retrospectively assessed in this study. The cardiovascular magnetic resonance examination protocol included a late gadolinium-enhanced (LGE) imaging technique and a cine-balanced steady-state free precession sequence. Statistical tests, including two independent sample t-test or Mann-Whitney U-test, analysis of variance, Kruskal-Wallis test, and multiple linear regression analysis models were performed. The MI (MR+) group exhibited significantly lower RV strain parameters in the radial, circumferential and longitudinal directions when compared to the control and the MI (MR-) groups (both P<0.05). The RV global longitudinal peak strain (GLPS) in the MI group significantly decreased when compared with that in the control group (P<0.05). As moderate-severe MR worsened in patients with MI, RV myocardial global peak strain and the peak systolic strain rate (PSSR) gradually decreased. Multiple linear regression analysis revealed that left ventricular (LV) GLPS, triglycerides, and age were independently correlated with RV GLPS (all P<0.05). RV end-systolic volume (RVESV) acted as an independent association factor for RV global peak strain. MR may exacerbate the impairment of RV peak strain and functions in patients with MI. LV GLPS was positively correlated with RV GLPS. However, RVESV, triglycerides, and age acted as independent risk factors associated with worsening RV GLPS.

Contemporary experience of mitral transcatheter edge-to-edge repair technology in patients with mitral annular calcification.

Mitral annular calcification (MAC) has been an exclusion for many of the earlier pivotal trials that were instrumental in gaining device approval and indications for mitral transcatheter edge-to-edge repair (M-TEER). To evaluate the impact of MAC on the procedural durability and success of newer generation MitraClip® systems (G3 and G4 systems). Data were collected from Northwell TEER registry. Patients that underwent M-TEER with third or fourth generation MitraClip device were included. Patients were divided into -MAC (none-mild) and +MAC (moderate-severe) groups. Procedural success was defined as ≤ grade 2 + mitral regurgitation (MR) postprocedure, and durability was defined as ≤ grade 2 + MR retention at 1 month and 1 year. Univariate analysis compared outcomes between groups. Of 260 M-TEER patients, 160 were -MAC and 100 were +MAC. Procedural success was comparable; however, there were three patients who required conversion to cardiac surgery during the index hospitalization in the +MAC group versus none in the -MAC group (though this was not statistically significant). At 1-month follow-up, there were no significant differences in MR severity. At 1-year follow-up, +MAC had higher moderate-severe MR (22.1% vs. 7.5%; p = 0.002) and higher mean transmitral gradients (5.3 vs. 4.0 mmHg; p = 0.001) with no differences in mortality, New York Heart Association functional class or ejection fraction. In selective patients with high burden of MAC, contemporary M-TEER is safe, and procedural success is similar to patients with none-mild MAC. However, a loss of procedural durability was seen in +MAC group at 1-year follow-up. Further studies with longer follow-ups are required to assess newer mTEER devices and their potential clinical implications in patients with a high burden of MAC.

Abstract 15629: Innovative Approach to Mitral Regurgitation in a Patient With Partially Dehisced Annuloplasty Band After Mitral Valve Repair

Case: A 65-year-old patient presented 4 months after mitral valve repair (annuloplasty band, commissuroplasty, neo-chordae to the anterior mitral leaflet (AL)). At follow up, he developed significant hemolytic anemia (Hemoglobin 10.1g/dL, LDH 650U/L, Bilirubin 1.4mg/dL and haptoglobin&lt;14 mg/dL). TEE revealed the substrate for hemolysis: moderate-severe mitral regurgitation (MR) starting at the coaptation of A2 and P2 scallops due to AL overriding the posterior (PL). The jet was then directed posteriorly to a small (3 x 6 mm confirmed by cardiac CT) area of annuloplasty band dehiscence at the base of the P2 scallop, with the band in direct path of the flow. The unique feature was that AL retained coaptation with the annuloplasty band, thus forming a small tunnel from the A2-P2 coaptation defect to the dehisced area. Given that redo surgery early after initial intervention would be challenging, the Heart Team decided to pursue percutaneous closure at the level of the dehisced annuloplasty to reduce regurgitation and mitigate hemolysis. Under 3D TEE guidance closure with a 12mm AVP plug was attempted but resulted in interference with PL motion with a new jet of regurgitation laterally. Using two 8mm AVP plugs was successful in closing the dehiscence with minimal impact on PL. Overall regurgitation was reduced to mild. Within a week hemolysis labs improved: LDH337 U/L, Bilirubin0.7 mg/dL. Discussion: Annuloplasty band dehiscence is a known cause of recurrent MR after repair. As regurgitation occurs at the leaflet coaptation zone, percutaneous closure of these defects is usually futile. In this patient we took advantage of the maintained coaptation between the AL and annuloplasty band.

Abstract 16806: Transcatheter Edge-to-Edge Repair Lessens Atrial Fibrillation Burden by Ameliorating Left Atrial Strain in Moderate-to-Severe Mitral Regurgitation Patients

Introduction: trans-catheter edge-to-edge repair (TEER) represents a therapeutic possibility in patients with moderate-severe mitral regurgitation (MR) considered at high surgical risk. Only in recent years, it has been realized that left atrial (LA) function plays a prognostic role in these patients. Hypothesis: since atrial fibrillation (AF) depends in part on LA geometry, we considered that two-dimensional speckle-tracking-echocardiography analysis could predict AF burden. Aim: we therefore evaluated the AF occurrence long term after TEER. Methods: one hundred nine patients treated by TEER between February ‘15 and April ’22 underwent reservoir (R_s), conduct (D_s), and contractile (C_s) evaluations strains before and 1,6,12 months after TEER. Cardiac rhythm was monitored through 24 hours Holter-ECG or previously implanted cardiac devices, when available. Statistical analysis was performed with SPSS. Comparisons were carried out by ANOVA and MANOVA. Results: to the permanent AF group (n=35), no paroxysmal (N=15), nor persistent (N=8) case was added during follow-up after TEER. Among the sinus rhythm (N=51) group, one episode of atrial tachyarrhythmia was found at device interrogation and one patient developed paroxysmal AF (2/51; 3,9%). Significant improvements in total cohort were observed at 12 months follow-up for R_s (from 10,77±5,74% to 16,28±6,93%; p&lt;0,0001), D_s (from -6,72±4,44% to -9,73±4,48%; p=0,0003) and C_s (from -5,21±5,11% to 7,72±5,4%; p=0,0184) compared to baseline. AF burden in paroxysmal AF (baseline: 9,2±4,7 hours, follow-up: 5,8±4,2 hours; p&lt;0,001) was significantly reduced as well as ventricular rate (baseline 88±14 bpm; 12 months 76±13 bpm; p&lt;0,001) in permanent AF group. Conclusions: MR reduction following TEER dictates positive LA remodelling and significant improvement of LA strain. Overall, the impact on LA geometry contributed to lessen incidence and burden of AF.

Relevance of Motion Artifacts in Planning Computed Tomography on Outcomes After Transcatheter Aortic Valve Implantation

BackgroundMotion artifacts in planning computed tomography (CT) for transcatheter aortic valve implantation (TAVI) can potentially skew measurements required for procedural planning. Whether such artifacts may affect safety or efficacy has not been studied. MethodsWe conducted a retrospective analysis of 852 consecutive patients (mean age, 82 years; 47% women) undergoing TAVI-planning CT at a tertiary care center. Two independent observers divided CTs according to the presence of motion artifacts at the annulus level (Motion vs. Normal group). Endpoints included surrogate markers for inappropriate valve selection: annular rupture, valve embolization or misplacement, need for a new permanent pacemaker, paravalvular leak (PVL), postprocedural transvalvular gradient, all-cause death. ResultsForty-six (5.4%) patients presented motion artifacts on TAVI-planning CT (Motion group). These patients had more preexisting heart failure, moderate-severe mitral regurgitation, and atrial fibrillation. Interobserver variability of annular measurement (Normal vs. Motion group) did not differ for mean annular diameter but was significantly different for perimeter and area. Presence of motion artifacts on planning CT did not affect the prevalence of PVL (≥moderate PVL 0% vs. 2.5% p = 0.5), mean transvalvular gradient (6±3 mmHg vs 7±5 mmHg, p = 0.1), or the need for additional valve implantation (0% vs. 2.8%, p = 0.6). One annular rupture occurred (Normal group). Pacemaker implantation, procedural duration, hospital stay, 30-day outcomes, and all-cause mortality did not differ between the groups. ConclusionsMotion artifacts on planning CT were found in about 5% of patients. Measurements for valve selection were possible without the need for repeat CT, with mean diameter-derived annulus measurement being the most accurate. Motion artifacts were not associated with worse outcomes.

Impact of mitral regurgitation aetiology on the outcomes of transcatheter aortic valve implantation.

Concomitant moderate/severe mitral regurgitation (MR) is observed in 17-35% of patients undergoing transcatheter aortic valve implantation (TAVI) and contributes to aworse prognosis. Studies analysing outcomes in patients undergoing TAVI with different MR aetiologies, including atrial functional MR (aFMR), are lacking. We aimed to analyse outcomes and changes in MR severity in patients with aFMR, ventricular functional (vFMR) and primary mitral regurgitation (PMR) following TAVI. We analysed all consecutive patients with at least moderate MR undergoing TAVI between January 2013 and December 2020 at the Munich University Hospital. Characterisation of MR aetiology was performed by detailed individual echocardiographic assessment. Three-year mortality, changes in MR severity and New York Heart Association (NYHA) Functional Class at follow-up were assessed. Out of 3,474patients undergoing TAVI, 631patients showed MR ≥2+ (172 with aFMR, 296 with vFMR, 163 with PMR). Procedural characteristics and endpoints were comparable between groups. The rate of MR improvement was 80.2% in aFMR patients, which was significantly higher compared to both other groups (vFMR: 69.4%; p=0.03; PMR: 40.8%; p<0.001). The estimated 3-year survival rates did not differ between aetiologies (p=0.57). However, MR persistence at follow-up was associated with increased mortality (hazard ratio 1.49, 95% confidence interval: 1.04-2.11; p=0.027), mainly driven by the PMR subgroup of patients. NYHA Class improved significantly in all groups. In patients with baseline MR ≥3+, the PMR aetiology was associated with the lowest MR improvement, the lowest survival rates and least symptomatic improvement. TAVI reduces MR severity and symptoms in patients with aFMR, vFMR and less-pronounced PMR. The presence of aFMR was associated with the greatest MR severity improvement.

Identifying Mitral Valve Prolapse at Risk for Arrhythmias and Fibrosis From Electrocardiograms Using Deep Learning

BackgroundMitral valve prolapse (MVP) is a common valvulopathy, with a subset developing sudden cardiac death or cardiac arrest. Complex ventricular ectopy (ComVE) is a marker of arrhythmic risk associated with myocardial fibrosis and increased mortality in MVP. ObjectivesThe authors sought to evaluate whether electrocardiogram (ECG)-based machine learning can identify MVP at risk for ComVE, death and/or myocardial fibrosis on cardiac magnetic resonance (CMR) imaging. MethodsA deep convolutional neural network (CNN) was trained to detect ComVE using 6,916 12-lead ECGs from 569 MVP patients from the University of California-San Francisco between 2012 and 2020. A separate CNN was trained to detect late gadolinium enhancement (LGE) using 1,369 ECGs from 87 MVP patients with contrast CMR. ResultsThe prevalence of ComVE was 28% (160/569). The area under the receiver operating characteristic curve (AUC) of the CNN to detect ComVE was 0.80 (95% CI: 0.77-0.83) and remained high after excluding patients with moderate-severe mitral regurgitation [0.80 (95% CI: 0.77-0.83)] or bileaflet MVP [0.81 (95% CI: 0.76-0.85)]. AUC to detect all-cause mortality was 0.82 (95% CI: 0.77-0.87). ECG segments relevant to ComVE prediction were related to ventricular depolarization/repolarization (early-mid ST-segment and QRS from V1, V3, and III). LGE in the papillary muscles or basal inferolateral wall was present in 24% patients with available CMR; AUC for detection of LGE was 0.75 (95% CI: 0.68-0.82). ConclusionsCNN-analyzed 12-lead ECGs can detect MVP at risk for ventricular arrhythmias, death and/or fibrosis and can identify novel ECG correlates of arrhythmic risk. ECG-based CNNs may help select those MVP patients requiring closer follow-up and/or a CMR.

Identifying Patients With Secondary Mitral Regurgitation and Heart Failure who may Benefit From Transcatheter Edge-to-Edge Repair in the Wellington Region

As the New Zealand population ages, the incidence of heart failure and valvular disease increases. The Cardiovascular Outcomes Assessment of MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation (COAPT) trial showed decreased rates of hospitalisation for heart failure and all-cause mortality with transcatheter edge-to-edge repair (TEER) for clinically significant secondary mitral regurgitation (MR) within 24 months of follow-up compared with medical therapy. This retrospective observational study aimed to identify patients who may benefit from TEER in Wellington. This study retrospectively reviewed the electronic records of 337 consecutive patients aged ≥18 years who presented to Wellington Hospital from April to September 2022 with heart failure and identified those who met modified COAPT criteria: at least moderate secondary mitral regurgitation, left ventricular ejection fraction (LVEF) 20%–50% on echocardiography, and who did not meet criteria for cardiac surgery or other valve intervention. Forty patients met the modified COAPT criteria: 27 (68%) were male and 13 (33%) were female. The mean age was 71.7 years. Of them, 55% were New Zealand European, 23% were Pasifika, and 13% were New Zealand Māori. A total of 58% had moderate MR, 33% had moderate–severe MR, and 10% had severe MR; the median LVEF was 30%. The median survival was 309 days in those who met the modified COAPT criteria compared with 365 days in those who did not (non-statistically significant). Among patients who presented to Wellington Hospital with heart failure, a significant proportion (11.9%) had clinically significant secondary MR, who trend towards shorter survival times compared with those who present with heart failure in general. According to international guidelines and trial data such as COAPT, these patients would have potentially benefitted from TEER.

Predictors of success of elective electrical cardioversion in patients with atrial fibrillation and atrial flutter

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Electrical cardioversion is an effective therapy for the restoration of sinus rhythm. The success of cardioversion has been related to different clinical and echocardiographic variables, although the available evidence is scarce and heterogeneous. Methods Ambispective, observational, single-center registry that consecutively included 271 patients scheduled for elective electrical cardioversion (ECV) on the inpatient ward for atrial fibrilation (AF) or flutter fibrilation (AFL) &amp;gt;48 hours of onset during the years 2018-2021. All patients scheduled for CVE that were ultimately discontinued on the day of the procedure were excluded, finally analyzing 244 patients. Results The baseline characteristics are shown in Picture 1. No statistically significant differences were observed in the main comorbidities, cardiovascular risk factors, CHAD2S2-VASc scale, the position of the paddles, or days to ECV between patients with successful ECV and those with a failed procedure. Neither were they observed in terms of pharmacological treatment, including the presence of previous antiarrhythmic treatment as part of a facilitated ECV strategy (Picture 2). Moderately-severely depressed systolic function and the presence of moderate-severe mitral regurgitation were associated with a higher rate of cardioversion failure (3% vs 2.6% p= 0.002; 3.3% vs 1.3% p=0.001), higher number of biphasic electric shocks (1.3 vs 1.6 p&amp;lt;0.001; 1.2 vs 1.6 p&amp;lt;0.001) and higher total voltage received (245J vs 310J p=0.32; 229J vs 325J p&amp;lt;0.001). Moderate-severe tricuspid regurgitation was also associated with lower cardioversion success rate (96.7% vs 85% p=0.02) although no differences were seen with respect to the number of shocks or energy received. On the other hand, severe left atrial dilatation, although it had a neutral impact on the success of ECV, was associated with greater immediate recurrence (&amp;lt;5 minutes after ECV) (4.2% vs 50% p&amp;lt;0.001). Conclusion Patients with moderate-severe systolic dysfunction and significant mitral and tricuspid regurgitation have a lower success rate of ECV. Previous antiarrhythmic therapy presents a neutral effect on sinus rhythm restoration and immediate recurrence.

Integrating Echocardiography Parameters With Explainable Artificial Intelligence for Data-Driven Clustering of Primary Mitral Regurgitation Phenotypes

BackgroundPrimary mitral regurgitation (MR) is a heterogeneous clinical disease requiring integration of echocardiographic parameters using guideline-driven recommendations to identify severe disease. ObjectivesThe purpose of this preliminary study was to explore novel data-driven approaches to delineate phenotypes of MR severity that benefit from surgery. MethodsThe authors used unsupervised and supervised machine learning and explainable artificial intelligence (AI) to integrate 24 echocardiographic parameters in 400 primary MR subjects from France (n = 243; development cohort) and Canada (n = 157; validation cohort) followed up during a median time of 3.2 years (IQR: 1.3-5.3 years) and 6.8 (IQR: 4.0-8.5 years), respectively. The authors compared the phenogroups’ incremental prognostic value over conventional MR profiles and for the primary endpoint of all-cause mortality incorporating time-to-mitral valve repair/replacement surgery as a covariate for survival analysis (time-dependent exposure). ResultsHigh-severity (HS) phenogroups from the French cohort (HS: n = 117; low-severity [LS]: n = 126) and the Canadian cohort (HS: n = 87; LS: n = 70) showed improved event-free survival in surgical HS subjects over nonsurgical subjects (P = 0.047 and P = 0.020, respectively). A similar benefit of surgery was not seen in the LS phenogroup in both cohorts (P = 0.70 and P = 0.50, respectively). Phenogrouping showed incremental prognostic value in conventionally severe or moderate-severe MR subjects (Harrell C statistic improvement; P = 0.480; and categorical net reclassification improvement; P = 0.002). Explainable AI specified how each echocardiographic parameter contributed to phenogroup distribution. ConclusionsNovel data-driven phenogrouping and explainable AI aided in improved integration of echocardiographic data to identify patients with primary MR and improved event-free survival after mitral valve repair/replacement surgery.

Hemodynamic changes associated to increments of PEEP in mechanically ventilated patients admitted into the cardiac intensive care unit

Abstract Funding Acknowledgements Type of funding sources: None. Background Current evidence suggests that incremental levels of PEEP generate an increase in right intracavitary pressures, diminishing venous return and consequently lessening left ventricular preload and stroke volume, resulting in a significant decrease of cardiac output. Nonetheless, most studies regarding these interactions have been done in patients requiring mechanical ventilation for non-cardiac disorders or in animals. We studied the effects of incremental levels of PEEP on cardiac intracavitary pressures and hemodynamics in mechanically ventilated patients admitted into the Cardiac Intensive Care Unit. Purpose We aimed to model how increments in PEEP alter cardiac output and other hemodynamic variables in patients with cardiac disfunction. Methods We included 14 mechanically ventilated patients admitted into a Cardiac Intensive Care Unit from 2018 to 2020. Data on intracavitary pressures and hemodynamics were recorded via Swan-Ganz catheterization and echocardiographic imaging. We documented measurements for all variables of interest at three different levels of PEEP: 5cmH2O, 10cmH2O and 15cmH2O. We conducted general descriptive statistics, mean comparison tests for paired data and linear regression models with Stata version 12.0 (StataCorp LP, College Station, TX). Results 7 (50%) patients admitted in the study had cardiogenic shock, 11 (79%) patients were mechanically ventilated in a volume-controlled setting and 3 (21%) were on pressure support ventilation. Seven (50%) patients needed vasoactive drugs during the study. Only 1 (7%) patient required an intra-aortic balloon pump. Seven (50%) patients had a visual left ventricular ejection fraction lesser than 40% and 3 (21%) had a moderate-severe mitral regurgitation. Paired mean testing by groups associated to gains of PEEP revealed statistically significant increments in Mean Pulmonary Artery Pressure (mPAP), Pulmonary Capillary Wedge Pressure (PCWP) and Central Venous Pressure (CVP). Inversely, increments of PEEP were linked to significant decrements in Cardiac Output (CO) [Figure 1 &amp; Table 1]. Conclusions In mechanically ventilated patients admitted into the Cardiac Intensive Care Unit, rises in PEEP are associated to increments in intracavitary cardiac pressures, and inversely, with decrements in cardiac output. Although our findings are statistically significant, we have yet to clarify whether these are clinically meaningful, specifically within PEEP increments of 5 to 10cmH2O, the usual range in clinical practice.

Effectiveness and feasibility of transcatheter aortic valve replacement in treating combined aortic and mitral regurgitation: a retrospective observational study.

Transcatheter aortic valve replacement (TAVR) is emerging as a less invasive procedure for aortic valve replacement. However, its effectiveness and feasibility in treating combined valvular disease remain controversial. In this study, we explored the clinical effectiveness and safety of TAVR in the treatment of combined aortic and mitral regurgitation. The basic clinical characteristics and 1-month follow-up of 11 patients with combined aortic and mitral regurgitation who were treated with TAVR at center of structural heart disease, Zhongnan Hospital of Wuhan University from December 2021 to November 2022 were retrospectively analyzed. Echocardiographic parameters of aortic and mitral valve, complications, and all-cause mortality were compared pre- and post-TAVR. Retrievable self-expanding valve protheses were used in all patients, and the protheses were implanted via the transfemoral route in 8 patients and via the transapical route in 3 patients. There were 9 male and 2 female patients with an average age of 74.7±2.7 years. The mean Society of Thoracic Surgeons score was 8.5±1.2. Among the patients, 1 required retroperitoneal sarcoma semi-elective surgery, and 3 of the 5 patients with atrial fibrillation had their rhythm converted to sinus rhythm after operation. No perioperative deaths were recorded. Two patients underwent permanent pacemaker implantations due to high-grade atrioventricular blocks after TAVR. Moderate/severe mitral regurgitation (MR) were mostly secondary to aortic regurgitation (AR) as no rupture of the subvalvular tendon cords or rheumatic changes being recognized during echocardiography before operation. The mean left ventricular end-diastolic diameter (65.5±10.7 vs. 58.6±8.8 mm, P<0.001) and mitral annular diameter (36.7±5.4 vs. 31.5±2.8 mm, P<0.001) was significantly reduced after operation. MR was improved as the ratio of the regurgitant jet area to the left atrial area decreased significantly after operation (24.7%±11.5% vs. 42.4%±6.8% before operation, P<0.001). During the 1-month follow-up, the mean left ventricular ejection fraction was significantly improved (50.0%±9.4% vs. 44.6%±9.3% at admission, P=0.022). TAVR is effective and feasible for high-risk patients with combined aortic and mitral regurgitation.

Prognostic value of mitral regurgitation in patients undergoing left ventricular assist device deployment: A systematic review and meta-analysis.

Left ventricular assist devices (LVADs) represent an important therapeutic option for patients progressing to end-stage heart failure. LVAD has previously been shown to have a promising role in improving mitral regurgitation (MR). Nevertheless, the prognostic value of preoperative uncorrected MR in this population remains unclear. A systematic database search with meta-analysis was conducted of comparative original articles of patients with preoperative mild MR (Grade 0-I) versus moderate-severe MR (Grade II-III) undergoing LVAD implantation, in EMBASE, MEDLINE, Cochrane database, and Google Scholar, from inception to June 2022. Primary outcomes were overall and operative mortality. Secondary outcomes were neurological dysfunction, gastrointestinal bleeding, right heart failure, LVAD thrombosis, and driveline infection. Our search yielded 2228 relevant studies. A total of 19 studies met the inclusion criteria with a total of 11 873 patients. LVAD caused a statistically significant decrease of 35.9% in the number of patients with moderate-severe MR (grade II-III) postoperatively. No significant difference was observed in terms of overall mortality, operative mortality, GI bleeding, LVAD thrombosis, and driveline infection rates between mild and moderate-severe MR. An increased rate of right heart failure was seen among patients with moderate-severe MR, while lower rates of neurological events were also observed. LVAD improves the haemodynamics of the left ventricle, to promote resolution of MR. Nevertheless, the severity of preoperative mitral regurgitation in patients undergoing LVAD deployment does not seem to affect mortality.

Cardiac reverse remodeling in primary mitral regurgitation: mitral valve replacement vs. mitral valve repair

BackgroundWhen feasible, guidelines recommend mitral valve repair (MVr) over mitral valve replacement (MVR) to treat primary mitral regurgitation (MR), based upon historic outcome studies and transthoracic echocardiography (TTE) reverse remodeling studies. Cardiovascular magnetic resonance (CMR) offers reference standard biventricular assessment with superior MR quantification compared to TTE. Using serial CMR in primary MR patients, we aimed to investigate cardiac reverse remodeling and residual MR post-MVr vs MVR with chordal preservation. Methods83 patients with ≥ moderate-severe MR on TTE were prospectively recruited. 6-min walk tests (6MWT) and CMR imaging including cine imaging, aortic/pulmonary through-plane phase contrast imaging, T1 maps and late-gadolinium-enhanced (LGE) imaging were performed at baseline and 6 months after mitral surgery or watchful waiting (control group). Results72 patients completed follow-up (Controls = 20, MVr = 30 and MVR = 22). Surgical groups demonstrated comparable baseline cardiac indices and co-morbidities. At 6-months, MVr and MVR groups demonstrated comparable improvements in 6MWT distances (+ 57 ± 54 m vs + 64 ± 76 m respectively, p = 1), reduced indexed left ventricular end-diastolic volumes (LVEDVi; − 29 ± 21 ml/m2 vs − 37 ± 22 ml/m2 respectively, p = 0.584) and left atrial volumes (− 23 ± 30 ml/m2 and − 39 ± 26 ml/m2 respectively, p = 0.545). At 6-months, compared with controls, right ventricular ejection fraction was poorer post-MVr (47 ± 6.1% vs 53 ± 8.0% respectively, p = 0.01) compared to post-MVR (50 ± 5.7% vs 53 ± 8.0% respectively, p = 0.698). MVR resulted in lower residual MR-regurgitant fraction (RF) than MVr (12 ± 8.0% vs 21 ± 11% respectively, p = 0.022). Baseline and follow-up indices of diffuse and focal myocardial fibrosis (Native T1 relaxation times, extra-cellular volume and quantified LGE respectively) were comparable between groups. Stepwise multiple linear regression of indexed variables in the surgical groups demonstrated baseline indexed mitral regurgitant volume as the sole multivariate predictor of left ventricular (LV) end-diastolic reverse remodelling, baseline LVEDVi as the most significant independent multivariate predictor of follow-up LVEDVi, baseline indexed LV end-systolic volume as the sole multivariate predictor of follow-up LV ejection fraction and undergoing MVR (vs MVr) as the most significant (p < 0.001) baseline multivariate predictor of lower residual MR. ConclusionIn primary MR, MVR with chordal preservation may offer comparable cardiac reverse remodeling and functional benefits at 6-months when compared to MVr. Larger, multicenter CMR studies are required, which if the findings are confirmed could impact future surgical practice.

Quadratic stratification of left ventricular hypertrophy and association with mitral insufficiency grading: a retrospective study using cardiac magnetic resonance.

Chronic primary mitral regurgitation (MR) is caused by the defect in >1 component of the mitral valve, potentially leading to left ventricular hypertrophy (LVH). The relationship between LVH subtypes and the insufficiency grading of chronic MR remains unclear. Thus, we aimed to investigate this association and explore the impact of unhealthy habits on LVH development in patients with chronic primary MR through a cross-sectional study. Cardiac magnetic resonance (CMR) data was retrospectively collected from 3T magnetic resonance imaging (MRI) scanners in 71 patients with chronic primary MR (range, 20-84 years, 52% men). Considered patients (with mild-to-severe MR) were enrolled between March 2015 and September 2022 from the Cardiovascular Imaging Registry of Calgary (CIROC) database. Left ventricle (LV) function was assessed using cvi42 v5.11.5. Patients were categorized into 'mild-to-severe' MR using regurgitation fraction (RF), according to the current imaging guidelines. LVH subtypes were determined using mass-to-volume (M/V) calculations. IBM SPSS was used to run all the statistical analyses. This study employed normality checks by using the Shapiro-Wilk test; one-way analysis of variance (ANOVA) and Kruskal-Wallis tests with post-hoc pairwise comparisons; Chi-squared tests, Fisher's Exact test, crosstabulation analysis, and multinomial logistic regression to examine relationships between MR severity, LVH types, and impact of lifestyle factors, significance at P<0.05. Eccentric LVH was significantly associated with increased severity of MR, while concentric remodeling (CR) was linked to decreased MR severity (χ2=13.276, P=0.03, stratified by sex χ2=7.729, P=0.005). Sex differences emerged in the overall study population. Eccentric LVH was dominantly higher than CR in both males and females (females: 57.7% vs. 42.3%, P=0.05, males: 82.8% vs. 17.2%, P=0.26). No differences were observed between age groups ('Young-Middle' = under 60 years, and 'Middle-Old' = over 60 years). Still, there were notable differences in LVH prevalence within the 'Young-Middle' age group for mild-moderate (P=0.01) and moderate-severe MR (P=0.02). Eccentric LVH was associated with higher body mass index (BMI), smoking, and frequent alcohol consumption [odds ratio (OR) 1.02, 95% confidence interval (CI): 0.56-1.26; OR 1.65, 95% CI: 1.31-6.52; OR 1.15, 95% CI: 0.26-1.34], while CR was solely associated with increased BMI (smokers OR =1.84, 95% CI: 1.25-3.91 and alcohol consumers OR =1.32, 95% CI: 0.86-2.48). Nicotine and caffeine consumption did not appear to be a risk factor for LVH (nicotine: eccentric, OR =0.99, 95% CI: 0.65-1.86; CR, OR =0.97, 95% CI: 0.69-2.39 and caffeine: eccentric, OR =0.69, 95% CI: 0.48-1.61; CR, OR =0.97, 95% CI: 0.78-4.01). This study reveals sex-based associations between LVH subtypes and severity of chronic primary MR. Lifestyle factors such as cigarette smoking, alcohol consumption, and elevated BMI influence LVH risk, while nicotine and caffeine consumption exhibit minimal effects.

Mitral valve repair and concomitant maze procedure versus catheter ablation in the treatment of atrial functional mitral regurgitation

BackgroundTo compare mitral valve (MV) repair and concomitant maze procedure with catheter ablation in treating patients with atrial functional mitral regurgitation (AFMR).MethodsWe retrospectively identified 126 patients with AFMR from January 2012 to December 2015. Of these patients, 60 patients underwent MV repair and concomitant maze procedure, and 66 patients received catheter ablation. Patients were followed up for 7.98 ± 2.01 years. The survival, readmission of heart failure (HF), persistent atrial fibrillation (AF), persistent moderate-severe mitral regurgitation (MR) and tricuspid Regurgitation (TR), and echocardiographic data were analyzed in the follow-up. Predictors of readmission of HF were analyzed.ResultsThere was no significant difference in baseline and echocardiographic characteristics, in-hospital mortality, and other adverse events postoperatively between two groups. The surgical group was associated with lower rates of MR > 2 + grade either at discharge (P = 0.0023) or in the follow-up (P = 0.0001). There was no significant difference in the incidence of overall survival between the two groups. The surgical group was associated with a lower rate of readmission of HF and AF in the follow-up. Univariable and multivariable analysis confirmed AF at discharge, moderate-severe MR at discharge, no MV surgery, moderate-severe TR at discharge, and LA volume as predictors of readmission of HF. Both groups experienced significant reverse cardiac remodeling.ConclusionsOur results suggest that for the treatment of AFMR with persistent or long-standing persistent AF and moderate-severe MR, MV repair and concomitant maze procedure may achieve a better outcome than catheter ablation procedure.