Proportionate Mitral Regurgitation Research Articles

Paradox of disproportionate atrial functional mitral regurgitation and survival after transcatheter edge-to-edge repair.

This study aims to assess the applicability of the mitral regurgitation (MR) proportionality concept in patients with atrial functional mitral regurgitation (aFMR) treated with transcatheter edge-to-edge repair (M-TEER). We hypothesized that patients with disproportionate MR (higher MR relative to left ventricular size) would exhibit different outcomes compared to those with proportionate MR, despite undergoing M-TEER. We retrospectively analysed 98 patients with aFMR from the EuroSMR registry who underwent M-TEER between 2008 and 2019. Patients met criteria for aFMR (normal indexed left ventricular end-diastolic volume [LVEDV], preserved left ventricular ejection fraction [LVEF]≥50% without regional wall motion abnormalities, and structurally normal mitral valves). We excluded patients with missing effective regurgitant orifice area (EROA) or LVEDV data. The primary endpoint was 2-year mortality, with an EROA/LVEDV ratio employed to differentiate disproportionate from proportionate MR. Procedural success and baseline characteristics were analysed, and multivariate Cox proportional hazards models were used to identify mortality predictors. The mean patient age was 79±7.3years, with 68.8% female, and 79% had a history of atrial fibrillation. The mean EROA was 0.27±0.14cm2, and LVEDV was 95.6±33.7mL. Disproportionate MR was identified with an EROA/LVEDV ratio >0.339cm2/100mL. While procedural success was similar in both groups, disproportionate MR was associated with a numerically higher estimate of systolic pulmonary artery pressures (sPAP) and rates of NYHA ≥III and TR≥3+. Disproportionate MR had a significant association with increased 2-year mortality (P<0.001). The EROA/LVEDV ratio and tricuspid annular plane systolic excursion (TAPSE) were independent predictors of 2-year mortality (EROA/LVEDV: HR: 1.35, P=0.010; TAPSE: HR: 0.85, P=0.020). This analysis introduces the MR proportionality concept in aFMR patients and its potential prognostic value. Paradoxically, disproportionate MR in aFMR was linked to a 1.35-fold increase in 2-year mortality post-M-TEER, emphasizing the importance of accurate preprocedural FMR characterization. Our findings in patients with disproportionate MR indicate that a high degree of aFMR with high regurgitant volumes may lead to aggravated symptoms, which is a known contributor to increased mortality following M-TEER. These results underline the need for further research into the pathophysiology of aFMR to inform potential preventative and therapeutic strategies, ensuring optimal patient outcomes.

Mitral Regurgitation “Proportionality” in Functional Mitral Regurgitation and Outcomes After Mitral Valve Transcatheter Edge-to-Edge Repair: A Systematic Review and Meta-Analysis

BackgroundCertain patients with functional mitral regurgitation survive longer with fewer heart failure hospitalizations after undergoing transcatheter edge-to-edge repair (TEER); however, clinical markers identifying who will benefit have not been established. The ‘proportionality’ of mitral regurgitation (MR) severity compared to left ventricular size has been hypothesized to predict clinical outcome. MethodsWe sought to combine existing studies to compare outcomes between ‘proportionate’ MR and ‘disproportionate’ MR in patients undergoing TEER. PubMed and Medline were searched from January 2018 until May 2023. Data was extracted and synthesized by 2 independent authors using random effects models with risk ratios (RRs) for binary outcomes. The primary outcome was a combined endpoint of all-cause mortality or heart failure hospitalization (ACM/HFH). Other outcomes of interest included ACM and residual >2+ MR after TEER. ResultsSix trials with a total of 1594 patients (mean age 71 years, 66% male) were included, which assessed MR proportionality using either a ratio of estimated regurgitant orifice area to left ventricular end-diastolic volume (EROA:LVEDV) or regurgitant fraction. Seven hundred and five (mean age 70 years, 75% male) were classified as proportionate MR, and 889 (mean age 72 years, 60% male) had disproportionate MR. There was no significant association between MR proportionality (by EROA:LVEDV) and ACM (RR 0.79, 95% confidence interval [CI] 0.44-1.42). Proportionality did not significantly associate with ACM/HFH, though there were divergent effect signals when proportionality was measured by EROA:LVEDV (RR 0.80, 95% CI 0.45-1.44) or regurgitant fraction (RR 1.48, 95% CI 0.53-4.11). Disproportionate MR showed a greater association with residual MR > 2+ post-TEER that did not meet statistical significance (RR 1.86, 95% CI 0.77-4.49). ConclusionsIn patients undergoing TEER for functional mitral regurgitation, MR proportionality was not significantly associated with ACM/HFH, all-cause mortality, or residual MR.

Challenges and pitfalls in classification of disproportionate mitral regurgitation.

The concept of disproportionate mitral regurgitation (dispropMR) has been introduced to identify patients with functional mitral regurgitation (MR) who benefit from percutaneous treatment. We aimed to examine echocardiographic characteristics behind this entity. We retrospectively included 172 consecutive patients with reduced left ventricular ejection fraction (LVEF), and more than mild MR referred to clinically indicated echocardiography. According to the proportionality ratio (effective regurgitant orifice area (EROA)/left ventricular end-diastolic volume (LVEDV)) patients were divided into dispropMR and proportionate MR (propMR) group. Potential factors which might affect proportionality definition were analyzed. 55 patients (32%) had dispropMR. Discrepant grading of MR severity was observed when using regurgitant volume (RegVol) by proximal isovelocity surface area (PISA) method or volumetric method, with significant discordance only in dispropMR (p < 0.001). Patients with dispropMR had more frequently left ventricular foreshortened images for LVEDV calculation than patients with propMR (p = 0.003), resulting in smaller LVEDV in dispropMR group. DispropMR group had more substantial dynamic variation of regurgitant flow compared to propMR. Accordingly, EROA was consistently overestimated by standard single-point PISA method compared to serial PISA method. This was more pronounced in dispropMR (bias:10.5 ± 28.3 mm2) compared to propMR group (bias:6.4 ± 12.8 mm2). DispropMR may be found in roughly one third of clinically indicated echocardiographic studies in patients with reduced LVEF and more than mild MR. EROA overestimation due to dynamic variation of regurgitant flow and LVEDV underestimation due to LV foreshortening were more frequently found in dispropMR. Our results indicate that methodological limitations of echocardiographic MR grading could not be neglected in classifying the proportionality of MR.

Impact of proportionate versus disproportionate mitral regurgitation on acute procedural changes and clinical outcomes following transcatheter mitral valve repair

Abstract Background Transcatheter mitral edge-to-edge repair (TEER) with MitraClip offers a less invasive alternative for patients with severe, symptomatic mitral regurgitation (MR) who are considered high risk for surgery. However, patient selection for TEER remains challenging given the variability in underlying MR pathology and current discordance among studies regarding predictors of procedural efficacy and clinical outcomes. Purpose This study aimed to assess acute procedural changes and long-term outcomes in patients who underwent TEER according to the proportionality of MR, defined as the ratio of the effective regurgitant orifice area (EROA) and left ventricular end-diastolic volume (LVEDV). Methods We analyzed patients who underwent TEER at our institution between 2014 and 2020 with available biplane left ventricular volume measurement. Relevant clinical comorbidities, demographics, and anthropometrics, along with pertinent pre- and post-procedural echocardiogram measurements, were obtained by review of the electronic medical record. The EROA to LVEDV index was calculated for all patients who were then stratified by quartiles. Patients with an EROA/LVEDV index in the lowest quartile were defined as having the most proportionate MR and those with an index in the highest quartile were defined as the most disproportionate MR. Baseline and post-TEER parameters were used to assess acute procedural and longitudinal outcomes. Results Baseline clinical and echocardiographic parameters of the 230 subjects according to quartile are shown in the table. Following TEER, there was a larger reduction in the left ventricular end-diastolic diameter and increased MR reduction with increasingly disproportionate MR (p=0.03 and p=0.05, respectively). The change in ejection fraction pre- versus post-TEER did not significantly differ across groups (p=0.64). Median follow up time was 1.7 (0.7–3.5) years; mortality occurred in 77 patients (33.5%) and heart failure hospitalizations occurred in 20 patients (8.7%) during follow up. No significant difference in all-cause mortality or post-procedural heart failure hospitalizations was identified across groups. Conclusions In our series, patients with proportionate MR were similarly symptomatic to those with disproportionate MR but had less severe MR with increased comorbidities. Post-TEER MR grade was similar between groups. Longer-term follow up in larger groups of patients is needed to determine the clinical implications. Funding Acknowledgement Type of funding sources: None.

Determinants and prognostic impact of afterload mismatch after MitraClip implantation

Abstract Introduction Mitral transcatheter edge-to-edge repair (TEER) is a widespread option to treat mitral regurgitation in high-risk patients. The sudden reduction of mitral regurgitation (MR) following TEER abruptly eliminates the low-impedance regurgitant flow into the left atrium, leading to an increase in left ventricle (LV) afterload with possible impairment of LV systolic function, defined afterload mismatch (AM). Purpose To explore a new definition of AM and to analyze the determinants and prognostic role of AM in patients with functional MR (FMR) undergoing TEER. Methods This was an international multicenter case-control study including adult patients with severe FMR and LVEF ≤35% undergoing TEER between 2012 and 2020. AM was defined as the acute need to initiate or increase inotropic support by a vasoactive inotropic score ≥3 or the need for a mechanical circulatory support following TEER. Results 80 patients with AM were compared to 80 consecutive patients undergoing TEER not meeting the criteria for AM. Median age was 67 years, 79% of patients were male, had a median LVEDV of 240 ml with severely reduced LVEF (median 26%) and pulmonary hypertension (median 48 mmHg). Median EROA/LVEDV ratio was 0.17 (IQR 0.12–0.24) based on which 37% of the total population presented with proportionate MR. Levosimendan was administered before TEER in 42% of patients while intravenous vasodilators in 43%. In most patients more than 1 clip were needed (2 clips in 88 patients, 3 clips in 11). Patients presenting AM more commonly had a lower EROA/LVEDV ratio (0.14 vs. 0.18, p&amp;lt;0.001) leading to a higher percentage of patients with proportionate MR (55% vs. 22%, p&amp;lt;0.001; Figure 1) and had more clips implanted (p=0.008). AM was graded as mild in 74% of patients, moderate in 15% and severe in 11%. At multivariate analysis, patients with proportionate MR were more likely to develop AM after TEER (OR 2.95, 95% CI: 1.32–6.60, p=0.008), while those treated with levosimendan (OR 0.32, 95% CI: 0.15–0.71, p=0.005) and/or IV vasodilators (OR 0.44, 95% CI: 0.21–0.96, p=0.040) before TEER were less likely to suffer from AM. In-hospital death occurred in 7 cases, all being part of AM group. Patients were more likely to die in-hospital if AM was more severe (OR 2.56, 95% CI: 1.19–5.54, p=0.017), and for higher grades of residual MR (OR 3.35, 95% CI: 1.27–8.79, p=0.014). The 2-year survival rate did not differ significantly between groups (66% vs 75%, HR 1.51, 95% CI: 0.73–3.12, p=0.270; Figure 2). At 2 years 51 patients (32%) were re-hospitalized for HF, independently from post-procedural AM (HR 1.36, 95% CI: 0.70–2.67, p=0.363). Conclusions In patients with LVEF ≤35% and severe FMR undergoing TEER, the development of AM predicted in-hospital mortality, while long-term outcomes were not affected by acute AM. The use of levosimendan or intravenous vasodilators during the pre-procedural phase reduced the risk of acute AM. Funding Acknowledgement Type of funding sources: None.

608 The VCX Index: a novel haemodynamic quantification of mitral regurgitation

Abstract Percutaneous edge-to-edge mitral valve (MV) repair is extensively used in different pathological MV conditions. Randomized controlled trials have evaluated the role of this technique in both primary (organic) and secondary (functional) mitral regurgitation (MR). Furthermore, recent analyses of these studies have shown the relevance of echocardiographic patient selection in the functional setting of MR, differentiating proportionate MR from disproportionate MR according to the degree of the effective regurgitant orifice area (EROA) related to the left ventricular volume. The haemodynamic impact of MR cannot be univocally measured by echocardiography alone and the aim of our study was to determine how invasive LAP monitoring during percutaneous edge-to-edge MV repair can predict long-term procedural success on top of the echocardiographic assessment by introducing the VCX INDEX and identifying haemodynamic variables with direct influence on filling pressures. The VCX INDEX, reflecting the impact of MR, is calculated by dividing the difference between v wave (ventricular systole in the left atrial pressure, LAP, or in the pulmonary capillary wedge pressure, PCWP, waveform) and the mean minimum LAP or mean minimum PCWP (mean between minimum LAP or minimum PCWP, x wave, and a/c wave) by systolic arterial pressure (SAP): (v wave – mean minimum LAP or mean minimum PCWP)/SAP. 85 patients at our centres underwent invasive intracardiac pressure monitoring either measuring LAP during percutaneous edge-to-edge MV repair or PCWP during right heart catheterization. Median VCX INDEX was 0.1 (Q1 0.05, Q3 0.16). The study population was further analysed according to the echocardiographic aetiology of MR: in the organic MR subgroup median VCX INDEX was 0.08 (Q1 0.05, Q3 0.14), in the functional proportionate MR subgroup median VCX INDEX was 0.07 (Q1 0.03, Q3 0.13) and in the functional disproportionate MR subgroup median VCX INDEX was 0.11 (Q1 0.06, Q3 0.19). 20 patients were deemed inoperable by the Heart Team and no further intervention was performed, while 65 patients underwent percutaneous edge-to-edge MV repair with MitraClip device and VCX INDEX was recalculated after the procedure. Median post-MitraClip VCX INDEX was 0.04 (Q1 0.02, Q3 0.07) and a subanalysis based on the echocardiographic MR aetiology was repeated: median post-MitraClip VCX INDEX was 0.02 in the organic MR subgroup (Q1 0.01, Q3 0.05), 0.03 in the functional proportionate MR subgroup (Q1 0.02, Q3 0.07) and 0.05 in the functional disproportionate MR subgroup (Q1 0.03, Q3 0.07). Median VCX INDEX in patients who did not undergo MitraClip implantation was 0.07 (Q1 0.04, Q3 0.12). The variation of VCX INDEX when comparing pre- and post-procedural invasive pressure assessment gives an insight of MitraClip’s favourable haemodynamic effect in terms of VCX INDEX reduction in the treated subgroup of the study and how the intervention has a comparable haemodynamic impact between different echocardiographic MR aetiologies. Further studies are needed to explore the incremental diagnostic role in the decision-making process as well as the prognostic value of the VCX INDEX in patients undergoing percutaneous edge-to-edge MV repair.

Disproportionate mitral regurgitation is associated with survival in acute heart failure with moderate range ejection fraction

Abstract Background In acute heart failure (AHF) with moderate-range ejection fraction (HFmrEF) the effect of mitral regurgitation (MR) is uncertain. Methods 103/440 consecutive patients in AHF had HFmrEF. They underwent bedside echocardiography within 24 hours of recruitment, prior to offloading, and were followed up for 2 years. The endpoint was all-cause mortality at 2 years. A novel proportionality index - where the effective regurgitant orifice is divided by the left ventricular end-diastolic volume (ERO/LVEDV)) - identified HFmrEF patients with disproportionate MR. Results 103/440 (23.4%) patients had HFmrEF with an average EF of 44.6±2.6%. 54.4% were male, with an average age of 80.5±11.4. 47.6% had a previous diagnosis of hypertension, 28.2% diabetes and 10.7% cerebrovascular disease. Patients did not present in shock, with average systolic/diastolic blood pressures of 141.7±26.2mmHg/ 78.5±19.3mmHg, nor did they primarily present with severe infections with mean CRP of 23.2±31.7. BNP at presentation was 1179.8±1028.5ng/L. Every patient had MR, 78/103 (75.7%) had MR quantifiable by PISA. 54/78 (69.2%) had disproportionate MR, defined by an ERO/LVEDV &amp;gt;0.14mm2/ml. When compared to proportionate MR, disproportionate MR in HFmrEF was associated with: greater LVEDV (136.3±53.6ml vs. 103.3±39.7ml [p=0.018]), greater mitral regurgitant volumes (41.8±18.5ml vs. 21.5±12.5ml [p&amp;lt;0.001]) and systolic pulmonary artery pressures (60.2±21.0mmHg vs. 48.0±14.7mmHg [p=0.012]) but not left-atrial size (30.2±7.1mm2 vs. 30.2±7.8mm2 [p=0.915]). Disproportionate MR in HFmrEF was also associated with worse 2-year outcome than proportionate MR – 40.1% vs. 16.7% (HR 2.30; 95% CI 1.02–5.17 [p=0.045]. Conclusion This is the first assessment of the effect of disproportionate volume loading secondary to MR in patients presenting in AHF with HFmrEF. Disproportionate MR was associated with worse outcome at 2 years. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Abbott

Disproportionate mitral regurgitation as a predictor of functional outcomes following edge-to-edge repair with the MitraClip system

Abstract Aims The concept of disproportionate mitral regurgitation (MR) was recently from the analysis of the results of two large randomized trials that compared edge-to-edge repair with the MitraClip system and optimal medical treatment alone in a cohort of patients with functional MR and reduced left ventricular (LV) function. Patients with disproportionate MR were defined as having higher degrees of MR, measured with the effective regurgitant orifice area (EROA), than expected with respect to the amount of LV enlargement, as measured using the enddiastolic volume (EDV). Interestingly, disproportionate MR patients were found to benefit more pronounced from an interventional mitral valve repair than those with proportionate MR with respect to the risk of death and hospitalization for heart failure, and these benefits were paralleled by a relevant decrease in LVEDV. In our study we tested this concept, that was derived from the very controlled setting of a randomized trial, in a “real world” retrospective analysis. Methods and results 137 patients (mean age 78.4±7, log. EuroScore 24.5±13.8%) with symptomatic functional mitral regurgitation (MR) undergoing MitraClip procedure were included and followed for 6±2 months. All patients were highly symptomatic (NYHA functional class 3 or 4: 94.9%, NT-proBNP 6645.5±7517.8 pg/ml). At baseline left ventricular ejection fraction (LVEF) was 34.4±10% with an EDV of 155.8±66.5 ml. When dividing groups following the proposed concept, we found 46.7% of patients having disproportionate MR with larger EDV (167.2±61.4 ml, 137.6±70.8 ml, p=0.026) and not different EROA values (0.45±0.13 cm2, 0.44±0.21 cm2, p=0.59) compared to patients with proportionate MR. When analyzing clinical outcomes after 6 months, we found no difference in mortality (p=0.5) and rehospitalizations for heart failure (p=0.7). Patients in both groups significantly improved in functional NYHA class at discharge (p&amp;lt;0.001, p=0.02, respectively). Of note, in patients with disproportionate MR NYHA class amelioration was sustained even after 6 months of follow up (p=0.4), whereas in patients with proportionate MR NYHA class was significantly worsened (p=0.04) after 6 months compared to evaluation at discharge. Conclusions We found no difference in mortality or rehospitalizations for heart failure when retrospectively analyzing our patient cohort divided in patients with proportionate and disproportionate MR. Both groups improved directly after MitraClip with respect to functional NYHA class, but only in patients with disproportionate MR this effect was sustained over the period of 6 months follow up. Patients with proportionate MR significantly worsened with respect to functional NYHA class 6 months after MitraClip and this effect is surely prone to lead to a higher rehospitalization rate when expanding follow up time to 12 months or more. Funding Acknowledgement Type of funding sources: Private hospital(s). Main funding source(s): Elisabeth Krankenhaus Essen

Mitral regurgitation: lessons learned from COAPT and MITRA-Fr.

Recent studies about percutaneous treatment of secondary mitral regurgitation (MR) underlined the importance of left ventricular geometry and features of mitral valve as determinants of procedural and long-term success. Guideline-directed medical therapy (GDMT), transcatheter mitral valve treatment (TMVT) and surgical procedures (mitral valve replacement, mitral valve repair at level of the annulus or subvalvular apparatus) have been extensively evaluated but not adequately compared in current clinical studies. A detailed analysis of the results of the study about transcatheter mitral valve repair would allow to evaluate the safety and effectiveness of such procedure and would provide potential indications for improving the quality of percutaneous and surgical repair in patients with moderate-to-severe secondary MR. Patients with proportionate MR (i.e., MR severity is proportional to the amount of left ventricular dilatation) are prone to respond to the optimization of medical therapy, while patients with disproportionate MR (i.e., MR severity is disproportionately higher than predicted by left ventricular dilatation, with high EROA and small left ventricle) are likely to benefit from additional repair. The identification of specific subpopulation of "high responders", based on the anatomic characteristics of the mitral valve and the relative dimensions of the annulus, the regurgitation and the left ventricle, can also apply to medical therapy. However, some pivotal component of MR (such as the symmetry of tethering and the differences in biomechanical features of leaflets) are not adequately investigated in current studies and warrant further evaluation.

New Evidence Supporting a Novel Conceptual Framework for Distinguishing Proportionate and Disproportionate Functional Mitral Regurgitation

ImportanceTraditionally, physicians distinguished between mitral regurgitation (MR) as a determinant of outcomes and MR as a biomarker of left-ventricular (LV) dysfunction by designating the lesions as primary or secondary, respectively. In primary MR, leaflet abnormalities cause the MR, resulting in modest increases in LV end-diastolic volume over time, whereas in patients with classic secondary MR, LV dysfunction and dilatation lead to MR without structural leaflet abnormalities. However, certain patients with global LV disease (eg, those with left bundle branch block or regional wall motion abnormalities) have the features of primary MR and might respond favorably to interventions that aim to restore the proper functioning of the mitral valve apparatus.ObservationsA novel conceptual framework is proposed, which classifies patients with meaningful LV disease based on whether the severity of MR is proportionate or disproportionate to the LV end-diastolic volume. Treatments that reduce LV volumes (eg, neurohormonal antagonists) are effective in proportionate MR but not disproportionate MR. Conversely, procedures that restore mitral valve function (eg, cardiac resynchronization and mitral valve repair) are effective in patients with disproportionate MR but not in those with proportionate MR. The proposed framework explains the discordant findings in the Multicentre Randomized Study of Percutaneous Mitral Valve Repair MitraClip Device in Patients With Severe Secondary Mitral Regurgitation (MITRA-FR) and the Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation (COAPT) trials; differences in procedural success and medical therapy in the 2 studies cannot explain the different results. In addition, the small group of patients in the COAPT trial who had the features of proportionate MR and were similar to those enrolled in the MITRA-FR trial did not respond favorably to transcatheter mitral valve repair.Conclusions and RelevanceThe characterization of patients with functional MR into proportionate and disproportionate subtypes may explain the diverse range of responses to drug and device interventions that have been observed.

424 Left ventricular function after correction of a proportionate mitral regurgitation: impact of the clipping approach

Abstract Aims : Secondary mitral regurgitation (MR) is associated with poor outcome in systolic heart failure (HF-)patients. Percutaneous edge-to-edge mitral valve repair (PMVR) recently failed to prove any beneficial effect over optimal medical treatment (OMT). Nevertheless, little is known about the effect of PMVR on LV performance and mechanics in HF-patients with severe secondary MR. Method and results Thirty-seven patients with severe secondary MR treated by PMVR were included and compared (according to indices of LV myocardial function) to nineteen patients with treated by OMT. Both groups were clinically comparable. At 6-month follow-up, only LV constructive work improve significantly in both groups (977 vs 1101 mmHg.%, p =0,003, 967 vs 1110 mmHg.%, p = 0,002 for PMVR and OMT groups, respectively) whereas left ventricular (LV) end-systolic volume index, LV ejection fraction and global longitudinal strain were not different. Compared to MITRA-FR and COAPT studies, our population had a proportionate MR (blue point in Figure 1, panel A). Figure 1-panel B demonstrate that only five patients of PMVR group had disproportionate MR (red points). Interestingly, these patients hadn’t any major event during 6 months FU. Conclusion Echocardiographic characteristics at 6-month follow-up are not different when compare PMVR and OMT for HF- patients with a severe proportionate secondary MR. Main echocardiographic characteristics PMVR OMT Inclusion 6-month p Inclusion 6-month p NYHA 2.6 ± 0.6* 1.8 ± 0.7* &amp;lt;0.0001 2.3 ± 0.5* 2.2 ± 0.4* 0.43 LVESVi(ml.m-2) 76 ± 36 75 ± 35 0.6 94 ± 32 90 ± 31 0.35 LVEF (%) 33 ± 6 33 ± 13 0.78 30 ± 8 31 ± 8 0.53 GLS (%) -9.8 ± 4 -9.9 ± 3.9 0.84 -10.0 ± 4 -10.3 ± 3.3 0.62 MR grade 3.4 ± 0.5 1.3 ± 1.0* &amp;lt;0.0001 3.5 ± 0.5 2.8 ± 1.1* 0.007 Global work index (mmHg.%) 831 ± 370 933 ± 406 0.07 875 ± 314 939 ± 304 0.14 Constructive work (mmHg.%) 977 ± 366 1101 ± 404 0.003 967 ± 290 1110 ± 349 0.002 *symbols denote p &amp;lt; 0.05 between both groups Abstract 424 Figure.

Left ventricular function after correction of a proportionate mitral regurgitation: Impact of the clipping approach

Secondary mitral regurgitation (MR) is associated with poor outcome in systolic heart failure (HF-) patients. Percutaneous edge-to-edge mitral valve repair (PMVR) recently failed to prove any beneficial effect over optimal medical treatment (OMT). Nevertheless, little is known about the effect of PMVR on LV performance and mechanics in HF-patients with severe secondary MR. Thirty-seven patients with severe secondary MR treated by PMVR were included and compared (according to indices of LV myocardial function) to nineteen patients with treated by OMT. Both groups were clinically comparable. At 6-month follow-up, only LV constructive work improve significantly in both groups (977 vs. 1101 mmHg%, P = 0,003, 967 vs. 1110 mmHg%, P = 0,002 for PMVR and OMT groups, respectively) whereas left ventricular (LV) end-systolic volume index, LV ejection fraction and global longitudinal strain were not different. Compared to MITRA-FR and COAPT studies, our population had a proportionate MR (blue point in Fig. 1 , panel A). Fig. 1 , panel B demonstrate that only five patients of PMVR group had disproportionate MR. Interestingly, these patients hadn’t any major event during 6 months FU ( Table 1 ). Echocardiographic characteristics at 6-month follow-up are not different when compare PMVR and OMT for HF- patients with a severe proportionate secondary MR.

Contrasting Effects of Pharmacological, Procedural, and Surgical Interventions on Proportionate and Disproportionate Functional Mitral Regurgitation in Chronic Heart Failure.

Two distinct pathways can lead to functional mitral regurgitation (MR) in patients with chronic heart failure and a reduced ejection fraction. When remodeling and enlargement of the left ventricle (LV) cause annular dilatation and tethering of the mitral valve leaflets, there is a linear relationship between LV end-diastolic volume and the effective regurgitant orifice area of the mitral valve. These patients, designated as having proportionate MR, respond favorably to treatments that lead to reversal of LV remodeling and a decrease in LV volumes (eg, neurohormonal antagonists and LV assist devices), but they may not benefit from interventions that are directed only at the mitral valve leaflets (eg, transcatheter mitral valve repair). In contrast, when ventricular dyssynchrony causes functional MR attributable to unequal contraction of the papillary muscles, the magnitude of regurgitation is greater than that predicted by LV volumes. These patients, designated as having severe but disproportionate MR, respond favorably to treatments that are directed to the mitral valve leaflets or their supporting structures (eg, cardiac resynchronization or transcatheter mitral valve repair), but they may derive little benefit from interventions that act only to reduce LV cavity size (eg, pharmacological treatments). This novel conceptual framework reflects the important interplay between LV geometry and mitral valve function in determining the clinical presentation of patients, and it allows characterization of the determinants of functional MR to guide the most appropriate therapy in the clinical setting.