Reduction Of Functional Mitral Regurgitation Research Articles

Abstract 17540: Functional Mitral Regurgitation is Associated With Decreased Papillary Muscle Viability Patients With Non-Ischemic Dilated Cardiomyopathy

Background: The underlying mechanisms of functional mitral regurgitation (FMR) in non-ischemic cardiomyopathy (NICM) are incompletely understood. Aims: We investigated the correlation between papillary muscle viability and FMR in NICM. Methods: We enrolled 66 patients with NICM (LVEF<40%, NHYA III) undergoing CD34 + cell transplantation. At baseline, patients underwent electroanatomical mapping; papillary muscle viability was quantified by local unipolar voltage (UV) measurement, and decreased viability was defined as UV<8.3 mV. All patients received granulocyte-colony stimulating factor; CD34 + cells were collected by apheresis and delivered by transendocardial injections. Echocardiography was performed at baseline and 6 months after cell therapy; severity of FMR was graded by multi-parametric approach. FMR improvement was defined as a reduction in FMR by ≥1 grade when compared to baseline. Results: At baseline, papillary muscle viability was decreased in 24 (36%) and preserved in 42 (64%) of patients. Moderate to severe (2-3+) FMR was more common in patients with decreased papillary muscle viability (6/24; 25%) than in patients with preserved viability (2/42; 5%, P=0.015). Transendocardial cell injections were performed in the papillary muscle area in 26 patients (Group A) and in other areas of the left ventricle in 40 patients (Group B). The groups did not differ in age (56±11 years in Group A vs. 54±10 years in Group B, P=0.32), sex (male: 96% vs. 85%, P=0.21), creatinine (0.98±0.27 mg/dL vs. 0.96±0.28 mg/dL, P=0.92), bilirubin (0.89±0.37 mg/dL vs. 0.92±0.35 mg/dL, P=0.45), LVEF (34±9% vs. 31±7%, P=0.12), NT-proBNP levels (1196±994 pg/mL vs. 1077±1176 pg/mL, P=0.68), the degree of FMR (1.28±0.78 vs. 1.02±0.38, P=0.20), or papillary muscle viability (9.9±3.0 mV vs. 10.3±3.2 mV, P=0.62). At 6 months after cell injection, FMR improved in 77% of patients in Group A vs. 13% in Group B (P=0.001). On multivariate analysis, cell injection in the papillary muscle area was an independent correlate of FMR improvement (P=0.01). Conclusions: FMR in patients with NICM is associated with decreased papillary muscle viability. Transendocardial injection of CD34 + cells in the papillary muscle area may improve FMR in this patient population.

Anesthesia-Induced Intraprocedural Downgrading of Mitral Regurgitation During Transcatheter Edge-to-Edge Repair

During transcatheter edge-to-edge repair (TEER), the reduction of functional mitral regurgitation (FMR) severity, compared with baseline evaluation, is not uncommon. Because the procedural strategies are mainly guided by the location and severity of the regurgitant jets, intraprocedural downgrading (ID) of regurgitation severity could affect the procedural strategy and the results. The aim of this study was to evaluate the prevalence of ID during TEER and to compare early and midterm outcomes in patients with and without ID. All patients with moderate-to-severe or severe FMR who underwent TEER in San Raffaele Hospital between 2018 and 2020 were evaluated in this single-center, retrospective study. ID was defined as mild (1+) or moderate (2+) regurgitation degree during intraprocedural evaluation. The outcomes, assessed at discharge and at 2 years of follow-up, were all-cause mortality, heart failure hospitalization, and recurrence of mitral regurgitation >2+. The final study cohort included 55 patients: 42% presented with ID. At discharge, 85.5% of patients achieved regurgitation reduction to 2+ or less: 100% in patients with ID versus 75% in patients without ID, p <0.009. At 2 years, no significant difference in the incidence of all-cause mortality, heart failure hospitalization, and the recurrence of mitral regurgitation >2+ between patients with ID or without ID was found. In conclusion, ID is frequent during TEER in FMR. No baseline characteristics were found to identify this group of patients. In patients with ID, the combination of live intraprocedural imaging and baseline ambulatory assessment of regurgitant jets seems effective in the procedural guiding to achieve a successful and durable mitral repair.

Cardiac Resynchronization Therapy. Incidence and Mechanisms Involved in the Reduction of Functional Mitral Regurgitation

Background: Functional mitral regurgitation (FMR) is common in heart failure, and moderate/severe (M/S) FMR is associated with worse prognosis. Objective: The aim of this study was to describe the prevalence of FMR and the mechanisms involved in its reduction in responders to cardiac resynchronization therapy (CRT) at 6 months compared with 12 and 24 months. Methods: Between 2009 and 2018, 338 patients received CRT. Patients who showed NYHA functional class (FC) reduction ≥1 or left ventricular ejection fraction (LVEF) absolute increase ≥5% were considered responders. Functional mitral regurgitation was graded using a 4-point scale into none-, mild-, M- and S-FMR, and was related to echocardiographic measurements. Baseline patient characteristics were: age 64±10 years, men 71%, NYHA FC II-III 92%, left bundle branch block (LBBB) 67%, QRS ≥150 ms 75%, LV diastolic diameter (LVDD) 68±9 mm, LV systolic diameter (LVSD) 52±12 mm, and LV EF 24±7%. Results: The prevalence of FMR was 92.6%. At 6 months, 86% were responders, 23% improved from M/S-FMR to mild/none-FMR and there was strong reverse remodeling: LVDD 68±10 vs. 63±11 mm, (p=0.0001), LVSD 55±12 vs. 50±13 mm, (p=0.0006) and LVEF 25±11 vs. 33±10%, (p=0.00001). Comparing 6 with 12 months, 89.4% were responders and 8% improved M/S-FMR to mild/none-FMR. Comparing 6 with 24 months, 88% were responders and 14.6% improved M/S-FMR to mild/none-FMR. Between 6 and 12 and 6 and 24 months, there was no significant reverse remodeling. Conclusions: The prevalence of FMR was high. The highest reverse remodeling and FMR reduction was observed at 6 months, the former being the main mechanism of FMR reduction. This improvement persisted at 12 and 24 months.

Abstract 9848: Image Guided Computational Model of the Mitral Valve in Heart Failure with Functional Mitral Regurgitation - A Platform for Preclinical Procedure Planning

Introduction: Therapeutic benefit of correcting functional mitral regurgitation (FMR) is increasingly recognized, since positive results from COAPT trial indicate a significant reduction in hospitalization rate and mortality. However, this benefit is strongly dependent on the extent of reduction in FMR with the MitraClip system, which is often variable and unpredictable. We report a patient-specific, 3D echo derived computational model of the mitral valve that faithfully mimics the FMR-like valve for procedure planning. Methods: FMR datasets were obtained in two pigs that received a myocardial infarction via percutaneous occlusion of the left circumflex artery. 3D echo was performed 3 months after infarction, and images were segmented to obtain annular and leaflet geometry, and papillary muscle (PM) locations in the ventricle. Chordal distribution was developed (Fig. A) based on anatomical measurements in hearts as they are not visible on echo. The PMs were sub-divided into three heads with marginal, strut and basal chordae emerging from these heads as seen in real hearts (Fig. B) . In FMR state, the PM locations are displaced, imposing a pre-strain on the chordae. Valve closure simulation was modeled by pre-straining the chordae and applying transvalvular pressure gradient on the leaflets, and stress analysis was performed. Results: Agreement in the truth dataset (echo image) and the model (simulated data) are shown in Fig. C , indicating fidelity of the model. Peak stresses were observed on A2 and P2 segments near the strut chordae insertion regions with maximum values of 7.62 and 4.93 MPa for each dataset (Fig. D) , which corresponds well with the previously reported findings. Conclusions: A proposed FMR modeling workflow allowed to obtain a realistic systolic configuration of the mitral valve. Such models may be used to virtually implement various FMR repair techniques, allowing to predict post-repair outcomes and optimize FMR repair at a patient-specific level.

The impact of substrate and trigger ablation for reduction of functional mitral regurgitation in patients with persistent atrial fibrillation

Abstract Background Functional mitral regurgitation (FMR) is not uncommon in atrial fibrillation (AF) patients. Left atrial (LA) substrate remodeling and corresponding mitral valve annulus dilation has been reported as the most possible cause of FMR. Percutaneous catheter ablation (CA) is an effective treatment for AF. Although significant FMR could be improved by sinus restoration, patients with mitral regurgitation were more likely to experience recurrent AF post ablation, especially those with significant mitral regurgitation. There is no information available on the efficacy of CA for persistent AF in patients with FMR. Purpose The purpose of this study is to investigate the predictors of FMR improvement by CA and to determine the efficacy of substrate and trigger CA for persistent AF in patients with FMR. Methods We prospectively studied 512 consecutive patients admitted for persistent AF ablation from the EARNEST-PVI (Prospective Multicenter Randomized Study of Effect of Extensive Ablation on Recurrence in Patients with Persistent Atrial Fibrillation Treated with Pulmonary Vein Isolation) trial. On admission, enrolled patients were randomly assigned in a 1:1 ratio to pulmonary vein isolation (PVI) or PVI-plus additional ablation (linear ablation or/and CFAE ablation). Of the 512 patients, we studied 94 patients with preoperative echocardiography showing moderate or greater baseline FMR. FMR grades were classified into 5 grades (0/1/2/3/4). The FMR improvement group (FMRI(+)) was defined as a case in which the FMR was improved by two or more grades compared the preoperative echocardiography and the one year follow-up examination. Results Of the 94 patients, 42 were in the PVI group and 52 were in the PVI-plus additional ablation group. There were 30 cases in the FMRI(+) group and 64 cases in the FMRI(−) group. There were no significant baseline differences in age, sinus rhythm maintenance, plasma B-type natriuretic peptide (BNP) level, left ventricular diastolic dimension, or left atrium dimension between the FMRI(+) and FMRI(−) groups. AF duration was significantly shorter in the FMRI(+) group than FMRI(−) groups (5.8±9.4 months vs 12.4±15.4 months, p&amp;lt;0.0001). In addition, significantly more additional ablation cases were observed in the FMRI(+) group than in the FMRI(−) group (73.3% vs 46.8%, p=0.016). In multivariate analyses, only additional ablation was an independent predictor of FMRI (odds ratio 0.226 95% CI 0.081–0.626; p=0.004). Conclusions Catheter ablation is a valid option for the treatment of AF in patients with functional MR and additional substrate and trigger ablation were the only independent predictor of FMR improvement. Funding Acknowledgement Type of funding sources: None.

Functional mitral regurgitation and cardiac resynchronization therapy in the “era” of trans-catheter interventions: Is it time to move from a staged strategy to a tailored therapy?

Cardiac resynchronization therapy (CRT) has been associated to left ventricle (LV) remodelling, reduction of functional mitral regurgitation (FMR) and clinical improvement in patients with heart failure and reduced ejection fraction (HFrEF). The prevalence of significant FMR in patients with LV dyssynchrony that are candidate to CRT is up to 40%. Current approach in patients with FMR undergoing CRT consists of re-evaluation of the amount of FMR following a waiting period of at least 3 months after the implant. In case of persistent significant FMR despite CRT and guideline directed medical therapy, trancatheter Mitral Valve repair (TMVR) is an important option to improve quality of life and prognosis. This stepwise approach does not take into account the probability of the individual response to CRT and the availability of TMVR solutions that are safe and effective in high risk patients. We reviewed the effects of CRT on FMR, the prognostic role of persistence of FMR after CRT treatment and the impact of treatment of FMR in patients CRT non responders. We aimed to point out the limits of current step-wised approach in light on more recent evidence regarding FMR treatment. A new, “tailored” approached is proposed.

P1364 Contractile reserve predicts reverse remodelling after successful percutaneous mitral valve repair in patients with functional mitral regurgitation

Abstract Background Recent randomised trials have shown conflicting results regarding the usefulness of percutaneous mitral valve repair using MitraClip in patients with severe functional mitral regurgitation (FMR). At present, it remains unclear whether patients with FMR and advanced heart failure might benefit from MitraClip therapy. Moreover, it has been shown that left ventricular reverse remodelling (LVRR) post-MitraClip is associated with a favourable outcome. Purpose We sought to assess whether baseline contractile reserve (CR) can predict LVRR and improvement of LV ejection fraction (EF) in FMR patients undergoing MitraClip therapy. Methods Consecutive patients with symptomatic severe FMR referred for MitraClip were recruited in two tertiary centres. All patients were scheduled for a semi-supine bicycle exercise echocardiography before and 6 months after the intervention. Patients who were not able to perform an exercise test and who did not complete 6 month follow up were excluded from further analysis. Baseline CR was obtained by subtracting peak exercise LVEF from LVEF at rest. LVRR was defined as a 10% decrease in LV end systolic volume (ESV) at follow-up. Results 34 patients completed 6 month follow up (61% male, age 71 ± 10 years, LVEF 32 ± 8%). LVRR was observed in 15 patients (44%). We found a trend towards a moderate correlation between baseline CR and relative decrease in LVESV at 6 months (Pearson Rho -0.321, p = 0.064). This correlation became significant in a sub-analysis considering only patients with post-procedural FMR grade ≤2 (n = 27; Pearson Rho -0.444, p = 0.020). In contrast, LVRR was not related to baseline LVEF, LV dimensions or volumes. Furthermore, baseline CR was strongly correlated with an increase of LVEF at 6 months post-MitraClip in these patients (Pearson Rho 0.653, p &amp;lt; 0.001). Conclusion CR predicts LVRR and improvement of LVEF in patients with FMR after successful MitraClip therapy (reduction of FMR towards grade ≤2), in contrast to resting indices of LV dysfunction and dilatation. More studies with outcome data are needed to determine whether CR is a useful parameter to identify patients with FMR who might benefit from MitraClip therapy.

5943Mechanistic insights of papillary muscle dyssynchrony mediated function mitral regurgitation and modulation by cardiac resynchronization

Abstract Abstract Background Mechanistic features of functional mitral regurgitation (FMR) include papillary muscle displacement due to left ventricular remodeling. Intraventricular conduction delay might further augment this condition by introducing interpapillary muscle dyssynchrony. Objectives To define this mechanism as a major contributing factor in FMR and prove the reversibility of FMR by interpapillary muscle resynchronization. Methods We enrolled 269 chronic HFrEF patients with conduction delay and comprehensively assessed dyssynchrony by complementary echocardiographic techniques. Opposing wall delay, calculated by speckle tracking, was determined as the time difference between peak longitudinal strain of the mid-anterior and inferior wall from a 2-chamber view. Furthermore, opposing wall delay was assessed as the time difference between peak strain values from tissue Doppler velocity-coded data of the mid-inferior septal and mid-lateral wall segments. Results Patients with severe FMR had markedly increased interpapillary longitudinal dyssynchrony (160ms [IQR 120–200]) compared to those with moderate (70ms [IQR 40–110]), no, or mild FMR (60ms [IQR 30–100]; P&lt;0.001). Increased interpapillary muscle dyssynchrony was correlated with effective regurgitant orifice area (P&lt;0.001; Figure A), regurgitant volume (P&lt;0.001, Figure B) and vena contracta width (P&lt;0.001, Figure C). Restoration of longitudinal papillary muscle synchronicity by cardiac resynchronization therapy (CRT) was correlated with FMR regression, as reflected by the reduction in regurgitant volume (P&lt;0.001) and vena contracta width (P&lt;0.001). Conversely, the improvement of FMR was associated with improved interpapillary radial (P=0.006) and longitudinal (P&lt;0.001) dyssynchrony. The improvement of dyssynchrony-mediated FMR signified a better prognosis compared to no improvement in FMR during the 8-year follow-up period even after comprehensive adjustment by a bootstrap-selected confounder model (adj. HR of 0.41; 95% CI 0.18–0.91; P=0.028; Figure D). The results remained virtually unchanged after adjustment for left bundle branch block. Figure 1. Dyssynchrony-FMR-CRT Conclusion Intraventricular dyssynchrony introduces unequal contraction by papillary muscle bearing walls, which has an adverse effect on FMR. CRT can effectively restore interpapillary balance and thus create a less tented leaflet configuration, resulting in a clinically meaningful reduction of FMR. The restoration of papillary muscle synchronicity in dyssynchrony-mediated FMR translates into a significantly better prognosis.

Combined flow-based imaging assessment of optimal cardiac resynchronization therapy pacing vector: a\xa0case report

BackgroundThere are still many pendent issues about the effective evaluation of cardiac resynchronization therapy impact on functional mitral regurgitation. In order to reduce the intrinsic difficulties of quantification of functional mitral regurgitation itself, an automatic quantification of real-time three-dimensional full-volume color Doppler transthoracic echocardiography was proposed as a new, rapid, and accurate method for the assessment of functional mitral regurgitation severity. Recent studies suggested that images of left ventricle flow by echo-particle imaging velocimetry could be a useful marker of synchrony. Echo-particle imaging velocimetry has shown that regional anomalies of synchrony/synergy of the left ventricle are related to the alteration, reduction, or suppression of the physiological intracavitary pressure gradients.Case summaryWe describe a case in which the two technologies are used in combination during acute echocardiographic optimization of left pacing vector in a 63-year-old man, Caucasian, who showed worsening heart failure symptoms a few days after an implant, and the effect of the device’s optimization at 6-month follow-up.DiscussionThe degree of realignment of hemodynamic forces, with quantitative analysis of the orientation of blood flow momentum (φ), can represent improvement of fluid dynamics synchrony of the left ventricle, and explain, with a new deterministic parameter, the effects of cardiac resynchronization therapy on functional mitral regurgitation. Real-time three-dimensional color flow Doppler quantification is feasible and accurate for measurement of mitral inflow, left ventricular outflow stroke volumes, and functional mitral regurgitation severity.ConclusionThis clinical case offers an innovative and accurate approach for acute echocardiographic optimization of left pacing vector. It shows clinical utility of combined three-dimensional full-volume color Doppler transthoracic echocardiography/echo-particle imaging velocimetry assessment to increase response to cardiac resynchronization therapy, in terms of reduction of functional mitral regurgitation, improving fluid dynamics synchrony of the left ventricle.

Persistent Reduction of Functional Mitral Regurgitation by Transvalvular Mitral Bridge Implantation - Durability and Effectiveness of the Repair at 4 years

Persistent Reduction of Functional Mitral Regurgitation by Transvalvular Mitral Bridge Implantation - Durability and Effectiveness of the Repair at 4 years

Cell Therapy is Associated with Reduction of Functional Mitral Regurgitation in Cardiomyopathy Patients with High End-Diastolic Volumes

Purpose In nonischemic cardiomyopathy (NICM), CD34+ cell transplantation was shown to improve left ventricular dimensions and function. We sought to investigate the effects of such therapy on functional mitral regurgitation (FMR) in this patient cohort. Methods Of 134 consecutive patients with NICM (LVEF Results During follow-up, 2 patients died, and 1 underwent heart transplantation. In the remaining cohort we found improvement of FMR in 41/109 patients (38%, Group A), and in 68/109 (62%) FMR did not improve (Group B). At baseline, Groups A and B did not differ in age (53±11 years in Group A vs. 54±10 years in Group B, P=0.38), sex (male: 88% vs. 84%, P=0.57), creatinine (0.94±0.21 mg/dL vs. 1.00±0.30 mg/dL, P=0.27), bilirubin (0.92±0.45 mg/dL vs. 0.93±0.53 mg/dL, P=0.68), LVEF (31.7±7.7% vs. 30.6±8.0%, P=0.23), or NTproBNP levels (1620±1978 pg/mL vs. 1490±1984 pg/mL, P=0.73). In contrast, baseline end-diastolic volume (EDV) was significantly higher in Group A than in Group B (245±56 mL vs. 190±82 mL, P Conclusion Transendocardial CD34+ cell transplantation appears to be associated with an improvement in FMR in nonischemic cardiomyopathy patients with high EDV. Further studies are warranted to investigate whether such approach can be used in broader population of chronic heart failure patients or in conjunction with percutaneous mitral valve repair.

Safety of centrifugal left ventricular assist device in patients previously treated with MitraClip system

IntroductionNo data regarding the safety of continuous-flow left ventricular assist device (CF-LVAD) implantation in patients with previous MitraClip have been reported. Thus, it remains unknown whether an initial treatment strategy with MitraClip therapy might complicate future heart failure management in patients who are also considered for CF-LVAD. MethodsWe retrospectively identified 6 patients (median age of 62 years; 2 women) who had been treated with MitraClip, that were eventually implanted with a CF-LVAD (all Heartware HVAD) in 3 hospitals between 2013 and 2018. ResultsPatients were treated in 4 cases with 2 clips, and in 2 cases with 1 clip. Median time from MitraClip implantation to CF-LVAD implant was 282 days (interquartile range 67 to 493), and median time on CF-LVAD support was 401 days (interquartile range 105 to 492 days). Two patients underwent a heart transplant, 3 patients died on support, and 1 is alive on support. In all cases, there was a reduction of functional mitral regurgitation without MitraClip-related complications. ConclusionsBased on this small case series, implantation of a CF-LVAD appears safe in patients with a previously positioned MitraClip system, at least, with 1 or 2 clips in place, with no need for additional mitral valve surgery.

Mechanisms of changes in functional mitral regurgitation by preload alterations

BackgroundThis study aimed to investigate the mechanisms of acute changes in functional mitral regurgitation (FMR) by preload alterations. MethodsTwenty-two consecutive patients with left ventricular ejection fraction <40% and at least mild FMR underwent transthoracic echocardiography. Passive leg lifting and sublingual administration of nitroglycerin were performed to alter preload. Mitral regurgitant volume (MRV) was assessed using the Doppler method. ResultsMRV changed in parallel with preload alterations. MRV correlated better with tenting height (TH) than with mitral annular area (MAA) at baseline, whereas the difference in the correlate coefficients was not statistically significant (R=0.69 and R=0.40, respectively; p=0.19). On the other hand, changes in MRV between each sequential stage correlated better with those in MAA than with those in TH (R=0.68 and R=0.44, respectively; p=0.043). Multiple regression analysis revealed that baseline TH was the independent determinant of baseline MRV (R=0.69, p=0.0004), whereas changes in MAA with preload alteration were the independent determinant of the changes in MRV (R=0.68, p<0.0001). Changes in left atrial (LA) volume were the independent determinant of the changes in MAA (R=0.30, p=0.0063). ConclusionsAcute changes in FMR with preload alterations resulted from the transverse changes in MAA rather than the longitudinal changes in tethering–tenting of mitral geometry, and mitral annular deformation was determined by changes in LA volume. Preload reduction might help heart failure treatment through the reduction in FMR resulting from the decrease in LA and mitral annular size.

Minimally invasive mitral valve annuloplasty confers a long-term survival benefit compared with state-of-the-art treatment in heart failure with functional mitral regurgitation

BackgroundClinical impact of the minimally invasive surgical mitral valve annuloplasty (MVA) of functional mitral regurgitation (FMR) in systolic heart failure on top of the state-of-the-art standards of care remains controversial. Therefore, we aimed to compare clinical outcomes of isolated MVA using the mini-invasive videothoracoscopic approach versus the state-of-the-art (CON=conservative) treatment in patients with chronic systolic heart failure and symptomatic FMR. MethodsThe study population consisted of 379 patients (age 68.9±11.0years, 62.8% males) with left ventricular (LV) systolic dysfunction, symptomatic FMR and previous heart failure hospitalization. A total of 167 patients underwent undersized MVA and 212 patients were treated conservatively. A concomitant MAZE was performed in 53 (31.7%) patients. ResultsIn the MVA group, the periprocedural and the 30-day mortality were 1.2% and 4.8%, respectively. During the median follow-up of 7.1years (IQR 3.5–9.8years) a total of 74 (44.3%) and 138 (65.1%) died in the MVA and the CON group, respectively (p<0.001). The lowest mortality was observed in MVA combined with MAZE (22.6%; p<0.01). In Cox regression analysis, age, MVA with MAZE emerged as independent predictors of both all-cause mortality and rehospitalizations for heart failure (all p<0.05). MVA was associated with significantly greater symptomatic improvement and reduction of FMR than the conservative treatment (both p<0.001). Reverse LV remodeling was observed only in the MVA combined with MAZE group (p<0.01). ConclusionsIn patients with symptomatic FMR, minimally invasive MVA, in particular in combination with MAZE, confers an independent long-term survival benefit compared with the state-of-the-art treatment.

Extracardiac approach to functional mitral regurgitation: a cost-effective approach to addressing heart failure

BackgroundHeart failure is frequently associated with severely impaired ventricular function and manifests often with functional mitral regurgitation (FMR). This is a complex syndrome that is primarily due to abnormal function...

Treatment of functional mitral regurgitation by percutaneous annuloplasty using the Carillon Mitral Contour System-Currently available data state.

The purpose of this study is to provide a systematic review of currently available data about the percutaneous trans-coronary-venous mitral annuloplasty with the Carillon Mitral Contour System. A systematic literature search was conducted using the common medical and scientific databases. The documented parameters included among others grade of mitral regurgitation (MR), vena contracta (VC), effective regurgitant orifice area (EROA), 6 minute-walk-test (6MWT), NYHA-classification, and Quality of Life (QoL) at baseline, 30 days and in the long-term follow-up. The exact total number of successfully implantations with available data remains unclear because so many publications are either of the same institution or study group, or they present overlapping results. Reduction of functional mitral regurgitation (FMR) was associated with significant inverse left-ventricular (LV)) remodeling, improvement in 6MWT, QoL and NYHA-class during the 12-month follow-up. In almost half of the enrolled patients, the Carillon System could not be implanted or had to be removed due to coronary compromission. Adverse advent rate (AE) ranged between 2.8-39%. Results with regard to reduction of MR and inverse LV remodeling have been remarkable. Indication and selection criteria for suitable patients, the expected complications, and the long-term results with regard to survival and quality of life still remain unclear. The available results do not establish superiority of the Carillon Mitral Contour System and support the lack of a clear benefit. The approach with the Carillon Mitral Contour System should be limited to participants of prospective and randomized trials.

Transapical Coaptation Plate for Functional Mitral Regurgitation: An In Vitro Study.

A novel transapical coaptation plate (TCP) device was developed and anchored by sutures in the mitral valve to treat functional mitral regurgitation. The objective of this study was to test efficacy of the TCP in an in vitro model. Eight fresh porcine mitral valves were mounted in a left heart simulator to simulate functional mitral regurgitation by means of annular dilatation and asymmetrical or symmetrical papillary muscle (PM) displacement. Six polyurethane TCPs in thickness of 6.4(#1), 4.8(#2), 3.2(#3) mm and hardness of durometer 30 A (H) and 30 OO(S),were fabricated and labeled as H1, H2, H3 and S1, S2, S3, respectively. These TCPs were anchored by the sutures in the mitral annulus and left ventricle apex, and tested. Steady backward flow leakage in a hydrostatic condition and regurgitant volume in a pulsatile flow were measured before and after implantation of the TCPs. Mean regurgitant volume fractions in the asymmetric PM displacement were reduced significantly from 59.1 to 37.2% for H1, 43.2% for H2, 35.9% for S1 and 34.2% for S2 (p<0.021), after implantation of the TCPs. No significant reduction in mitral regurgitation was seen for H3 and S3 (p>0.067). Mitral regurgitation was mild in the symmetric PM displacement, and was not significantly reduced after implantation of the TCPs. In conclusion, the TCP anchored by the sutures in the mitral annulus and left ventricle apex functions successfully as a plug in the mitral valve leaflet gap. The TCP with thickness equal to or greater than 4.8mm is effective to reduce functional mitral regurgitation. The TCP hardness has no effect on difference in reduction of functional mitral regurgitation.

Impact of mitral geometry and global afterload on improvement of mitral regurgitation after trans-catheter aortic valve implantation.

ObjectiveTo assess the impact of mitral geometry, left ventricular (LV) remodelling and global LV afterload on mitral regurgitation (MR) after trans-catheter aortic valve implantation (TAVI).MethodsIn this study, 60 patients who underwent TAVI were evaluated by 3D echocardiography at baseline, 1 month and 6 months after procedure. The proportional change in MR following TAVI was determined by examining the percentage change in vena contracta (VC) at 6 months. Patients having a significant reduction of at least 30% in VC were defined as good responders (GR) and the remaining patients were defined as poor responders (PR).ResultsAfter 6 months of TAVI, 27 (45%) patients were GR and 33 (55%) were PR. There was a significant decrease in 3DE-derived mitral annular diameter and area (P = 0.001), mitral valve tenting area (TA) (P = 0.05), and mitral papillary muscle dyssynchrony index (DSI) (P = 0.05) in the GR group. 3DE-derived LVESV (P = 0.016), LV mass (P = 0.001) and LV DSI, (P = 0.001) were also improved 6 months after TAVI. In addition, valvulo-arterial impedance (ZVA) was significantly higher at baseline in patients with PR (P = 0.028). 3DE-derived mitral annular area (β: 0.47, P = 0.04), mitral papillary DSI (β: −0.65, P = 0.012) and ZVA (β: 0.45, P = 0.028) were the strongest independent parameters that could predict the reduction of functional MR after TAVI.ConclusionGR patients demonstrate more regression in mitral annulus area and diameter after significant decrease in high LVEDP and trans-aortic gradients with TAVI. PR patients appear to have increased baseline ZVA, mitral valve tenting and restriction in mitral valve coaptation. These factors are important for predicting the impact of TAVI on pre-existing MR.

Effects of Mitral Annulus Remodeling Following MitraClip Procedure on Reduction of Functional Mitral Regurgitation

Introduction and objectivesThe percutaneous mitral valve repair procedure (MitraClip) appears to reduce mitral annulus diameter in patients with functional mitral regurgitation, but the relationship between this and regurgitation severity has not been demonstrated. The aim of this study was to determine the effect of mitral annulus remodeling on the reduction of mitral regurgitation in patients with functional etiology. MethodsThe study included all patients with functional mitral regurgitation treated with MitraClip at our hospital until January 2015. Echocardiogram (iE33 model, Philips) was performed in all patients immediately after device positioning. Changes in the mitral annulus correlated with mitral regurgitation severity, as assessed using the effective regurgitant orifice area. ResultsThe study included 23 patients (age, 65±14 years; 74% men; left ventricular ejection fraction, 31%±13%; systolic pulmonary artery pressure, 47±10 mmHg). After the procedure, the regurgitant orifice area decreased by 0.30 cm2±0.04 cm2 (P<.0005), from a baseline of 0.49 cm2±0.09 cm2. Anteroposterior diameter decreased by 3.14 mm±1.01 mm (P<.0005) from a baseline of 28.27 mm±4.9 mm, with no changes in the intercommissural diameter (0.50 mm±0.91 mm vs 40.68 mm±4.7 mm; P=.26). A significant association was seen between anteroposterior diameter reduction and regurgitant orifice area reduction (r=.49; P=.020). ConclusionsIn patients with functional mitral regurgitation, the MitraClip device produces an immediate reduction in the anteroposterior diameter. This remodeling may be related to the reduction in mitral regurgitation.

THE EFFICACY OF PERCUTANEOUS TRANS-VENOUS MITRAL ANNULOPLASTY FOR THE TREATMENT OF FUNCTIONAL MITRAL REGURGITATION: PREDICTIVE VALUE OF ECHOCARDIOGRAPHIC PARAMETERS

Implantation of Carillon device into the coronary venous system was shown to result in the reduction in functional mitral regurgitation (FMR), but it is not clear which patient would benefit the most. We investigated which echo parameters may help in prediction of the efficacy of percutaneous mitral