Predictors Of Recurrent Mitral Regurgitation Research Articles

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

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

Coaptation Length as Predictor of Recurrent Mitral Regurgitation After Surgical Repair for Degenerative Mitral Valve Disease: Meta-Analysis of Reconstructed Time-to-Event Data

Coaptation Length as Predictor of Recurrent Mitral Regurgitation After Surgical Repair for Degenerative Mitral Valve Disease: Meta-Analysis of Reconstructed Time-to-Event Data

Recurrent Mitral Regurgitation After MitraClip: Predictive Factors, Morphology, and Clinical Implication.

Recurrent mitral regurgitation (MR) following MitraClip has not been thoroughly investigated. We aimed to examine the predictive factors, morphology, and long-term outcome of recurrent MR after MitraClip. We assessed data from the Heart Failure Network Rhineland registry from August 2010 to October 2018. Competing risk analyses were performed using the Fine and Gray model to assess the risk of recurrent MR. Among 685 MitraClip patients with a reduction in MR to ≤2+, 61 patients developed recurrent MR within the first 12 months. Flail leaflet (hazard ratio, 3.68; P=0.002) and residual MR (MR grade 2+ versus ≤1+: hazard ratio, 2.56; P=0.03) were the predictors of recurrent MR in primary MR patients, while left atrial volume (per 10 mL increase: hazard ratio, 1.11; P<0.001) and residual MR (hazard ratio, 2.45; P=0.01) were independently associated with recurrent MR in secondary MR patients. In primary MR patients, loss of leaflet insertion or leaflet tear were the predominant morphologies with recurrent MR. In secondary MR patients, more than half of the patients with recurrent MR did not show any disorder of the clip or leaflets. Patients with recurrent MR were more likely to experience unplanned heart failure hospitalization or heart failure symptom with New York Heart Association scale III/IV (54.1% versus 37.8%; P=0.018) and undergo a repeat mitral valve intervention (9.8% versus 2.2%; P=0.005) during the follow-up. In the landmark survival analysis, patients with recurrent MR tended to have lower long-term survival (58.7% versus 83.9%; P=0.08) than patients without recurrent MR. Flail leaflet and residual MR were the predictors of recurrent MR in primary MR patients, while a larger left atrial volume and residual MR were associated with recurrent MR in secondary MR patients, which may be associated with long-term clinical outcomes of patients after MitraClip.

Short Coaptation Length is a Predictor of Recurrent Mitral Regurgitation After Mitral Valve Plasty

Long-term predictors of recurrent mitral regurgitation (MR) after mitral valve plasty (MVP) remain to be elucidated. This study sought to determine the prognostic factors of recurrent MR during long-term follow-up after MVP, by analysing findings of three-dimensional transoesophageal echocardiography (TEE) conducted after MVP. This study analysed 207 patients who underwent MVP for A2 and/or P2 prolapse and received TEE before discharge. Recurrent MR was defined as moderate or worse regurgitation detected by annual transthoracic echocardiography. During a median follow-up period of 49 months after MVP, 18 patients experienced recurrent MR and six patients needed reoperation. In the recurrent group, 16 of 18 patients showed less than moderate MR before discharge. Patients in the recurrent group underwent repair for worse MR (effective orifice area, 54±19 vs 44±16 mm2; p=0.01) and had shorter A2-P2 coaptation length (5.3±1.4 vs 7.3±1.5 mm; p<0.001) after MVP compared with the non-recurrent group. Cox proportional hazards regression analysis identified the A2-P2 coaptation length as significant risk of recurrent MR (coaptation length increase: HR, 0.44; 95% CI, 0.32-0.59; p<0.0001). The receiver operator characteristics curve demonstrated that a coaptation length of <5.6 mm had 78% sensitivity and 89% specificity for predicting recurrent MR. Coaptation length measured by post-MVP TEE predicted the tendency of recurrent MR. Patients with short coaptation length should be carefully monitored, even when residual MR is less than moderate after MVP.

Functional and Degenerative Mitral Regurgitation: One Ring Fits All?

Three-dimensional saddle-shaped annuloplasty rings have been shown to create a larger surface of leaflet coaptation in mitral valve repair (MVR) for functional mitral regurgitation (FMR) and degenerative mitral regurgitation (DMR) which may increase repair durability. For the first time, this study reports mid-term results after MVR for DMR and FMR using a rigid three-dimensional ring (Profile 3D, Medtronic). Between June 2009 and June 2012, 369 patients with DMR (n = 326) or FMR (n = 43) underwent MVR (mean age 62.3 ± 12.6 years). A total of 205 patients (55.6%) underwent isolated MVR and 164 patients (44.4%) a combined procedure. Follow-up examinations were performed in 94.9% (mean 4.9 ± 0.9 years). Echocardiographic assessment was complete in 93.2% (mean 4.3 ± 1.2 years). The 30-day mortality was 1.5% (5/326) for DMR (1.5% for isolated and 1.6% for combined procedures) and 9.3% (4/43) for FMR (0% for isolated and 10.5% for combined procedures). Survival at 6 years was 92.1 ± 1.9% for DMR (92.9 ± 2.6% for isolated and 90.7 ± 2.7% for combined procedures) and 66.4 ± 7.9% for FMR (80.0 ± 17.9% for isolated and 63.7 ± 8.9% for combined procedures). Cumulative risk for mitral valve-related reoperation at 6 years was 0% for FMR and 7.1 ± 1.5% for DMR. At echocardiographic follow-up, one patient presented with mitral regurgitation (MR) more than moderate. The only predictor of recurrent MR after MVR for DMR was residual mild MR at discharge. Repair of FMR with the three-dimensional Profile 3D annuloplasty ring shows excellent mid-term results with regard to recurrence of MR. In cases of DMR, the results are conforming to the current literature.

Invited Commentary

The inability to predict the response of the left ventricle to myocardial revascularization and mitral valve repair in ischemic mitral regurgitation (MR) patients remains problematic. Morgan and colleagues [1Morgan A.E. Zhang Y. Tartibi M. et al.Ischemic mitral regurgitation: abnormal strain overestimates nonviable myocardium.Ann Thorac Surg. 2018; 105: 1754-1762Abstract Full Text Full Text PDF Scopus (10) Google Scholar] compared the ability of tagged cardiac magnetic resonance imaging (MRI) and late gadolinium-enhanced (LGE) MRI to determine the amount of nonviable myocardium in patients with ischemic MR. Their hypothesis was that strain measurements using tagged cardiac MRI overestimate the amount of nonviable myocardium in ischemic MR when compared with LGE MRI, suggesting that much of the myocardium deemed nonviable by strain measurements is actually viable but nonfunctional (ie, stunned or hibernating). This is a critical issue because it is believed that the degree of stunned myocardium in patients with ischemic MR correlates not only with functional myocardial recovery due to revascularization but also with the degree of ventricular remodeling and, thus, the success or failure of mitral valve surgery in these patients. Although LGE MRI is helpful in identifying nonviable myocardium, it is not necessarily as helpful in determining the response of viable myocardium to surgery for ischemic MR. Gadolinium chelate distributes in the extracellular space but does not cross the intact cell membrane. Through a combination of increased extracellular volume and slower washout kinetics, there is a relative accumulation of gadolinium in areas of necrosis, fibrosis, and inflammation in the late washout phase. LGE MRI depends on this relative accumulation of gadolinium in areas of damaged myocardium, but it may miss areas of diffuse fibrosis and underestimate the true extent of nonviable muscle. Grapsa and colleagues [2Grapsa J. Zimbarra Cabrita I. Jakaj G. et al.Strain balance of papillary muscles as a prerequisite for successful mitral valve repair in patients with mitral valve prolapse due to fibroelastic deficiency.Eur Heart J Cardiovasc Imaging. 2015; 16: 53-61Crossref PubMed Scopus (3) Google Scholar], using 3-D echo speckle-tracking, showed that a disproportionate increase in the deformation of the papillary muscles is a predictor of recurrent MR following mitral valve annuloplasty and that global longitudinal deformation depends on the degree of mitral regurgitation. The amount of deformation of the mitral apparatus in patients with only minor degrees of MR was zero. It would be instructive to include tagged cardiac MRI and LGE MRI in a group of patients with ischemia and no MR to compare with patients with ischemic MR. Pasque and associates used MRI-based multiparametric strain data calculated from 15,300 grid points per patient in normal volunteers and in ischemic patients with and without MR [3Lancaster T.S. Kar J. Cupps B.P. et al.Topographic mapping of left ventricular regional contractile injury in ischemic mitral regurgitation.J Thorac Cardiovasc Surg. 2017; 154: 149-158.e1Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar]. They showed that ischemic MR is caused by dysfunction of the subpapillary ventricular wall and that the free ventricular wall segments outside the subpapillary regions showed the same strain patterns in ischemic MR patients and in ischemic patients without MR. The relationships between nonviability, functional recovery, and response to surgical intervention for ischemic MR are not yet clear. What is needed now are studies comparing these types of preoperative measurements in patients with ischemic MR with similar postoperative measurements on the same patients that might clarify the preoperative parameters that are truly capable of predicting postoperative outcomes. Perhaps we would then have a better understanding of precisely how to treat ischemic MR in individual patients. Ischemic Mitral Regurgitation: Abnormal Strain Overestimates Nonviable MyocardiumThe Annals of Thoracic SurgeryVol. 105Issue 6PreviewTherapy for moderate ischemic mitral regurgitation remains unclear. Determination of myocardial viability, a necessary prerequisite for an improvement in regional contractility, is a likely key factor in determining response to revascularization alone. Myocardial strain has been proposed as a viability measure but has not been compared with late gadolinium enhancement (LGE) cardiac magnetic resonance imaging. We hypothesized that abnormal strain overestimates nonviable left ventricular (LV) segments measured with LGE and that ischemia and mechanical tethering by adjacent transmural myocardial infarction (TMI) also decreases strain in viable segments. Full-Text PDF

A 25-year study of chordal replacement with expanded polytetrafluoroethylene in mitral valve repair†.

This study examines the outcome of mitral valve repair with chordal replacement using expanded polytetrafluoroethylene over the past 25 years. From July 1988 to February 2013, 224 consecutive patients (mean age 57 years, 34% women) underwent mitral valve repair with chordal replacement using expanded polytetrafluoroethylene sutures at our institution. Isolated anterior leaflet prolapse was observed in 134 patients (60%), isolated posterior leaflet prolapse was observed in 13 patients (6%) and bileaflet prolapse was observed in 77 patients (34%). The number of replaced artificial chordae ranged from 2 to 12 (mean 3.7) per patient. Transthoracic echocardiography was performed pre- and postoperatively and in the follow-up period. The follow-up period ranged from 0.3 to 25.3 years (mean 7.4, median 6.2). There was 1 early death and 15 late deaths, of which 7 were cardiac related. The actuarial survival rates at 10 and 20 years were 92 and 81%, respectively. Thirty-three patients (15%) developed recurrent moderate or severe mitral regurgitation during the follow-up period and 30 patients (13%) required reoperation on the mitral valve. Rates of freedom from reoperation and freedom from recurrent moderate or severe mitral regurgitation were 84 and 82% at 10 years, and 74 and 59% at 20 years, respectively. Multivariate analysis revealed that the independent predictors of recurrent mitral regurgitation were mitral valve repair without annuloplasty ring and greater than mild postoperative mitral regurgitation; and the independent predictors of mitral reoperation were previous cardiac surgery and greater than mild postoperative mitral regurgitation. Histopathological analysis of the expanded polytetrafluoroethylene sutures removed during reoperation revealed complete endothelialization without calcification or microthrombi. Our 25-year follow-up demonstrated reliable long-term outcomes of chordal replacement with expanded polytetrafluoroethylene sutures.

TCT-705 Tethering Area is an Important Predictor of Recurrent Mitral Regurgitation Following the MitraClip Procedure

TCT-705 Tethering Area is an Important Predictor of Recurrent Mitral Regurgitation Following the MitraClip Procedure

CARDIAC SURGERY Clinical and echocardiographic predictors of recurrent mitral regurgitation following restrictive mitral annuloplasty. Evaluation in patients with chronic ischemic mitral regurgitation

Aim of the study: The aim of this study was to determine the clinical and echocardiographic predictors of recurrent mitral regurgitation after undersized ring implantation for ischemic mitral regurgitation (MR). Recurrent MR occurs in up to 30% of patients after undersized ring implantation. Understanding the causes of recurrent MR should improve the results of this kind of surgery. Material and methods: The pre- and postoperative echocardiograms of 134 patients operated on for ischemic mitral regurgitation using ring implantation were analyzed. The median follow-up period was 13 months. Results: The strongest influence on MR recurrence was exerted by coaptation length (OR 0.022; p = 0.001), effective regurgitant orifice area (EROA) (OR 1.85; p < 0.002), and vena contracta measured preoperatively (OR 1.42; p = 0.007). The independent predictors of recurrent MR included: the postoperative length of leaflet coaptation, preoperative left ventricular ejection fraction, the severity of regurgitation, and body surface area (BSA). The coaptation length cut-off value of < 6.2 mm was associated with 94% sensitivity and 85% specificity in the prediction of recurrent MR. Conclusions: This study showed that the recurrence of MR after undersized mitral ring implantation is low. The measure of coaptation length is superior to other echocardiographic parameters in the prediction of MR recurrence. Our model of risk stratification may predict mitral valve repair failure after restrictive annuloplasty.

Editorial Comment: Mitral repair for functional mitral regurgitation in idiopathic dilated cardiomyopathy: a good operation done well may help

In this issue, De Bonis et al. [1] described a very interesting retrospective series of 54 patients with idiopathic dilated cardiomyopathy who underwent mitral valve repair for severe functional mitral regurgitation. No patients had coronary artery disease. These patients, very typically, had severe mitral regurgitation, class III–IV New York Heart Association failure with large ventricles, poor ejection fractions, and many had atrial fibrillation and tricuspid regurgitation. In this series, as has been shown by others, the patients underwent correction of their mitral regurgitation with low in-hospital mortality (5%). The actuarial survival at 6.5 years was 70%. The survival was further improved if the patients had either atrial fibrillation ablation or cardiac resynchronization therapy. In follow-up, patients showed improvement in their left ventricular geometry, ejection fraction and in NYHA class. Most importantly, in this series, the freedom from recurrence of significant mitral regurgitation was 90% at 6.5 years. Functional mitral regurgitation is a complication of idiopathic dilated cardiomyopathy, occurring secondary to left ventricle geometrical distortion from stenting, inferobasilar migration, apical displacement, annular dilation and posterior leaflet restriction, with altered ventricular shape and/or regional LV wall dysfunction. Mitral regurgitation (MR) leads to a vicious cycle of LV volume overload, geometric distortion and progressive MR. MR complicating congestive heart failure (CHF) predicts poor survival [2]. Mitral reconstruction surgery to treat MR in dilated cardiomyopathy has been undertaken with an acceptably low operative mortality [3, 4]. However, MR surgery for these patients remains controversial, as substantial residual or recurrent MR has been noted, and may mitigate any benefits. In fact, some series show an early (6 months) recurrence rate of significant MR of up to 50%, which certainly negatively influences or obscures potential survival advantage [5, 6]. When reviewing literature series of both surgical and percutaneous outcome studies on patients with MR in dilated idiopathic cardiomyopathy, one should be critically aware of the negative impact, mechanism and rates of recurrent MR. At present, many of the mechanisms of recurrent functional MR have been elucidated and include annular level and subvalvular components. Predictors of recurrent MR have included LV size >65 mm, a coaptation depth of >1 cm below the annular plane and angulation of the mitral valve apparatus, all of which indicate a degree of LV distortion [6]. We have also learned that the intertrigonal distance is not stable, with dilatation occurring along both the insertion of the posterior leaflet, but also in the anterior portion. This intertrigonal portion dilates and, although at one time, was considered to be a stable ‘measurable’ standard by which to size annuloplasty rings, we now know from a landmark paper of Hueb et al. [7] that this is not the case. Therefore, our previous method of sizing was incorrect and ‘undersizing’ rings has become the standard for these functional MR patients. This may partly explain the operation ‘failing’ and recurrence of mitral regurgitation in functional MR patients when using too large ‘standard-sized’ rings or when using a partial or flexible rings. Perhaps, the most important mechanistic predictor of recurrent mitral regurgitation is an increased anterior–posterior or septal– lateral mitral annular diameter. This CHF-related change has been shown not only in animal models, but also in humans. Three-dimensional magnetic resonance imaging and echo studies showed that the mitral annulus flattens and significantly increases its anterior-posterior (AP) diameter. Kongsaerepong et al. [8] found that the strongest predictor of a recurrent MR, following mitral repair, was a residual large AP diameter, i.e. a ‘too large’ ring size. Finally, Spoor et al. [9] demonstrated that the use of flexible rings (which flex and allow the largest AP diameter) as opposed to a rigid complete ring was associated with a five times higher recurrent mitral regurgitation rate. At present, numerous rigid, complete rings with stable AP dimension reduction are available [10]. In this present series, all patients were uniformly treated with an undersized rigid complete ring. The authors noted an extremely low long-term rate of recurrent MR, with excellent LV remodelling and survival. The use of a rigid complete ring has been adopted for these functional MR patients by a majority of surgeons and is becoming our best practice standard. Of course, many factors in these difficult patients determine the long-term outcome including patient comorbidities, some of which (atrial fibrillation, tricuspid regurgitation, cardiac resynchronization therapy) have been shown by these authors to be beneficial when corrected. In dealing with functional MR in idiopathic cardiomyopathy, it has been noted that a good operation when done poorly will not help; however, the manuscript by De Bonis et al. reveals that a good operation done well will help these functional MR patients.

Baseline left ventricular function and surgical annular stiffening to predict outcome and reverse left ventricular remodeling after undersized annuloplasty for intermediate-degree ischemic mitral regurgitation

We sought to identify determinants of clinical and functional outcome after myocardial revascularization and associated undersized annuloplasty in patients with intermediate-degree ischemic mitral regurgitation. Fifty-seven patients with 2+ or 3+ ischemic mitral regurgitation underwent coronary bypass surgery and implantation of undersized semirigid or flexible complete ring or autologous pericardial band and were followed up to 8.6 years. Operative mortality was 5%. Baseline left ventricular end-systolic volume index, the strongest multivariable predictor of early postoperative outcome, was correlated with end-systolic volume index (P < .001, R(2) = 0.67) and ejection fraction (P < .001, R(2) = 0.40) after repair. More compromised ejection fraction and end-systolic volume index predicted comparatively greater early functional improvement but higher residual postoperative end-systolic volume index (P < .01). Cox multivariable analysis identified wall motion as the best baseline predictor of late death and heart failure and regional inferoposterior wall motion as the strongest predictor of recurrent mitral regurgitation (P < or = .01). More rigid annuloplasty carried a higher probability of functional recovery in terms of ejection fraction, wall motion, and the occurrence and earlier timing of left ventricular reverse remodeling, expressed by different degrees of end-systolic volume index reduction (P < .001, hazard ratio >6). Combination of undersized mitral annuloplasty and coronary revascularization presents low operative mortality and determines left ventricular unloading in patients with intermediate-degree ischemic mitral regurgitation. Global and regional wall motion are powerful predictors of late outcome. Stiffer mitral annular repair promotes functional recovery and predicts higher probability and earlier timing of reverse remodeling.

Progression of mitral regurgitation following ischemic mitral valve repair

Durability of mitral valve repair for ischemic mitral regurgitation remains questionable. The aim of our study was to reveal predictors of recurrent mitral regurgitation following ischemic mitral valve repair. The study population consisted of 136 patients with ischemic heart disease and ischemic mitral regurgitation. Mitral valve repair was performed at the Kaunas University of Medicine Hospital in 2000-2004. Preoperative echocardiographic examinations were performed two days before surgery, early postoperative examinations 5-10 days after mitral valve repair, late postoperative examinations at 1.89+/-0.15 years after operation. Mitral regurgitation increased from 0.78+/-0.77 at early period to 1.46+/-0.81 at late postoperative period (P<0.001). At late follow-up mitral regurgitation increased in 13 (9.5%) patients in comparison with preoperative mitral regurgitation and in 69 (50.7%) patients in comparison with early postoperative mitral regurgitation. Left ventricular end-diastolic diameter decreased significantly from 56.44+/-6.29 mm at early period to 54.44+/-5.98 mm at late period (P<0.004). Left ventricular ejection fraction increased from 35+/-10% at early period to 38+/-10% at late period (P<0.047). Left atrial diameter decreased from 46.12+/-6.35 mm at early period to 43.95+/-6.94 mm at late period (P<0.034). Multivariate analysis revealed predictors of late postoperative mitral regurgitation: preoperative left ventricular end-systolic diameter index (P=0.037), left ventricular wall motion score index (P=0.042), mitral regurgitation (P=0.013), and systolic pulmonary artery pressure (P=0.04). It is possible to predict the progression of mitral regurgitation following ischemic mitral valve repair. Late postoperative mitral regurgitation depends on these preoperative echocardiographic variables: left ventricular end-systolic diameter index, left ventricular wall motion score index, mitral regurgitation, and systolic pulmonary artery pressure.