Regurgitant Orifice Research Articles

Extent and predictors of exercise-induced changes in ischemic mitral regurgitation during handgrip exercise

Abstract Background Mitral regurgitation (MR) is frequent in patients with ischemic heart disease and carries a dismal prognosis. Recent studies suggest that ischemic MR is a dynamic condition influenced by global and regional left ventricular (LV) remodeling as well as mitral valvular deformation. Handgrip exercise may serve as alternative exercise intervention to bicycle exercise. Purpose To assess degree and determinants of exercise-induced changes in ischemic MR during handgrip exercise. Methods We prospectively enrolled 205 patients with at least mild ischemic MR that underwent echocardiography at rest and during three minutes of handgrip exercise according to a standardized protocol. Results Mean age in our patient cohort was 75±10 years, 30% were female, and 58% suffer from atrial fibrillation. Median NT-proBNP was 2657 (1331–6599) ng/l. Mean left ventricular ejection fraction was 44±14%. At rest, MR severity was graded as mild in 57% of patients, moderate MR in 34% and severe in 9%. Mean effective regurgitant orifice area (EROA) at rest was 15±6 mm2 and regurgitation volume was 25±11 ml. During handgrip exercise, 58 patients (28%) showed an increase in MR severity in at least one grade; 30 patients (15%) with non-severe MR at rest, developed severe MR during handgrip exercise. The EROA decreased (>5 mm2) in 5% of patients, remained unchanged in 50% (between −5 mm2 and +5 mm2), and increased (>5 mm2) in 45% of patients (Fig. 1B). A small increase (5–10 mm2) was observed in 30%, while 15% of patients revealed a marked increase in EROA (>10 mm2) (Fig. 1B). The degree of MR at rest was not associated with exercise-induced increases in EROA (r=−0.03; p=0.641)(Fig. 1C). However, echocardiographic parameters of local (e.g. tenting height) and global (e.g. LVESVi) LV remodeling, as well as mitral valvular deformation correlated with exercise-induced changes in EROA (Table 1). Conclusion In patients with secondary MR due to ischemic heart disease, handgrip echocardiography unmasks exercise-induced increases of MR severity in a significant proportion of patients. Dynamic MR during handgrip exercise is associated with parameters of global and local LV remodeling as well with parameters of mitral valvular deformation. Future studies need to address the prognostic importance of exercise-induced changes in MR severity in patients with ischemic cardiomyopathy. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): This work was supported by the Forschungskommission of the Medical Faculty of the Heinrich Heine University Düsseldorf to Maximilian Spieker for a Clinician Scientist Track.

Isolated functional tricuspid regurgitation, how define patient at-risk for event?

Abstract Introduction Functional tricuspid regurgitation (TR) is a turning point in cardiac diseases. Symptoms typically appear late, and the optimal timing for proposing a valve repair remains a challenge. We sought to analyse the characteristics of right heart remodelling in patients with significant functional TR to identify the parameters that could be used in an easily achievable and fair prognostic model predicting clinical events. Methods We designed a prospective observational French multicentre study including 160 patients with significant functional TR (effective regurgitant orifice area >30mm2) and LVEF >40%. Clinical, echocardiographic, and ECG data were collected at baseline, and at the 1- and 2-year follow-up. The primary outcome was all-cause death or hospitalization for heart failure. Results At 2 years, 56 patients (35%) achieved the primary outcome. The subset with events showed more advanced right heart remodelling at baseline, but similar TR severity. Right atrial volume index (RAVI) and the TAPSE/sPAP ratio, reflecting right-ventricle-pulmonary artery coupling, were 73 mL/m2 and 0.40 versus 64.7 mL/m2 and 0.50 in the event vs event-free group, respectively (both p<0.05). None among all the clinical and imaging parameters tested had a significant group × time interaction. In multivariable analysis, the model including TAPSE/sPAP ratio >0.4 (OR=0.41, 95%CL 0.2 to 0.82) and RAVI >60 mL/m2 (OR=2.13, 95%CL 0.96 to 4.75) permitted the fairest and most parsimonious prognostic evaluation. Conclusion RAVI and TAPSE/sPAP are relevant for predicting the risk for event at 2-year follow-up in patient with an isolated functional TR. Funding Acknowledgement Type of funding sources: None.

Utility and futility of MitraClip implantation in secondary mitral regurgitation in a real-world population: the role of 3D transthoracic echocardiography

Abstract Introduction Two recent prospective trials have been published, reporting opposite results on the efficacy and utility of the MitraClip (MC) procedure in patients with secondary mitral regurgitation (SMR). A ratio between the effective regurgitant orifice area (EROA) and left ventricular end-diastolic volume (LVEDV) ≥0.150 by two-dimensional (2D) transthoracic echocardiography (TTE) has been proposed to identify patients with disproportionate SMR, who would benefit from MC. Purpose To assess the prognostic role of clinical and echocardiographic parameters in a real-world population of SMR patients undergoing the MC procedure at our Institute. Methods Ninety-two patients underwent MC implantation. We retrospectively reviewed their clinical, and laboratory data, as well as 2D and three-dimensional (3D) TTE, and intraoperative transoesophageal echocardiography (Figure 1). The primary endpoint was a composite of cardiovascular death and/or hospitalisation for heart failure within 12-months follow-up. Results Thirty-one patients reached the endpoint (EP+), 61 did not (EP−). Demographics and anti-remodelling drugs were similar in EP+ and EP. Among comorbidities and laboratory data, EP+ significantly differed from EP− in smoking history, and extracardiac artery disease prevalence (65% vs. 39%, and 39% vs. 16%, respectively); EuroScoreII (12.2% vs. 5.2%); NYHA class ≥3 (94% vs. 69%); haemoglobin (12±2 vs. 13±2 g/dL), and brain natriuretic peptide levels (855 [426–1500] vs. 357 [170–902] pg/mL). At 2D TTE no significant difference emerged, including the SMR grade, except for the tricuspid annular plane systolic excursion (Figure 2). Biventricular 3D ejection fraction was significantly lower in EP+ vs. EP− (Figure 2). Residual intraoperative SMR grade after MC deployment was 1.9±0.6 in EP+ vs. 1.3±0.5 in EP− (p<0.001). Conclusion The proposed cut-off for EROA/LVEDV ratio may be suboptimal for predicting the MC utility in real-world populations. Rather, prognosis may be more influenced by the patient's pre-operative clinical status, right ventricular systolic function, 3D left ventricular ejection fraction, and by the success of the procedure. Funding Acknowledgement Type of funding sources: None.

Capability of CT aortic regurgitant orifice to predict aortic regurgitation severity with cardiovascular magnetic resonance as reference

Abstract Background Regurgitant orifice area (ROA) measurements by cardiac CT have not been extensively compared with a quantitative classification of aortic regurgitation (AR) severity based on regurgitant fraction (RF) by phase-contrast cardiovascular magnetic resonance (PC-CMR) [1–3]. Purpose To evaluate ROA diagnostic accuracy by 256-slice CT for predicting severe AR with PC-CMR as reference. Material and methods We consecutively enrolled 57 patients with AR prior to surgery assessed by echocardiography, PC-CRM, and CT. Mean age 67.3±15.3 (84% males). Cardiac CT data sets were reconstructed at 75–78% of the R-R interval to measure ROA. According to previous data (4), a cut-off value of 33% by PC-CMR defined severe AR. Receiver operating curve (ROC) were calculated to detect the best CT-ROA cut-off to predict severe AR by CMR. Results There were no differences between both groups of AR patients in terms of age, gender, or anthropometric measures. CT-ROA was significantly smaller in patients with RF<33% by PC-CMR (0.24±0.09 vs 0.49±0.22; p<0.001). AR etiology, jet eccentricity, ascending aorta diameters and ejection fraction (LVEF) also were not significantly different according to AR-RF group (Table 1). CT-ROA significantly correlated with the RF>33% by PC-CMR (Pearson's correlation coefficient (R)=0,48, p<0.001) (Figure 1A). In the ROC curve analysis to predict significant RF, a CT-ROA cut-off of 0.27 cm2 correctly classified 93% of patients with sensitivity of 97.6% (CI95%:87,7–99,6); specificity of 73.33% (CI95%:48–89); PPV 95,3% (CI95%: 84,5–98,7); NPV 91,7% (CI95%: 64,6% a 98,5%) and area under the curve (AUC) of 0.93 (CI95%: 0.85–1.00; p<0.001) (Figure 1B). Conclusion CT-RAO could be useful to distinguish AR severity determined by PC-CMR with a cut-off value of 0.27 cm2 as best predictor. Funding Acknowledgement Type of funding sources: None.

The mitral to aortic/pulmonary velocity-time integral ratio is a simple, feasible and accurate discriminator for echocardiographic evaluation of severe isolated mitral regurgitation

Abstract Background Echocardiographic quantification of mitral regurgitation (MR) remains challenging, requiring dedicated image acquisition, and is limited by potential error from geometric assumptions of annular dimensions. Volume is a product of area and flow and assuming proportional mitral/aortic areas, an increased mitral-inflow volume compared to LV/RV-outflow semi-quantitatively represents greater MR regurgitant volume. Therefore, we investigated the feasibility and diagnostic performance of the mitral-aortic velocity-time integral (VTI) ratio in isolated MR. We also investigated the use of the mitral-pulmonary VTI ratio as an alternative in clinical situations where the LV outflow tract (LVOT) VTI could not be used. Methods We reviewed 166 consecutive patients (54 (33% severe MR by multi-parameter integrated expert opinion)). Pulsed-Doppler VTI at the mitral leaflet tips and the left ventricular outflow and continuous-wave Doppler of the right ventricular outflow tract were measured individually and independently by blinded readers (expert and trainee status) to derive the ratio. Receiver operator characteristic area under the curve (AUC) comparison was calculated and compared with effective regurgitant orifice area (EROA >40 mm), regurgitant volume (RVol >6 0mL), vena contracta (VC >0.7 cm), E-velocity >1.2 cm, systolic flow reversal (SFR), left atrial and ventricular dilatation. Results Increasing ratio was associated with severe MR (AUC 0.94) with optimal threshold defined at 1.3. This provided significant discrimination for severe MR (AUC 0.81) compared to EROA (0.68), VC (0.52), LV dilatation (0.69), LA dilatation (0.70), SFR (0.73), E-velocity (0.68) all p<0.05, with sensitivity 82% and specificity 94%. The mitral-pulmonary VTI ratio demonstrated similar discrimination (AUC 0.92) with optimal threshold defined at 1.14. Excellent inter-observer reproducibility (intra-class correlation 0.97) was seen between trainee and expert readers. There was no difference in AUC comparison by MR mechanism or patient rhythm. Conclusions The mitral-aortic or mitral-pulmonary VTI ratio is a simple, geometric-free parameter feasibly reproducible from routine echocardiographic datasets and is an excellent discriminative tool for severe MR. Readers should consider integration of this parameter in routine reporting. Funding Acknowledgement Type of funding sources: None.

1-Year Outcomes of Cardioband Tricuspid Valve Reconstruction System Early Feasibility Study.

Tricuspid regurgitation (TR) is prevalent and undertreated, with mortality and morbidity increasing with TR severity. Given poor outcomes with medical therapy and high in-hospital mortality for isolated tricuspid valve surgery, emerging transcatheter repair devices offer a promising alternative. The Edwards Cardioband Tricuspid Valve Reconstruction System Early Feasibility study (NCT03382457) evaluates the treatment of functional TR via annular reduction with the Cardioband Tricuspid Valve Reconstruction System (Edwards Lifesciences). Patients with≥ moderate functional TR were eligible for this prospective, single-arm multicenter study. At 1year, patients were evaluated for echocardiographic parameters, clinical and quality-of-life measures, and major adverse events. The 37 patients enrolled had a mean age of 78 years; 76% were female; and they had≥ severe functional (97.3%) or mixed (2.7%) TR, atrial flutter/fibrillation (97%), and New York Heart Association functional class III/IV (65%). At 1 year, 73.0% achieved≤ moderate TR (P< 0.0001), and 73.1% had≥2 grade reductions. Echocardiography showedsignificant reductions in the tricuspid annulus diameter (P< 0.0001), mean vena contracta (P< 0.0001), proximal isovelocity surface area effective regurgitant orifice area (P< 0.0001), right ventricular end-diastolic diameter (P< 0.0001), and inferior vena contracta (P = 0.0006). New York Heart Association functional class improved significantly (P< 0.0001), with 92.3% achieving class I/II, and Kansas City Cardiomyopathy Questionnaire scores improved by 19.0 points (P< 0.0001). One-year cardiovascular mortality was 8.1%, reinterventions were necessary in 5.4%, major access site complications occurred in 8.1%, and severe bleeding was noted in 35.1% of patients. Kaplan-Meier estimates of survival and freedom from heart failure rehospitalization were 85.9% and 88.7%, respectively. One-year experience using the Cardioband system for tricuspid valve repair shows high survival and low rehospitalization rates with durable outcomes in TR reduction and echocardiographic, clinical, and quality-of-life outcomes.

Edge-to-Edge Repair for Tricuspid Valve Regurgitation. Preliminary Echo-Data and Clinical Implications from the Tricuspid Regurgitation IMAging (TRIMA) Study.

Background: The natural history of tricuspid valve regurgitation (TR) is characterized by poor prognosis and high in-hospital mortality when treated with isolated surgery. We report the preliminary echocardiographic and procedural results of a prospective cohort of symptomatic patients with high to prohibitive surgical risk and at least severe TR who underwent transcatheter edge-to-edge repair through the TriClipTM system. Methods: From June 2020 to March 2022, 27 consecutive patients were screened, and 13 underwent transcatheter TriClipTM repair. In-hospital, 30-day and six-month clinical and echocardiographic outcomes were collected. Results: Nine patients had severe, three massive and one baseline torrential TR. Sustained TR reduction of ≥1 grade was achieved in all patients, of which 90% reached a moderate TR or less. On transthoracic echocardiographic examination, there were significant reductions in vena contracta width (p < 0.001), effective regurgitant orifice area (p < 0.001) and regurgitant volume (p < 0.001) between baseline and hospital discharge. We also observed a significant reduction in tricuspid annulus diameter (p < 0.001), right ventricular basal diameter (p = 0.001) and right atrial area (p = 0.026). Conclusion: Treatment with the edge-to-edge TriClip device is safe and effective. The resulting echocardiographic improvements indicate tricuspid valve leaflet approximation does not just significantly reduce the grade of TR but also affects adjacent structures and improves right ventricular afterload adaptation.

The impact of transcatheter edge-to-edge repair on right ventricle-pulmonary artery coupling in patients with functional mitral regurgitation.

The impact of transcatheter edge-to-edge repair on right ventricle-pulmonary artery coupling in patients with functional mitral regurgitation.

Atrial Functional Tricuspid Regurgitation: Novel Definition and Impact on Prognosis.

Atrial functional tricuspid regurgitation (atrial TR) has received growing recognition as a TR entity with a distinct cause owing to its independence from valvular tethering as the predominant mechanism underlying TR. However, characterization of atrial TR varies, and a universal definition is lacking. In total, 651 patients with significant functional TR were analyzed, including 438 conservatively treated individuals and 213 patients who received transcatheter tricuspid valve repair (TTVR). Based on a clustering approach, we defined atrial TR as tricuspid valve (TV) tenting height ≤10 mm, midventricular right ventricular diameter ≤38 mm, and left ventricular ejection fraction ≥50%. Patients with atrial TR were more often females, had higher right ventricular fractional area change, higher left ventricular ejection fraction, and lower LV end-diastolic diameter, TV tenting area and height, lower right ventricular and tricuspid annular size, enlarged, but lower right atrial area and lower TV effective regurgitant orifice area (all P<0.05). Patients with atrial TR had significantly better long-term survival than non-atrial TR in the conservatively treated TR cohort (P<0.01, n=438). Atrial TR was independently associated with a lower rate of the combined end point of mortality and heart failure hospitalization at 1-year follow-up in the TTVR cohort (hazard ratio, 0.39; P<0.05, n=213). TR degree was significantly reduced after TTVR in non-atrial and atrial TR (P<0.01). Functional parameters significantly improved following TTVR independent of TR cause (P<0.05). An echocardiography-based atrial TR definition is associated with prognostic relevance in patients with functional TR in conservatively treated TR and after TTVR.

AVNeo improves early haemodynamics in regurgitant bicuspid aortic valves compared to aortic valve repair.

Calcified or fibrotic cusps in patients with bicuspid aortic valves and aortic regurgitation complicate successful aortic valve (AV)-repair. Aortic valve neocuspidization (AVNeo) with autologous pericardium offers an alternative treatment to prosthetic valve replacement. We compared patients with regurgitant bicuspid valves undergoing AV-repair or AVNeo. We retrospectively analysed patients with regurgitant bicuspid valves undergoing AV-repair or AVNeo. We focused on residual regurgitation, pressure gradients and effective orifice area, determined preoperatively and at discharge. AV-repair was performed in 61 patients (mean age: 43.2 ± 11.3 years) and AVNeo in 22 (45.7 ± 14.1). Prior to the operation patients of the AV-repair group showed severe regurgitation in 38 cases (62.3%) and moderate in 23 (37.6%); in the AVNeo group, all patients exhibited severe regurgitation. Postoperatively, 57 patients (93.4%) patients had no or mild regurgitation after AV-repair and 21 (95.4%) after AVNeo. In AVNeo-patients, peak (10.6 ± 3.1 mmHg vs 22.7 ± 11 mmHg, P&lt; 0.001) and mean pressure gradients (5.9 ± 2 mmHg vs 13.8 ± 7.3 mmHg, P &lt; 0.001) were significantly lower and the orifice area significantly larger (2.9 ± 0.8 cm2 vs 1.9 ± 0.7 cm2, P &lt; 0.001) compared to repair. Compared to AV-repair, patients AVNeo showed lower mean pressure gradients and larger orifice areas at discharge. The functional result was not different.

Paravalvular Leak After Implantation of the ACURATE neo and the ACURATE neo2 Transcatheter Heart Valve

BackgroundThe ACURATE neo has been associated with more paravalvular leak (PVL) than other transcatheter valves. The ACURATE neo2 is equipped with an extended sealing skirt, but data on this novel valve is scarce. The PREDICT PVL study aimed to assess PVL after implantation of the ACURATE neo and the ACURATE neo2. MethodsPatients undergoing transcatheter aortic valve implantation with the ACURATE neo (n = 30) and the ACURATE neo2 (n = 30) were enrolled in the prospective PREDICT PVL study. Postprocedural evaluation included transthoracic and transesophageal echocardiography and computed tomography. ResultsBaseline and procedural characteristics and short-term clinical outcomes were comparable between the two groups. More than 90 % of PVL was localized around the left coronary cusp. The ACURATE neo2 with its extended sealing skirt reduced the cumulative effective regurgitation orifice area (EROA) of the PVLs by 48 % from 13.7 ± 9.7 mm2 to 7.1 ± 5.7 mm2 (p < 0.001). The average number of PVL jets remained unchanged (2 jets per patient), but the sealing skirt reduced the size of the PVL jets. Multivariable predictors for less PVL were use of the ACURATE neo2, less valvular calcification, deeper valve implantation and valve size S or M as opposed to L. ConclusionsMore than 90 % of PVL occurred adjacent to the left coronary cusp. The sealing skirt of the ACURATE neo2 reduced PVL EROA by 48 % without an increase in conduction disorders. The best results with ACURATE neo2, in terms of low PVL, are achieved in patients with lower valve calcification, deeper implantation and with S or M sizes.

Mortality and Clinical Predictors After Percutaneous Mitral Valve Repair for Secondary Mitral Regurgitation: A Systematic Review and Meta-Regression Analysis.

BackgroundPercutaneous mitral valve repair (PMVR) provides an available choice for patients suffering from secondary mitral regurgitation (SMR), especially those whose symptoms persist after optimal, conventional, heart-failure therapy. However, conflicting results from clinical trials have created a problem in identifying patients who will benefit the most from PMVR.ObjectiveTo pool mortality data and assess clinical predictors after PMVR among patients with SMR. To this end, subgroup and meta-regression analyses were additionally performed.MethodsWe searched PubMed, EMBASE, and Cochrane databases, and 13 studies were finally included for meta-analysis. Estimated mortality and 95% confidence intervals (CIs) were obtained using a random-effects proportional meta-analysis. We also carried out a meta-regression analysis to clarify the potential influence of important covariates on mortality.ResultsA total of 1,259 patients with SMR who had undergone PMVR were enrolled in our meta-analysis. The long-term estimated pooled mortality of PMVR was 19.3% (95% CI: 13.6–25.1). Meta-regression analysis showed that mortality was directly proportional to cardiac resynchronization therapy (CRT) (β = 0.009; 95% CI: 0.002–0.016; p = 0.009), an effective regurgitant orifice (ERO) (β = 0.009; 95% CI: 0.000–0.018; p = 0.047), and a mineralocorticoid receptor antagonist (MRA) use (β = −0.015; 95% CI: −0.023–−0.006; p < 0.001). Subgroup analysis indicated that patients with preexisting AF (β = −0.002; 95% CI: −0.005– −0.000; p = 0.018) were associated with decreased mortality if they received a mitral annuloplasty device. Among the edge-to-edge repair device group, a higher left ventricular (LV) ejection fraction, or lower LV end-systolic diameter, LV end-systolic volume, and LV end-diastolic volume were proportional to lower mortality.Conclusion and RelevanceThe pooled mortality of PMVR was 19.3% (95% CI: 13.6–25.1). Further meta-regression indicated that AF was associated with a better outcome in conjunction with the use of a mitral annuloplasty device, while better LV functioning predicted a better outcome after the implantation of an edge-to-edge repair device.

Impact of correcting the 2D PISA method on the quantification of functional tricuspid regurgitation severity.

In functional tricuspid regurgitation (FTR) patients, tricuspid leaflet tethering and relatively low jet velocity could result in proximal flow geometry distortions that lead to underestimation of TR. Application of correction factors on two-dimensional (2D) proximal isovelocity surface area (PISA) equation may increase its reliability. This study sought to evaluate the impact of the corrected 2D PISA method in quantifying FTR severity. In 102 patients with FTR, we compared both conventional and corrected 2D PISA measurements of effective regurgitant orifice area [EROA vs. corrected (EROAc)] and regurgitant volume (RegVol vs. RegVolc) with those obtained by volumetric method (VM) using three-dimensional echocardiography (3DE), as reference. Both EROAc and RegVolc were larger than EROA (0.29 ± 0.26 vs. 0.22 ± 0.21 cm2; P &lt; 0.001) and RegVol (24.5 ± 20 vs. 18.5 ± 14.25 mL; P &lt; 0.001), respectively. Compared with VM, both EROAc and RegVolc resulted more accurate than EROA [bias = -0.04 cm2, limits of agreement (LOA) ± 0.02 cm2 vs. bias = -0.15 cm2, LOA ± 0.31 cm2] and RegVol (bias = -3.29 mL, LOA ± 2.19 mL vs. bias = -10.9 mL, LOA ± 13.5 mL). Using EROAc and RegVolc, 37% of patients were reclassified in higher grades of FTR severity. Corrected 2D PISA method led to a higher concordance of TR severity grade with the VM method (ĸ = 0.84 vs. ĸ = 0.33 for uncorrected PISA, P &lt; 0.001). Compared with VM by 3DE, the conventional PISA underestimated FTR severity in about 50% of patients. Correction for TV leaflets tethering angle and lower velocity of FTR jet improved 2D PISA accuracy and reclassified more than one-third of the patients.

Left atrial volume index and outcome after transcatheter edge-to-edge valve repair for secondary mitral regurgitation.

To investigate the role of left atrial volume index (LAVi) in patients with secondary mitral regurgitation (SMR) undergoing transcatheter edge-to-edge mitral valve repair (TEER). Outcomes were evaluated in SMR patients of a European multicentre registry according to baseline LAVi. Main analysis was performed for all-cause mortality; residual mitral regurgitation (MR) and New York Heart Association (NYHA) class improvement were analysed for patients available. A total of 1074 patients were included with a median LAVi (interquartile range) of 58 ml/m2 (46-73). Postprocedural reduction of MR grade to ≤2+ was similar across LAVi quintiles, ranging 91%-96% (p=0.26). Symptomatic benefit (≥1 NYHA class improvement) also did not differ by LAVi quintiles (61%-68% of patients) (p=0.66). The risk of mortality increased by 23%-42% in the four upper quintiles compared to the bottom quintile (LAVi <42 ml/m2 ). The hazard ratio (HR) of mortality was 1.35 (95% confidence interval [CI] 1.02-1.78, p=0.035) associated with a LAVi >42 ml/m2 , which was attenuated after multivariable adjustment (HR 1.18, 95% CI 0.83-1.67, p=0.36). A significant interaction was found for MR severity and pulmonary hypertension, with an increased risk of death associated with enlarged LAVi in patients with inframedian effective regurgitant orifice area (HR 1.99, 95% CI 1.06-3.74, p=0.032) and in patients with systolic pulmonary pressure ≤50 mmHg (HR 1.67, 95% CI 1.02-2.75, p=0.042) in multivariable analysis. Procedural success and symptomatic benefit were high throughout the whole range of LAVi. The prognostic impact of left atrial enlargement was relevant in patients with less severe SMR and without pulmonary hypertension, reinforcing the need to identify patients in the early course of backward congestion to achieve good long-term outcome after TEER.

Secondary mitral regurgitation: Maintaining coherence with the American Society of Echocardiography grading guidelines, which proportionality concept best predicts prognosis in the real world?

IntroductionProportionality of secondary mitral regurgitation (sMR) may be a key factor in deciding whether a patient may benefit from mitral intervention. The aim of this study was to evaluate the prognostic value of two different concepts of proportionality and assess their ability to improve MR stratification proposed by the American Society of Echocardiography (ASE) guidelines. MethodsWe conducted a retrospective analysis in patients with reduced left ventricular ejection fraction (LVEF) (<50%) and at least mild sMR. Proportionality status was calculated using formulas proposed by a) Grayburn et al. – disproportionate sMR defined as EROALVEDV >0.14; b) Lopes et al. – disproportionate sMR whenever measured EROA>theoretical EROA (determined as 50%×LVEF×LVEDVMitralVTI). Primary endpoint was all-cause mortality. ResultsA total of 572 patients (69±12 years; 76% male) were included. Mean LVEF was 33±9%, with a median left ventricular end-diastolic volume of 174 mL [136;220] and a median effective regurgitant orifice area of 14 mm2 [8;22]. During mean follow-up of 4.1±2.7 years, there were 254 deaths. There was considerable disagreement (p<0.001) between both formulas: of 96 patients with disproportionate sMR according to Lopes’ criteria, 46 (48%) were considered proportionate according to Grayburn's; and of 62 patients with disproportionate sMR according to Grayburn's, 12 (19%) were considered proportionate according to Lopes’ formula.In multivariate analysis, only Lopes’ definition of disproportionate sMR maintained independent prognostic value (hazard ratio 1.5; 95% confidence interval 1.07–2.1, p=0.018) and improved the risk stratification of ASE sMR classification. ConclusionOf the two formulas available to define disproportionate sMR, Lopes’ model emerged as the only one with independent prognostic value while improving the risk stratification proposed by the ASE guidelines.

Change in Lung Fluid Volume during Exercise in Patients with Exercise-Induced Mitral Regurgitation

Exercise-induced mitral regurgitation (MR) can be diagnosed during stress echocardiography testing. Remote dielectric sensing (ReDSTM) is a noninvasive electromagnetic-based modality to measure lung fluid levels. The change in lung fluid levels in patients with MR during stress echocardiography remains unknown. Patients with symptomatic MR at baseline and suspected worsening exercise-induced MR underwent stress echocardiography. ReDS values were measured before and after the tests. A total of four patients (ages ranging between 74 and 84 years old, three women) underwent stress echocardiography testing using a bicycle ergometer. In patient A, MR effective regurgitant orifice area (EROA) remained unchanged and ReDS values decreased. EROA increased significantly with a small incremental change in ReDS values in patient B and patient C, who underwent valve repair with MitraClip later. Patient D had a mild increase in MR EROA but a considerable increase in ReDS values (from 22% to 32%), and eventually received valve repair with MitraClip. The ReDS system may be a complementary tool to conventional stress echocardiography in the evaluation of clinically significant MR and considering mitral valve intervention.

Novel Computed Tomography Variables for Assessing Tricuspid Valve Morphology: Results from the TRIMA (Tricuspid Regurgitation IMAging) Study.

Background: Computed tomography (CT) is the recommended imaging technique for defining the anatomical suitability for current transcatheter technologies and planning tricuspid valve (TV) intervention. The aim of the Tricuspid Regurgitation IMAging (TRIMA) study was to assess the geometrical characteristics of the TV complex using novel CT parameters. Methods: This prospective, single-center study enrolled 22 consecutive patients with severe tricuspid regurgitation, who underwent a cardiac CT study dedicated to the right chambers. The following variables were obtained: annulus area and perimeter, septal-lateral and antero-posterior diameters, tenting height, and anatomical regurgitant orifice area. Moreover, the following novel annular parameters were assessed: distance between commissures, distance between TV centroid and commissures, and angles between centroid and commissures. Results: A significant phasic variability during the cardiac cycle existed for all variables except for eccentricity, angles, and distance between the postero-septal and antero-posterior commissure and distance between the centroid and antero-posterior commissure. There was a significant relationship between the TV annulus area and novel annular parameters, except for annular angles. Additionally, novel annular variables were found to predict the annulus area. Conclusions: These novel additional variables may provide an initial platform from which the complexity of the TV annular morphology can continue to be better understood for further improving transcatheter therapies.

Color Doppler Splay in Mitral Regurgitation: Hemodynamic Correlates and Outcomes in a Clinical Cohort

Recently, an artifactual horizontal extension of the color Doppler signal was described in patients with mitral regurgitation (MR), called color Doppler splay (CDS). This side-lobe artifact was shown to be associated with concealed and significant MR. In the present study, the authors assessed the prognostic significance of CDS and its hemodynamic correlates. Consecutive patients with primary and secondary MR underwent comprehensive transthoracic echocardiography. Machine settings were fixed for all patients. MR severity was assessed using an integrated approach, as advocated in current international guidelines. The presence of CDS and CDS width and duration were assessed. The outcome measures included the incidence of major adverse cardiac events (a composite of cardiovascular mortality, hospitalization for decompensated heart failure, mitral valve surgery, or percutaneous mitral intervention). One hundred twenty-seven of 469 patients (27%) with MR demonstrated CDS. The presence of CDS was associated with worse MR, and CDS width correlated with effective regurgitant orifice area, regurgitant volume, and vena contracta width. Mitral annular or leaflet calcification was inversely associated with the presence of CDS. Patients with CDS experienced worse event-free survival. For CDS width, a cutoff of >29mm was identified as optimal regarding outcome prediction in our cohort and termed "severe CDS." In multivariate Cox regression, the presence of severe CDS was associated with adverse outcome, independent of MR etiology or severity and other clinical and echocardiographic predictors of outcome, and provided incremental prognostic value on top of these parameters. In patients with MR, the presence of CDS is associated with more severe MR and worse outcomes. Severe CDS provides incremental prognostic value on top of traditional MR metrics and should alert the echocardiographer that MR severity may be underestimated.

New ESC/EACTS guideline recommendations for the treatment of secondary mitral regurgitation: reflections on the evidence

New <scp>ESC</scp>/<scp>EACTS</scp> guideline recommendations for the treatment of secondary mitral regurgitation: reflections on the evidence

Functional Diagnostics by Rational Echocardiography

Functional diagnostics by rational echocardiography are the base of a verifiable and reliable analysis of ventricular and valvular function. The most important functional parameters in echocardiography are cardiac volumes - especially total and effective left ventricular stroke volume -, global longitudinal strain, effective orifica areas in valvular stenoses and effective regurgitant volumes, regurgitant fraction and regurgitant orifice areas in valvular regurgitations. Standardized documentation and correct measurements are the prerequisites for accurate echocardiographic estimations. In addition, optimization of image quality supports the correctness of measurements to ensure plausibility of hemodynamics in each individual patient. However, measurements of cardiac volumes by planimetry are error-prone. In addition, calculation of the effective orifice areas using the continuity equation needs methodological accuracy and standardization. Finally, assessment of regurgitant volumes, regurgitant fraction, and regurgitant orifice is often inconsistent with stable hemodynamic conditions - especially by functional assessment the 2D-PISA method. Thus, functional diagnostics by echocardiography in valvular heart diseases should focus on a plausible hemodynamic assessment.