Reduction In Mitral Regurgitation Severity Research Articles

The prognostic value of changes in pulmonary vein flow patterns after surgical repair for primary mitral regurgitation

Background: The pulmonary vein (PV) flow pattern is influenced by the presence of mitral regurgitation (MR). After a successful reduction in MR severity, the pattern is expected to be changed. We aimed to evaluate the prognostic value of a change in the PV flow pattern in patients with primary MR undergoing mitral valve repair (MVR). Methods: The PV flow pattern was assessed with transthoracic echocardiography in 216 patients (age 65 [IQR 56–72] years, 70% male) with primary MR before and after surgical MVR. The population was divided according to a change in the PV flow pattern following MVR into ‘improvers’ and ‘non-improvers’. Results: Non-improvers (15%) had a higher prevalence of paroxysmal AF at baseline (46% vs. 22%, p = 0.004), left ventricular dysfunction (LVEF ≤60%) (39% vs. 21%, p = 0.020), and had lower systolic pulmonary artery pressure (28[IQR 25–38] vs. 35[IQR 26–48] mmHg, p = 0.018) compared to improvers (85%). After a median follow-up of 83[IQR 43–140] months, 26(12%) patients died. Non-improvers had higher mortality rates than improvers (p = 0.009). On multivariable Cox regression analysis, a lack of improvement in the PV flow pattern remained independently associated with all-cause mortality (HR 2.322, 95% CI 1.140 to 4.729, P = 0.020). Conclusion: A lack of improvement in the PV flow pattern is independently associated with worse long-term survival in patients with primary MR undergoing MVR.

Transcatheter edge-to-edge mitral valve repair in patients with acute decompensated heart failure due to severe mitral regurgitation.

Transcatheter edge-to-edge mitral valve repair (TEER) has been established as a therapy for severe symptomatic mitral regurgitation (MR) in stable patients, and it has recently emerged as a reasonable option for acutely ill patients. The aim of this study was to evaluate the safety and efficacy of TEER in hospitalized patients with acute decompensated heart failure (ADHF) and severe MR that was deemed to play a major role in their deterioration. We included 31 patients who underwent emergent TEER for MR ≥ 3+ from 2012 to 2022 at Sheba Medical Center. Outcomes included procedural safety, procedural success, all-cause mortality, heart failure readmission, and functional improvement. Outcomes were evaluated at 3 months and at 1 year. Data were obtained retrospectively by chart review. Implantation of a TEER device was achieved in 97% of patients, and reduction in MR severity of at least two grades and final MR ≤ 2+ at discharge was achieved in 74%. No intra-procedural mortality or life-threatening complications were noted. Mortality at 30 days was 23%. No excess mortality occurred beyond 6 months, with a total mortality of 41%. At 1 year all survivors had MR ≤ 2+, all were free of heart failure hospitalizations, and 88% were at New York Heart Association class ≤ II. Mitral valve TEER for patients with ADHF and significant MR is safe, feasible, and achieves substantial reduction in MR severity. Despite high early mortality, procedural success is associated with good long-term clinical outcomes for patients surviving longer than 6 months.

Evolution of functional mitral regurgitation and left atrial function in patients receiving cardiac resynchronization therapy

Abstract Background Left atrial (LA) function is a strong prognostic marker in patients with heart failure and patients with functional mitral regurgitation (MR). Although cardiac resynchronization therapy (CRT) has shown to improve MR severity, the interaction between a reduction in MR severity and an improvement in LA function, as well as their association with outcomes, has not been investigated. Purpose To investigate the association between a reduction in MR severity and an improvement in LA function, as well as their association with outcomes. Methods LA reservoir strain (RS) was evaluated with speckle tracking echocardiography in patients with moderate and severe functional MR. MR improvement was defined as at least 1 grade improvement in MR severity at 6 months after CRT implantation. The association between MR improvement and change in LARS was evaluated using multivariable logistic regression analysis. Patients were dividing into 3 groups: MR non-improvers; MR improvers with no LARS improvement; and MR improvers with LARS improvement. The primary endpoint was all-cause mortality. Results A total of 340 patients (mean age 66±10 years, 73% male) were included, of whom 200 (59%) showed MR improvement after CRT implantation. On multivariable analysis, an improvement in MR was independently associated with an improvement in LARS (OR 1.008; 95% CI 1.003–1.013; p=0.002) (Table 1). MR improvers showing LARS improvement had the lowest mortality rate, whereas outcomes were not significantly different between MR non-improvers and MR improvers showing no LARS improvement (p=0.236) (Figure 1). Conclusion In patients with HF and significant functional MR, an improvement in MR after CRT implantation is independently associated with an improvement in LARS, which in turn, is associated with better survival. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): ESC Training Grant App000064741

Mineralocorticoid Receptor Antagonists Mitigate Mitral Regurgitation-Induced Myocardial Dysfunction.

Mitral regurgitation (MR), the disruption of the mitral valve, contributes to heart failure (HF). Under conditions of volume overload, excess mineralocorticoids promote cardiac fibrosis. The mineralocorticoid receptor antagonist spironolactone is a potassium-sparing diuretic and a guideline-recommended therapy for HF, but whether it can ameliorate degenerative MR remains unknown. Herein, we investigate the efficacy of spironolactone in improving cardiac remodeling in MR-induced HF compared with that of a loop diuretic, furosemide. Using a novel and mini-invasive technique, we established a rat model of MR. We treated the rats with spironolactone or furosemide for twelve weeks. The levels of cardiac fibrosis, apoptosis, and stress-associated proteins were then measured. In parallel, we compared the cardiac remodeling of 165 patients with degenerative MR receiving either spironolactone or furosemide. Echocardiography was performed at baseline and at six months. In MR rats treated with spironolactone, left ventricular function—especially when strained—and the pressure volume relationship significantly improved compared to those of rats treated with furosemide. Spironolactone treatment demonstrated significant attenuation of cardiac fibrosis and apoptosis in left ventricular tissue compared to furosemide. Further, spironolactone suppressed the expression of apoptosis-, NADPH oxidase 4 (NOX4)- and inducible nitric oxide synthase (iNOS)-associated proteins. Similarly, compared with MR patients receiving furosemide those prescribed spironolactone demonstrated a trend toward reduction in MR severity and showed improvement in left ventricular function. Collectively, MR-induced cardiovascular dysfunction, including fibrosis and apoptosis, was effectively attenuated by spironolactone treatment. Our findings suggest a potential therapeutic option for degenerative MR-induced HF.

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

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

Mitral regurgitation severity dynamic during acute decompensated heart failure treatment

Acute decompensated heart failure (ADHF) treatment leads to significant hemodynamic changes. The aim of our study was to quantitatively analyze the dynamics of mitral regurgitation (MR) severity (evaluated by transthoracic echocardiography) which occur during the treatment of ADHF and to correlate these changes with the clinical condition of patients as well as heart failure biochemical markers. The study included 27 consecutive adult patients (40.7% females, mean age 71.19 ± 11.2 years) who required hospitalization due to signs of acute HF. Echocardiographic assessment was performed upon admission and discharge together with clinical and laboratory evaluation. Significant reduction in dyspnea intensity [0–100 scale] (81.48 ± 9.07 vs. 45.00 ± 11.04 pts, p < 0.001), body weight (84.98 ± 18.52 vs. 79.77 ± 17.49 kg, p < 0.001), and NT-proBNP level (7520.56 ± 5288.62 vs. 4949.88 ± 3687.86 pg/ml, p = 0.001) was found. The severity of MR parameters decreased significantly (MR volume 44.92 ± 22.83 vs. 30.88 ± 18.77 ml, p < 0.001; EROA 0.37 ± 0.17 vs. 0.25 ± 0.16 cm2, p < 0.001; VC 6.21 ± 1.48 vs. 5.26 ± 1.61 mm, p < 0.001). Left atrial area (35.86 ± 9.11 vs. 32.47 ± 9.37, p < 0.001) and mitral annular diameter (42.33 ± 6.63 vs. 39.72 ± 5.05. p < 0.001) also underwent statistically significant reductions. An increase in LVEF was observed (34.73 ± 13.88 vs. 40.24 ± 13.19%, p < 0.001). In 40.7% of patients, a change in MR severity class (transition from a higher class to a lower one) was observed: 6/8 (75%) patients transitioned from severe to moderate and 6/18 (33.3%) patients transitioned from moderate to mild class. Treatment of ADHF leads to a significant reduction in MR severity, together with significant reductions in left atrial and mitral annular dimensions. Quantitative measurement of MR dynamics offer valuable assistance for ADHF management.

676 Impact of transcatheter aortic valve implantation in patients with severe aortic stenosis and concomitant mitral regurgitation

Abstract Aims Severe aortic stenosis (AS) and functional mitral regurgitation (MR) frequently coexist. There is no consensus about the optimal therapeutic strategy for patients with combined valve disease. Evidence has shown that double valve surgery is associated with high complication rates and mortality, whereas MR severity may improve after transcatheter aortic valve implantation (TAVI). To date, little is known on prognostic parameters associated with MR improvement after TAVI. Recently, a new echocardiographic parameter based on the ratio between peak E velocity and peak atrial longitudinal strain (E/PALS) has demonstrated to be accurate and sensitive in the prediction of elevated filling pressure. Its role in the setting of AS patients undergoing TAVI has never been investigated. Our study aims to evaluate haemodynamic conditions and left ventricular (LV) systolic and diastolic function in patients with severe AS and concomitant MR undergoing TAVI and to identify new echocardiographic parameters associated with MR improvement 1 month after the aortic valve replacement. Methods We prospectively enrolled 87 consecutive patients (mean age 80 ± 6 years) with severe symptomatic AS and concomitant MR undergoing TAVI between 2016 and 2021, for whom a complete echocardiographic assessment was available at baseline and 1 month after the procedure, selected from the EffecTAVI registry. Exclusion criteria were prior valve surgery, severe mitral stenosis, permanent atrial fibrillation, and poor ultrasound acoustic window. Echo-Doppler assessment, including global longitudinal strain (GLS) and peak atrial longitudinal strain (PALS), was performed before and after 1 month to TAVI procedure. Changes (Δ) of the main echo parameters before and after intervention were computed. Results A month after the procedure, 20 (23%) patients had a reduction of at least one degree of MR (P &amp;lt;0.001). Dividing study population in two groups, based on whether or not MR was reduced after TAVI, we found that patients with MR improvement had higher LV end-diastolic volume (P = 0.036) and left atrial volume (P = 0.015) at baseline compared with those without MR reduction. After TAVI no significant differences were found in heart chambers size between the two groups, but a significant increase in PALS (23.2 ± 7.3 vs. 22.3 ± 7, P=0.028), together with a reduction in E/A ratio (0.69 ± 0.14 vs. 0.90 ± 0.46, P = 0.046) were detected in patients with MR reduction. Furthermore, Δ E/PALS (−17.3±34.4% vs. 3.9±35.0% P=0.027), Δ E/A (−12.6±33.9% vs. 24.7±64.3%, P=0.018) and Δ systolic pulmonary artery pressure (sPAP) (−13.0±20.2% vs. −2.0±18.3, P=0.031) were significantly higher in patients with MR improvement to compared those without MR reduction. By the multivariate logistic regression analysis performed in the pooled population, Δ E/PALS (OR 0.968, 95% CI: 0.947–0.990, P=0.005), together with LV mass at baseline (OR 1.056, 95% CI: 1.007–1.107, P = 0.024) appeared to be independently associated with MR reduction post-TAVI. Conclusions Our study demonstrated that: after TAVI in a significant percentage of patients a relevant improvement in concomitant MR was detected; in the group of patients with improved MR a parallel improvement of sPAP, E/A and E/PALS ratio post TAVI was found; Δ E/PALS appears to be the main parameter independently associated with the reduction of MR severity.

Edge-to-edge transcatheter valve repair of atrial functional mitral regurgitation positively influences atrial pathology

Abstract Introduction Functional mitral regurgitation (FMR) is the result of an insufficient coaptation of the mitral valve leaflets lacking relevant degeneration or morphological alterations of the valve apparatus. In most patients, this is caused by left ventricular (LV) systolic dysfunction and remodelling (ischemic or non-ischemic). However, a small subset of FMR patients is seen in the context of left atrial (LA) enlargement due to isolated atrial dilation in the absence of a ventricular pathology and has been termed “atrial functional MR” (AFMR) as a distinct etiology of FMR. The effect of transcatheter mitral valve repair (TMVR) by edge-to-edge-repair (e.g., MitraClip®) on AFMR reduction has not been studied, but it is considered to be effective regarding its effect on the anterior-posterior mitral annular diameter. Methods We retrospectively screened all 737 patients treated with TMVR by edge-to-edge repair in our center between January 2013 and April 2019. AFMR was defined as FMR with: (1) relevant LA dilatation, (2) no LV systolic dysfunction or (3) dilatation, (4) no ischemic etiology of FMR. LA mean pressure was invasively measured peri-interventionally before and after device implantation. Echocardiographic assessment was repeated at 1 year follow-up (1yFUP). Results Among 350 patients (47.5%) with FMR, 57 patients (16.3%) met the inclusion criteria for AFMR and were included in the data analysis. All patients in the AFMR group (mean age 81.4±5.7 years, 78.9% female) were symptomatic (82.2% functional NYHA class≥III) at baseline and were assessed to be at elevated risk for surgery (mean logistic EuroScore of 24.8±12.0%). TVMR was successfully performed in all patients without any peri-interventional major complications. At hospital discharge, 78.3% of patients had mild residual MR and 17.4% had no detectable MR. At 1 year, the echocardiographic prevalence of residual moderate MR was 11.4% and 2.9% of patients had severe MR (Figure A). Invasive LA mean pressure measurements were available in 39 patients (68.4%). In average, LA mean pressures decreased from 18.8 mmHg to 12.8 mmHg (p&amp;lt;0.001). Analysis at 1yFUP showed a significant reduction in LA volume, both at end-systole (79.6±31.9 vs. 66.9±31.8 ml/m2 p&amp;lt;0.001; Figure B) and at end-diastole (61.6±21.5 vs. 50.4±27.37 ml/m2; p&amp;lt;0.01; Figure C). LA ejection fraction increased from 18.8%±12.6% to 30.1%±12.3% in 54.8% of patients. These findings were accompanied by a relevant symptomatic benefit (NYHA class I/II was found in 66.7% of patients at 1 year). Conclusions Transcatheter mitral valve repair by edge-to-edge therapy in symptomatic patients with atrial functional mitral regurgitation is safe and capable of a relevant reduction of mitral regurgitation severity accompanied by symptomatic improvement and positive atrial remodeling. Funding Acknowledgement Type of funding sources: None.

The Effect of Depth of Anaesthesia on the Severity of Mitral Insufficiency by Transesophageal Echocardiography

Abstract Background The assessment of mitral regurgitation (MR) is complex and complicated by the dynamic nature of this valvular abnormality. Intraoperative transesophageal echocardiography (TEE) is a well-established tool that is used to assess the mitral regurgitation (MR) before and after mitral valve reconstruction. Objectives This study conducted in the National Heart Institute in Cairo aimed at assessing the effect of depth of anaesthesia guided by bispectral index on the severity of mitral insufficiency as measured by transesophageal echocardiography. Patients and Methods This study was conducted in the National Heart Institute in Cairo. The study was conducted for a period of about six months after the approval from Ethical committee. Informed oral consent for every patient was obtained. Prospective observational cross-sectional study with a random sample of 20 patients at National Heart Institute. A sample size of at least 15 data pairs achieves 80% power to reject the null hypothesis of zero effect size when the population effect size is 0.80 and the significance level (alpha) is 0.05 using a two-sided paired ttest. Adult patients undergoing elective cardiac surgery in National Heart Institute. Results The MR severity decreased at a deeper anaesthesia at low BIS than at a shallower anaesthesia at high BIS in patients with organic MR. Eight patients out of twenty patients (40% with organic MR) showed a + 1 grade of improvement in MR grade, by semi-quantitively measuring maximal JA and VC width. Improvement in mitral regurge severity thought to be secondary to unloading effect of general anaesthesia on left ventricle causing a decrease in afterload, preload, and left ventricular dimensions. This study demonstrated that, a comparison between deep anaesthesia and shallow anaesthesia using BIS showed there is a significant reduction in multiple parameters of MR severity assessment secondary to unloading effect of general anaesthesia on left ventricle caused by a decrease in both afterload and preload. Conclusion This reduction in MR severity appeared to be significant enough to modify intraoperative decisions regarding valve surgery by underestimation of valve severity. Thus, strong consideration should be given to thorough preoperative assessment of MR severity, rather than relying on intraoperative findings.

Preliminary Outcome of a Novel Edge-to-Edge Closure Device to Manage Mitral Regurgitation in Dogs.

Background: Veterinary management of mitral valve regurgitation due to mxyomatous valve disease in dogs is limited to medical treatments, which only postpones the onset of congestive heart failure or alleviates clinical symptoms. Most surgical procedures to manage this condition in humans require cardiopulmonary bypass and have a high risk of complications.Animals: Eight dogs with naturally occurring mitral valve regurgitation.Methods: Prospective observational study. All dogs were treated with a novel edge-to-edge transcatheter device named ValveClamp. The total surgical procedural time and total catheterization time were recorded. Echocardiographic variables measured pre- and post-procedure were compared using Wilcoxin-signed rank test with a P < 0.05 considered significant. Data were expressed as median and interquartile range and absolute numbers and percentages.Results: The procedural success rate was 100% and all the dogs survived without complications. The median (interquartile range) total surgical procedural time was 86.5 (76–96.2) minutes and catheterization time was 23.5 (22–33.8) minutes. Echocardiography revealed a significant reduction in mitral regurgitation severity in all dogs following the procedure based on both a reduced mitral regurgitant maximum jet area (P = 0.012) and a reduced mitral regurgitant maximum jet area to left atrial area (P = 0.018).Conclusion: The ValveClamp device is effective at reducing the severity of mitral regurgitation in dogs with naturally occurring myxomatous valve disease.

Catheter Ablation of Atrial Fibrillation in Patients With Functional Mitral Regurgitation and Left Ventricular Systolic Dysfunction.

Background: The efficacy of catheter ablation for atrial fibrillation (AF) in patients with functional mitral regurgitation (MR) and left ventricular (LV) systolic dysfunction (LVSD) is not known. The aim of the study is to determine the efficacy of catheter ablation for AF in patients with functional MR and LVSD, and to validate its effects on the severity of MR and cardiac reverse remodeling.Methods: We performed a retrospective study of 54 patients with functional MR who underwent AF ablation, including 21 (38.9%) with LVSD and 33 (61.1%) with normal LV systolic function (LVF). The primary outcomes evaluated were freedom from recurrent atrial tachyarrhythmia (ATa), severity of MR, and left atrial (LA) and LV remodeling.Results: During a mean follow-up of 20.7 ± 16.8 months, freedom from recurrent ATa was not significantly different between patients with LVSD and those with normal LVF after the first ablation (P = 0.301) and after multiple ablations (P = 0.728). Multivariable predictors of recurrent ATa were AF duration [hazard ratio (HR) 1.12, 95% confidence interval (CI) 1.01–1.25; P = 0.039), previous stroke (HR 5.28, 95% CI 1.46–19.14; P = 0.011), and estimated glomerular filtration rate (HR 0.97, 95% CI 0.95–0.99; P = 0.012). Compared with baseline, there was a significant reduction in severity of MR (P = 0.007), LA size (P < 0.001) and LV end-systolic dimension (P = 0.008), and improvement in the LV ejection fraction (P = 0.001) after restoring sinus rhythm in patients with LVSD.Conclusion: Catheter ablation is a valid option for the treatment of AF in patients with functional MR and LVSD, even though multiple procedures may be required.

Joint preoperative transthoracic and intraoperative transoesophageal echocardiographic assessment of functional mitral regurgitation severity provides better association with long-term mortality.

Functional mitral regurgitation (MR) is observed with ischaemic heart disease or aortic valve disease. Assessing the value of mitral valve repair or replacement (MVR/P) is complicated by frequent discordance between preoperative transthoracic echocardiographic (pTTE) and intraoperative transoesophageal echocardiographic (iTOE) assessment of MR severity. We examined the association of pTTE and iTOE with postoperative mortality in patients with or without MR, at the time of coronary artery bypass grafting (CABG) and/or aortic valve replacement without MVR/P. Medical records of 6629 patients undergoing CABG and/or aortic valve replacement surgery with or without functional MR and who did not undergo MVR/P were reviewed. MR severity assessed by pTTE and iTOE were examined for association with postoperative mortality using proportional hazards regression while accounting for patient and operative characteristics. In 72% of 709 patients with clinically significant (moderate or greater) functional MR detected by pTTE, iTOE performed after induction of anaesthesia demonstrated a reduction in MR severity, while 2% of patients had increased severity of MR by iTOE. iTOE assessment of MR was better associated with long-term postoperative mortality than pTTE in patients with moderate MR [hazard ratio (HR) 1.31 (1.11-1.55) vs 1.02 (0.89-1.17), P-value for comparison of HR 0.025] but was not different for more than moderate MR [1.43 (0.96-2.14) vs 1.27 (0.80-2.02)]. In patients undergoing CABG and/or aortic valve replacement without MVR/P, these findings support intraoperative reassessment of MR severity by iTOE as an adjunct to pTTE in the prediction of mortality. Alone, these findings do not yet provide evidence for an operative strategy.

Use of Intraoperative Dobutamine Stress Echocardiography on Outcomes of Septal Myectomy

Septal myectomy is the standard treatment for obstructive hypertrophic cardiomyopathy. We studied the impact of intraoperative pre- and postprocedure dobutamine stress transesophageal echocardiography on surgical planning and outcomes of septal myectomy. We identified 55 patients undergoing septal myectomy over a 24-month period. All patients underwent resting and dobutamine stress (20-40 mcg/kg/min) echocardiography after induction of anesthesia pre- and postprocedure. Demographic, clinical, and imaging data were prospectively collected. Mean age was 59 (42-68). A total of 69% of patients were New York Heart Association Class III/IV. During outpatient evaluation, peak preoperative resting left ventricular outflow tract gradient was 91.6 mm Hg and 94% (50/53) had severe stress-induced mitral regurgitation (MR). After induction, peak resting gradient fell to 47.8 mm Hg and 43% (24/55) had improved gradients (<30 mm Hg). With stress, preprocedure left ventricular outflow gradient increased to 130 mm Hg and all occult gradients were unmasked. Postprocedure, peak resting and stress gradients were substantially reduced (10.2 ± 6.8 mm Hg and 23.6 ± 8.5 mm Hg, respectively). With stress, 84% (42/50) demonstrated reduction in severity of MR to none and/or mild with no patients having greater than moderate. Postprocedure stress echocardiography identified 3 patients with residual gradients, which led to return to bypass for additional procedures and resulted in resolution of elevated residual gradients. Postoperative 60-day stress echocardiography showed sustained resolution of gradients and MR. In this series, 43% of patients had occult left ventricular outflow gradients after induction of anesthesia. Intraoperative stress echocardiography during septal myectomy is useful to unmask occult gradients and confirm adequate myectomy. This imaging strategy is associated with reliable relief of obstruction and MR as demonstrated at 60-day follow-up.

MitraClip therapy in patients with acute severe mitral regurgitation

Abstract Background There is a lack of data to support the optimal management of high-risk patients with acute severe mitral regurgitation (MR). The role of the MitraClip implantation in treatment of acute severe mitral regurgitation (MR) is undetermined. Methods We screened all patients who underwent MitraClip implantation at the Hadassah Medical Center between October 2015 and December 2019. We evaluated immediate, 30-day and 1-year outcomes after the procedure. We evaluated patients with severe MR due to ruptured cord because of degenerative disease and acute-on-chronic functional MR due to ischemic (after a recent myocardial infarction (MI)) or non-ischemic etiology (secondary to decompensated HF). Results From a cohort of 151 patients, who underwent MitraClip implantation in our center, we identified 35 patients (23.2%) with acute severe mitral regurgitation (4+) and decompensated refractory heart failure. Patients' mean age was 74.15 years, 66.9% - were males. One, 2, or 3 clips were implanted. Reduction of MR from 4+ to 1+ was achieved in 34 patients (66.7%). Twenty-eight patients (80%) had acute-on-chronic severe MR and refractory heart failure including 6 cases after recent MI, other 7 patients presented with heart failure and acute severe MR secondary to ruptured cord due to degenerative disease. After MitraClip implantation, reduction of MR severity was achieved in all patients. Seven patients were withdrawn from intravenous therapy and intra-aortic balloon pump 2–3 days after the procedure. Four patients died during hospitalization, three of them due to sepsis. 30-day follow-up showed improvement of NYHA functional class and a tendency toward improvement in left ventricle systolic function with signs of reverse remodeling. Nevertheless, we observed high 30-day and 1-year mortality rate (11.4 and 23.8% respectively). Conclusions MitraClip therapy could be an alternative option for treatment of patients with acute and acute-on-chronic severe MR of ischemic and non-ischemic etiology. Funding Acknowledgement Type of funding source: None

Ventricular arrhythmias in patients with functional mitral regurgitation and implantable cardiac devices: implications of mitral valve repair with Mitraclip

Abstract Background Limited information has been reported regarding the impact of percutaneous mitral valve repair (PMVR) on ventricular arrhythmic (VA) burden. The aim of this study was to address the incidence of VA and appropriate antitachycardia implantable cardiac defibrillator (ICD) therapies before and after PMVR. Methods We retrospectively analyzed all consecutive patients with heart failure with reduce left ventricular ejection fraction, functional mitral regurgitation grade 3+ or 4+ and an active ICD or cardiac resynchronizer who underwent PMVR in any of the eleven recruiting centers. Only patients with complete available device VA monitoring from one-year before to one year after PMVR were included. Baseline clinical and echocardiographic characteristics were collected before PMVR and at 12-months follow-up. Results 93 patients (68.2±10.9 years old, male 88.2%) were enrolled. PMVR was successfully performed in all patients and device success at discharge was 91.4%. At 12-months follow-up, we observed a significant reduction in mitral regurgitation severity, NT-proBNP and prevalence of severe pulmonary hypertension and severe kidney disease. Patients also referred a significant improvement in NYHA functional class and showed a non-significant trend to reserve left ventricular remodeling. After PMVR a significant decrease in the incidence of non-sustained ventricular tachycardia (VT) (5.0–17.8 vs 2.7–13.5, p=0.002), sustained VT or ventricular fibrillation (0.9–2.5 vs 0.5–2.9, p=0.012) and ICD antitachycardia therapies (2.5–12.0 vs 0.9–5.0, p=0.033) were observed. Conclusion PMVR was related to a reduction in arrhythmic burden and ICD therapies in our cohort. Proportion of patients who presented ven Funding Acknowledgement Type of funding source: None

Ventricular arrhythmias in patients with functional mitral regurgitation and implantable cardiac devices: implications of mitral valve repair with Mitraclip®.

BackgroundLimited information has been reported regarding the impact of percutaneous mitral valve repair (PMVR) on ventricular arrhythmic (VA) burden. The aim of this study was to address the incidence of VA and appropriate antitachycardia implantable cardiac defibrillator (ICD) therapies before and after PMVR.MethodsWe retrospectively analyzed all consecutive patients with heart failure with reduce left ventricular ejection fraction (LVEF), functional mitral regurgitation (FMR) grade 3+ or 4+ and an active ICD or cardiac resynchronizer who underwent PMVR in any of the eleven recruiting centers. Only patients with complete available device VA monitoring from one-year before to one year after PMVR were included. Baseline clinical and echocardiographic characteristics were collected before PMVR and at 12-months follow-up.ResultsNinety-three patients (68.2±10.9 years old, male 88.2%) were enrolled. PMVR was successfully performed in all patients and device success at discharge was 91.4%. At 12-month follow-up, we observed a significant reduction in mitral regurgitation severity, NT-proBNP and prevalence of severe pulmonary hypertension and severe kidney disease. Patients also referred a significant improvement in NYHA functional class and showed a non-significant trend to reserve left ventricular remodeling. After PMVR a significant decrease in the incidence of non-sustained ventricular tachycardia (VT) (5.0±17.8 vs. 2.7±13.5, P=0.002), sustained VT or ventricular fibrillation (0.9±2.5 vs. 0.5±2.9, P=0.012) and ICD antitachycardia therapies (2.5±12.0 vs. 0.9±5.0, P=0.033) were observed.ConclusionsPMVR was related to a reduction in arrhythmic burden and ICD therapies in our cohort.

CRT-600.36 A Balancing Act: The Impact of Reducing Mitral Regurgitation at the Expense of Increased Mitral Gradients Using Percutaneous Mitral Valve Repair

Percutaneous mitral valve repair (PMVR) using the MitraClip system (Evalve Inc., Menlo Park, California) has emerged as a minimally invasive treatment option for patients at prohibitive risk for surgical treatment of mitral regurgitation (MR). However, a reduction of MR severity may be at the cost

P198 Long-term outcomes after mitraclip implantation

Abstract Background Mitraclip implantation (MI) is a well-established option for patients (P) with severe mitral regurgitation (MR) noneligible to surgery. Its impact on long term prognosis is being addressed by several recent studies. Purpose To identify predictors of morbidity and mortality in P undergoing MI and evaluate if the COAPT, Everest and MITRAFR exclusion criteria (EC) had any impact on the outcome of our population. Methods prospective study of P who underwent MI between 2013 and 2018 in one medical center. EC: COAPT: LVEF &amp;lt; 20%, LV end-diastolic diameter &amp;gt; 70mm or pulmonary artery systolic pressure &amp;gt; 70mmHg; Everest: LVEF &amp;lt; 25% or LV end-systolic diameter (LVESD)&amp;gt;55mm; MITRA-FR: LVEF &amp;lt; 15% or &amp;gt;40% or primary MR. An univariate analysis was performed followed by a multivariate Cox analysis to evaluate overall mortality (M), overall mortality/ heart failure hospitalization (MH) and mortality in the first year post-MI(M1). Survival analysis using Kaplan-Meier plots. p &amp;lt; 0.05 were considered significant. Results 40P, 60% male, mean age 66 ± 12 years (Y) and mean follow-up time of 18 ± 15 months. 67.5% presented with MR grade IV and 75% had functional MR. Successful implantation in 97.5%, with 55% presenting mild MR post-procedure. Overall mortality was 30% (12P), mostly due to cardiovascular causes, with 9P dying in the first year (30%). There was no difference between pts with functional and primary MR: M- 33%vs20% (p = 0.6); MH– 53.3%vs30% (p = 0.5). P who met the COAPT exclusion criteria (N-22) presented an inferior 1Ysurvival (64.5%vs86.7%, p = 0.046). The overall outcome was comparable between P who matched and didn"t match Everest and MITRA-FR exclusion criteria. Basal BNP value (p = 0.037), mean preprocedural MAGGIC score (p = 0.040) and EROA (p = 0.039) were associated to M1. Multivariate Cox analysis revealed that basal BNP was an independent predictor of M (p = 0.017), whereas a higher distance in the pre-procedural 6 minute walk test (p = 0.008) and the "reduction in the MR severity and PASP" (p = 0.008) presented a protective effect. LVESD &amp;gt; 55mm was an independent predictor of MH (p = 0.017), but MR of grade 2 or less after procedure was protective (p = 0.006). Conclusion There was no M difference between P with functional and primary MR. P with COAPT exclusion criteria had worse 1Ysurvival. A higher distance in 6MWT and a reduction in MR severity and PASP were protective. An LVESD &amp;gt; 55 mm had a worse prognosis. Careful P selection may be crucial to improve MI"s results Abstract P198 Figure. Kaplan-Meier Plots

P753 Impact of transcatheter aortic valve implantation on concomitant mitral regurgitation in patients with severe aortic stenosis

Abstract Background Severe aortic stenosis (AS) and functional mitral regurgitation (MR) frequently coexist. There is no consensus about the optimal therapeutic strategy for patients with combined valve disease. Evidence has shown that double valve surgery is associated with high complication rates and mortality, whereas MR severity may improve after transcatheter aortic valve implantation (TAVI). Purpose Aim of our study was to evaluate hemodynamic parameters and cardiac function in patients with severe AS and concomitant MR undergoing TAVI. Methods We prospectively enrolled consecutive TAVI patients with concomitant MR. Exclusion criteria were primary cardiomyopathies, prior valve surgery, permanent atrial fibrillation and inadequate echocardiographic imaging. Echo-Doppler assessment, including global longitudinal strain (GLS) and peak atrial longitudinal strain (PALS) (absolute value), was performed before TAVI and after 1-3 months. MR grading was assessed according to quantitative methods (vena contracta and/or PISA). Changes (Δ) of the main echo parameters before and after intervention were computed. On the basis of MR grading changes, the study population was divided in two groups: no improvement in MR grading (NIMR) and improvement in MR grading (IMR). Results Of 49 included patients (M/F = 20/29, age 80.7 ± 5.6 years), 23 had mild MR and 26 moderate to severe MR before TAVI. After the procedure, MR grading improved in 11 (IMR) and remained stable in 38 (NIMR) patients. The two groups were comparable for sex, age, body mass index, blood pressure and heart rate. After TAVI, both groups showed an improvement in GLS (17.8 ± 4.7 to 20.1 ± 4.4%, p &amp;lt; 0.0001 and 16.8 ± 3.8 to 19.0 ± 3.1%, p &amp;lt; 0.01, in NIMR and IMR respectively) and in PALS (20.4 ± 7.4 to 24.2 ± 7.3%, p &amp;lt; 0.0001 in NIMR and 19.5 ± 4.5 to 26.7 ± 6.1%, p &amp;lt; 0.001, in NIMR and IMR respectively), without significant changes in ejection fraction (p = 0.12). Only in IMR group, a significant decrease of systolic pulmonary arterial pressure (sPAP) (45.5 ± 10.6 to 36.3 ± 6.9 mmHg, p &amp;lt; 0.001) and left atrial volume index (54.9 ± 14.8 to 48.9 ± 13.3 ml/m², p &amp;lt; 0.01) was observed after TAVI. Changes of sPAP (ΔsPAP) (9.1 ± 6.4 vs. -0.07 ± 6.7, p &amp;lt; 0.0001) was higher and ΔPALS (-7.2 ± 5.1 vs. -3.8 ± 4.3, p &amp;lt; 0.03) lower in IMR compared with NIMR group (Figure). By a multiple linear regression analysis performed in the pooled population, after adjusting for ΔPALS, Δ aortic valve area and ΔGLS, the association between ΔsPAP and MR grading improvement remained significant (beta = 0.53, p &amp;lt; 0.001) (cumulative R²=0.31, SEE = 6.9 mmHg, p = 0.007). Conclusion Afterload reduction following TAVI may induce hemodynamic changes determining also a reduction in MR severity. This mechanism implies a reduction in left atrial pressure, whose PALS is a reliable marker, and a consequent reduction of post-capillary pulmonary hypertension. The association between MR improvement and ΔsPAP reduction is independent on echocardiographic confounders. Abstract P753 Figure. ΔsPAP and ΔPALS in NIMR and IMR

P589Assessment of cardiac reverse remodelling following mitral valve repair and mitral valve replacement in degenerative mitral regurgitation: a cardiovascular magnetic resonance study

Abstract Background Mitral valve (MV) repair is currently recommended over replacement (1). The guidelines suggesting this are however based on historic evidence which compared outdated techniques of MV replacement. Recent data cast doubts on its validity in the current era of chordal-preservation techniques in MV replacement. Purpose Using cardiovascular magnetic resonance (CMR) imaging, this study aimed to assess the impact of MV repair and MV replacement on cardiac left ventricular (LV) reverse remodelling. Methods 65 patients with moderate-severe and severe mitral regurgitation (MR) were prospectively recruited. Of these, 37 patients (59% men, 65±15 years) to date with paired CMR scans at baseline and at 6 months were evaluated. Patients either underwent MV repair (n=9), MV replacement (n=10) or watchful waiting (n=18). The CMR protocol included cines for left ventricle (LV), left atria (LA), and aortic flow assessment. The LA and LV parameters, and MR fraction were analysed. Results At 6 months, both the MV repair and replacement groups exhibited a reduction in LV end-diastolic volume (LVEDV) and LA volumes when compared to the control group. The indexed LVEDV decreased significantly from 129±33ml/m2 to 99±37ml/m2, p&lt;0.001 in the repair group, from 118±24ml/m2 to 90±26ml/m2, p&lt;0.001 in the replacement group and remained unchanged in the control group 115±25ml/m2 to 113±25ml/m2, p=0.53. The absolute reduction in indexed LVEDV was not significantly different between the repair and replacement groups (−30±15ml/m2 vs −29±19ml/m2, repair vs replacement, p=1.00). Similarly, both surgical groups also sustained an equal degree of LA size reduction (−42±26ml/m2 vs −36±23ml/m2, repair vs replacement; p=1.00). There was a decline in the global postoperative LV ejection fraction (Table 1). The degree of reduction in LV ejection fraction however did not differ between the repair and replacement group (−9±6% vs −6±8%, repair vs replacement; p=1.00). Those undergoing surgery experienced a significant reduction in their MR severity, although those with replacement had a more effective reduction in MR severity (MR fraction for repair: 47±9% to 15±10%, p&lt;0.001 vs replacement: 41±13% to 5±4%, p&lt;0.001). Conclusion MV surgery leads to atrial and left ventricular reverse remodelling, and a decline in global LV ejection fraction. In this small series, MV replacement with chordal preservation showed similar cardiac reverse remodelling benefits to MV repair. Although residual MR is often seen following repair, this did not lead to less favourable cardiac reverse remodelling. Acknowledgement/Funding Leeds NIHR infrastructure