Severe Regurgitation Research Articles

Evolution of primary mitral regurgitation during echocardiographic follow-up

Abstract Background Routine echocardiographic follow-up of patients with mitral regurgitation (MR) is common practice recommended by clinical practice guidelines. However, there is limited contemporary data on the natural course of primary mitral regurgitation, particularly in those without severe regurgitation at presentation. Purpose To evaluate outcomes in patients undergoing repeated echocardiograms due to mild, moderate and severe primary mitral regurgitation. Methods We identified all patients at a tertiary referral center who were in follow-up due to MR between the years 2004-2019. Patients with a history of heart failure or secondary MR were excluded. Additional age and sex matched individuals without history of cardiac disease and in whom echocardiography showed no valvular heart disease were included as a control group. Data on echocardiographic severity of mitral regurgitation, all-cause mortality, stroke, myocardial infarction, diabetes mellitus and mitral valve interventions were collected from electronic medical records. Primary endpoints were all-cause mortality and survival free from intervention. Results The study cohort consisted of 614 patients with a mean follow-up duration of 6.1 ± 3.8 years. At baseline, 275 (45%) had mild (age 65 years, 58% men), 221 (36%) moderate (age 68 years, 66% men) and 118 (19%) severe (age 65 years, 85% men) MR. The control group consisted of 647 individuals (age 66 years, 66% men). Compared to patients with moderate MR at baseline, significantly fewer patients with mild MR at baseline progressed to severe MR during follow-up (27% vs. 4%, p<0.001). Out of patients with mild MR at baseline, 9 (3.3%) underwent mitral valve intervention (surgical mitral valve repair in 7 and implantation of mitral valve prosthesis in 2) during follow-up. Out of these, referral for intervention was based on development of symptoms in 7 (acute heart failure in 2 and atrial fibrillation in 1), endocarditis in 1, whereas 1 patient was operated due to asymptomatic severe MR. All 9 patients had an uncomplicated course of intervention and post-operative left ventricular ejection fraction was >50%. Out of patients with moderate and severe MR at baseline, 47 (21%) and 77 (64%) underwent intervention during follow-up, respectively. Based on a Kaplan-Meier analysis adjusted for stroke, myocardial infarction and diabetes mellitus, survival of patients with mild MR did not differ from control patients without valvular heart disease (Figure). Conclusions Our findings indicate that only few patients with mild MR progress to severe MR during 6 years of follow-up and out of these only one asymptomatic patient had surgery. The likelihood of left ventricular function remaining normal in those who have had mitral valve intervention triggered by MR related symptoms seems high. Survival by time in follow-up (years)

Mitral regurgitation in obstructive hypertrophic cardiomyopathy: assessing the impact of mavacamten

Abstract Background Hypertrophic cardiomyopathy (HCM) is a genetic cardiac condition that leads to a hypercontractile state. This, as well as other features of HCM, such as abnormal mitral valve morphology and septal protrusion can lead to left ventricular outflow tract (LVOT) obstruction. Mitral regurgitation (MR) is a frequent finding in patients with hypertrophic cardiomyopathy (HCM), usually due to systolic anterior motion (SAM) of the mitral valve. Patients with outflow obstruction can present with a myriad of symptoms. With the introduction of myosin inhibitors such as mavacamten, reductions in the LVOT gradient and improvement in symptoms has been well documented. However, the impact on SAM and SAM-mediated MR has not been well explored. Objectives We aimed to evaluate whether mavacamten resulted in a change in SAM and subsequently a change in mitral regurgitation, in patients with obstructive HCM from baseline following a period of established mavacamten pharmacotherapy. Methods Transthoracic echocardiography (TTE), which is used to facilitate the safe prescription and monitoring of mavacamten therapy, was retrospectively analysed. Severity of mitral regurgitation (graded as 0-4 to delineate trivial, mild, moderate, moderate to severe and severe disease), grade of SAM (0-3) and LVOT gradients were documented, with baseline studies compared to the most recent follow up scan for the patient in question. MR severity was based on the visual impression of the reporting sonographer, and was reviewed by an imaging cardiologist. Patients had undergone between 4 and 24 weeks of mavacamten pharmacotherapy depending on their time of enrolment into the mavacamten clinic. Concurrent changes in NT-pro BNP were also evaluated. Results 24 patients (female n=4; male n = 20) in the mavacamten clinic underwent retrospective analysis of their echocardiographic parameters. Improvement in the severity of MR occurred in 75% of patients (n=18; p<0.001). In 39% of these patients, severity improved by 2 grades or more. Systolic anterior motion of the mitral valve was downgraded in 75% of patients (n=18; p<0.001), with an improvement by 2 grades or more in 42% of individuals. Mavacamten therapy resulted in a reduction in LVOT gradient at rest (-28.96± 5.124mmHg P=<0.0001) and with Valsalva (-60.95± 7.551mmHg P=<0.0001). Furthermore, a significant reduction in serum NT-proBNP levels was demonstrated from baseline (-975.2± 7.551ng/L P=<0.0001). 1 patient had to discontinue therapy at 4 weeks primarily due to a drop in left ventricular ejection fraction. Conclusion In patients with obstructive HCM, mavacamten resulted in a significant reduction in SAM-mediated mitral regurgitation, with corresponding falls in LVOT gradients. Cardiac myosin inhibitor scanning protocols should include detailed mitral valve assessment, to allow accurate evaluation of both SAM-dependent and SAM-independent MR mechanisms. Severity of mitral regurgitation. Change in grade of SAM.

Myocardial remodelling and left ventricular recovery after guideline-directed medical therapy in non-ischaemic dilated cardiomyopathy

Abstract Aims We aimed to identify the proportion of patients with presumed dilated cardiomyopathy (DCM) who undergo left ventricular (LV) reverse remodelling on initiation of guideline-directed medical therapy (GDMT). Our secondary aim was to identify if any clinical or echocardiographic parameters of presentation were predictive of reverse remodelling. Methods We prospectively recruited patients diagnosed by echocardiography with DCM as defined by the current criteria, who were referred for early CMR examination. Patients with an established diagnosis of coronary artery disease and known structural or congenital heart disease were excluded. LV reverse remodelling was defined as LV cavity dilatation on intial echocardiography with subsequent normalisation of LVEDVi measured by cardiovascular magnetic resonance (CMR) . Results A total of 395 patients were recruited including 166 (42%) who fulfilled the definition of LV reverse remodelling. DCM patients who did not achieve reverse remodelling exhibited larger LV (LVEDVi 111.8 ±31.7 vs 81 ± 16.5 mL/BSA, p<0.0001), worse LVEF (26.7 ± 9.24 vs 30.7 ±9.8%, p<0.0001), greater left atrium dilatation (LAVi 49.7 ± 16.5 vs 43 ± 9.7 mL/BSA, p=0.0008), higher incidence of mitral regurgitation (MR) of greater severity, more congestion requiring diuretic therapy and a higher probability of pulmonary hypertension as determined by echocardiography. These individuals also presented higher prevalence of ischaemic LGE (24.1 vs 15.7%, p= 0.04), LBBB (39.6 vs 18%, p=0.0003), and greater QRS duration (124.2 ±30.7 vs 105.7 ± 23.5 ms, p<0.0001), but a lower incidence of AF(26.6 vs 47%, p=0.0005). The multivariable regression analysis adjusted for NYHA class, number of days between echocardiography and CMR, and diuretic use showed that LVEDVi (OR 1.08, 95% CI 1.05 to 1.12, p <0.0001), LVEF (OR 0.97, 95%CI 0.94 to 0.99, p=0.01), more than mild mitral regurgitation (MR, OR 2.08, 95% CI 1.32 to 3.27, p = 0.0017 ), more than mild tricuspid regurgitation (TR, OR 1.99, 95% CI 1.07 to 3.69, p = 0.03), LBBB (OR 3.26 , 95% CI 1.64 to 6.45, p = 0.0007) and QRS duration (OR 1.03 , 95% CI 1.01 to 1.04, p < 0.0001) remained independent predictors of failure of LV reverse remodelling in patients with DCM. Conversely, the presence of AF was associated with a higher probability of LV reverse remodelling (OR 0.45, 95% CI 0.28 to 0.71, p = 0.0007). Ischaemic LGE was also independently associated with LV reverse remodelling (OR 1.82, 95%CI 1.03 to 3.21, p=0.04). Conclusion Contemporary GDMT leads to reverse remodelling in a significant proportion of patients presenting with DCM. Predictors of failure to reverse remodel included larger LV cavity, lower LVEF, greater severity of MR and TR, wider QRS complex, and lower incidence of AF. Incidental ischaemic LGE was also associated with LV reverse remodelling. This has potential therapeutic significance as multimodality imaging is a powerful predictor of cardiovascular outcome in heart failure. Univariable logistic regression Multivariable logistic regression

Hemodynamics and prognostic values of exercise stress echocardiography in the perioperative period for patients undergoing transcatheter edge-to-edge repair

Abstract Background Exercise stress echocardiography (ESE) is widely used and recommended by guidelines for assessing the severity and prognostic values of mitral regurgitation (MR). However, the changes observed in ESE after MR improvement through transcatheter edge-to-edge repair (TEER) and the relationship between pre- and post-operative ESE evaluations and prognosis remain unclear. Purpose The aim is to investigate the hemodynamic changes observed in ESE before and after TEER using echocardiographic parameters, and to identify factors related to prognosis based on the hemodynamics before and after the procedure. Methods The study included 75 out of 250 cases that underwent TEER from January 2019 to August 2023, which were evaluated with ESE before and after the procedure. Cases with significant valvular disease other than mitral valve disease, those who could not achieve adequate exercise load, and cases with MR due to multiple factors were excluded. Results A significant correlation was observed between postoperative mean pressure gradient (mPG) and pulmonary arterial systolic pressure (PASP) at peak stress (r=0.40, p<0.001), while no significant correlation was found between changes in stroke volume (SV) and changes in PASP (r=0.25, p=0.03). An increase in SV observed on ESE after TEER was associated with a better prognosis compared to cases without such increase, suggesting it as a potential predictor for cardiovascular death (p<0.0001). However, stratification of prognosis based on the presence of peak mPG elevation (mPG ≥ 5 mmHg) or the occurrence of exercise-induced pulmonary hypertension (EIPH) was not achievable. Furthermore, patients who showed an increase in SV in either preoperative or postoperative ESE showed the most favorable prognosis for cardiovascular death (p<0.001). Conclusions Exercise-induced systolic pulmonary artery pressure elevation was found to correlate with the mean pressure gradient postoperatively. Performing exercise stress echocardiography not only for preoperative diagnosis but also postoperatively is useful for prognostic evaluation. Patients with increased stroke volume exhibit a favorable prognosis.

PISA method correction by leaflet tethering angle and regurgitant jet velocity, and its association with outcomes in patients with secondary tricuspid regurgitation

Abstract Background Although the correction of the proximal isovelocity surface area (PISA) method has been shown to improve the accuracy of assessing the severity of secondary tricuspid regurgitation (STR), its clinical impact remains to be investigated. Purpose To compare the strength of the association of the quantitative parameters of STR severity obtained from the corrected and conventional PISA methods with outcomes in patients with either atrial- or ventricular STR. Methods We used both the conventional and corrected PISA method to obtain effective regurgitant orifice area (EROA and EROAc, respectively), regurgitant volume (RegVol and RegVolc, respectively), and regurgitant fraction (RegFr and RegFrc, respectively) in 519 consecutive patients (75±12 years, 44% men, 74% ventricular STR) with moderate and severe STR. The endpoint was a composite of heart failure hospitalization and all-cause death. Results EROAc, RegVolc, and RegFrc were significantly larger than EROA (bias= 21 mm2, Limits of agreement, LOA= 25 mm2), RegVol (bias= 18 mL, LOA= 18 mL), and RegFr (bias= 24%, LOA= 17%) (P < 0.001 for all). After a follow-up of 19±15 months, 210 patients reached the endpoint. Threshold values for an excess of events using the corrected PISA parameters were larger in patiets with ventricular (EROAc = 51 mm², RegVol = 42 mL) than atrial STR (EROAc = 46 mm², RegVolc = 30 mL), except the RegFr that was significantly smaller in patients with ventricular STR (56% vs. 69%). Using time-dependent ROC curves, the AUCs of the parameters obtained from the corrected PISA were more closely associated with outcomes at two years than those obtained with the conventional PISA: EROAc vs. EROA (0.62 vs. 0.60, p<0.001), RegVolc vs. RegVol (0.63 vs. 0.62, p=0.001), and RegFrc vs. RegFr (0.66 vs. 0.63, p<0.001) in patients with ventricular STR. Conversely no significant differences between AUCs were detected in patients with atrial STR. In both univariable and multivariable analyses, both EROA and EROAc, RegVol and RegVolc, or RegFr and RegFrc consistently emerged as independently associated with outcomes in patients with ventricular STR (p<0.001 for all). Conversely, in patients with atrial STR, although EROA and EROAc retained their independent predictive power, neither uncorrected nor corrected RegVols and RegFrs were found to be independent predictors of outcomes after multivariable adjustment. Conclusions Correcting the PISA method for the leaflet tethering angle and the velocity of the regurgitant jet provides larger quantitative parameters of STR severity. In patients with ventricular STR, the parameters obtained with the corrected PISA method are more closely associated with those obtained with the conventional PISA.

Natural history of tricuspid regurgitation, a single center cohort analysis

Abstract Background-Purpose High severity of tricuspid valve regurgitation (TR) is associated with poor clinical outcomes. However, the natural history of progression from less severe to more severe TR has not been well characterised. Methods A retrospective cohort analysis was performed on patients who underwent TTE from 2008-2024 on a single center. Patients with congenital heart disease or prior tricuspid valve intervention were excluded. Results Of initial 28715 patients, 4807 (mean age 71 years) had serial TTE evaluation and were included for analysis. Median follow-up was 917 days (Interquartile range 326-1934 days). Patients were categorised by TR severity on initial TTE: 2051 (42.6%) had none/trace, 2092 (43,5%) were mild, 480 (9,9%) were moderate, and 184 (3,8%) were severe. At median follow up, progression to severe TR was seen in 0.1%, 1.5% and 12.0% of the none/trace, mild, and moderate groups, respectively (Log rank p<0.001). At 3600 days, progression to severe TR was seen in 17.95% of the moderate group. Patients with depressed LV function (LVEF<50%) were associated with greater risk of progression to severe TR compared to preserved LVEF (EF≥50%) (Relative Risk 2.8, 95% CI 2.01-3.7, Log rank p<0.001). Conclusion Moderate TR is associated with significant risk of progression to severe TR within 10 years. Patients presenting with moderate TR and LVEF< 50% were associated with increased risk of progression to severe TR. Further studies are required to determine if earlier identification and intervention on patients in this greater risk cohort can result in improved patient outcomes.

Descriptive analysis of portal vein flow variations in patients with tetralogy of Fallot

Abstract Background and purpose Patients with repaired Tetralogy of Fallot (TOF) develop significant pulmonary regurgitation (PR) as a main sequel in the adulthood, leading to right ventricular (RV) dilatation and dysfunction. Our objective was to evaluate in adult patients with repaired TOF, the differences in portal venous flow pulsatility (PVFP) compared to controls without structural heart disease, and the relationship between PVFP with the severity of PR and tricuspid regurgitation (TR), as well as parameters of right chamber remodeling and inferior vena cava (IVC) dilation. Methods Single center, observational study. Sixty-seven patients with repaired TOF (prosthetic pulmonary valve: n=27) were included. TOF patients were compared with a control group (n=74). PVFP was assessed using maximum (Vmax) and minimum (Vmin) Doppler velocities in portal vein flow: (Vmax-Vmin)/Vmax. Results There were no differences in age and sex between the two groups. A higher PVFP was observed in the group of patients with TOF compared to the control group (0.4 vs 0.22, p < 0.001; Figure 1A). Pulmonary valve intervention in adulthood was non-significantly associated with an increase in PVFP (intervention vs no intervention 0.46 vs 0.37, p=0.1, Figure 1B). Regarding PR severity, we observed that the 33 patients with severe PR showed a trend to higher PVFP values in relation to patients with moderate PI (n=5); 0.37 vs 0.26, p=0.06 (Figure 1C). No relationship was observed between PVFP and the severity of TR: absence of TR (n=9) 0.36, mild TR (n=49) 0.41, moderate TR (n=7) 0.45, severe TR (n=2) 0.43, p=0.84 (Figure 1D). In patients with TOF, PVFP was not correlated with right atrial area (R=0.02), RV end-diastolic area (R=0.23), RV strain (R=0.36), or with IVC dimensions (R=-0.1). Conclusions In this descriptive study, we identified an altered pattern of portal venous flow in patients with repaired TOF compared to subjects without structural heart disease. This increase in PVFP did not show an evident association with right valvular heart disease associated with TOF, nor with other markers of volume overload, suggesting the influence of multiple determining factors and a potential incremental value over standard measurements in these patients.

Frequency, course and prognostic yield of valvular heart disease in the general population- Results from the STAAB cohort study

Abstract Background Valvular heart disease (VHD) is a major burden to public health. The complexity and the long asymptomatic phase of VHD pose significant challenges to its recognition and monitoring. Assuming gradual disease progression, the ACC/AHA define consecutive stages of VHD from "at risk" through "progressive stage" to "severe symptomatic VHD". Purpose To determine the frequency and course of VHD stages in the general population and to estimate their respective prognostic value regarding all-cause mortality. Methods The STAAB study recruited a representative sample of inhabitants of a medium-sized town in Germany stratified for sex (1:1) and age decades (30-79 years), who had no preceding diagnosis of heart failure. All participants underwent standardized transthoracic echocardiography (TTE). VHD was graded into stages A to D: stage A = at risk for valve dysfunction: valve deformity, sclerosis, mild mitral or tricuspid regurgitation (MR/TR); stage B = progressive valve dysfunction: mild or moderate aortic regurgitation or stenosis, mild mitral stenosis, moderate MR and TR; stage C/D VHD = asymptomatic/symptomatic severe valve dysfunction: severe valvular regurgitation or stenosis. The relevance of baseline markers with respect to VHD progression and all-cause mortality was analysed using multivariable model and Cox proportional hazards regression model, respectively. Results N=4943 STAAB participants (mean age 55±12 years, 52% women) with valid TTE entered our baseline analysis, and 24% of them were free from VHD. Stage A VHD was present in n=2694 (54%) participants, stage B in n=1056 (21%), and stage C/D in n=16 (0.3%). Participants with stage C/D VHD were older, more frequently male, and showed higher levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity troponin (Table). Over a median follow-up of 34 months (quartiles 30–41), 35 participants died. Stage C/D VHD (HR, 6.23 [95% CI, 1.24 – 31.34], p=0.026) was associated with all-cause mortality after adjusting for age and sex. N=3833 participants (mean age 58 ±11 years, 52% women) underwent a repeat echocardiography at follow-up. In this sample, 10% of stage A and 1.3% of stage B had progressed from baseline to higher VHD stages, respectively (Figure). Determinants of disease progression were E/e´ (stage A, OR 1.14 [95% CI, 1.03 –1.26], p=0.01) and NT-proBNP (stage B, OR 7.48 [95% CI, 1.38 –40.4], p=0.019) at baseline, respectively. Conclusions In this well-characterized population-based sample, we found a high prevalence of VHD stages A and B. Stage C/D VHD was associated with higher levels of cardiac injury indicators such as troponin and NT-proBNP as well as with a higher risk of death. The majority of individuals with stage A and B VHD was asymptomatic, but a sizable fraction showed VHD progression in the subsequent three years. Elevated E/e´ and NT-proBNP might be helpful in identifying patients at higher risk for disease progression. Baseline characteristics Distribution of VHD stages

Comparison of myocardial work parameters between the transplanted heart and patients after other cardiac surgery

Abstract Introduction The transplanted heart (HTX) has pathophysiological differences compared to standard hearts, partially understood. Early detection of abnormal grafts function (e.g. cellular or immune-mediated rejection, coronary artery vasculopathy) by advanced echocardiography can significantly improve management and prognosis of HTX patients. Speckle tracking-derived global longitudinal strain (GLS) and myocardial work (MW) have lower values in healthy HTX patients compared to controls. How much these abnormalities can be dependent on the surgical procedure itself is not known yet. Aim to compare MW values in stable patients after HTX and other cardiac surgical procedures to evaluate possible different impact of surgery on heart function. Methods in a monocentric study, we screened stable post-operative patients with a preserved left ventricular (LV) ejection fraction who underwent surgery at our hospital for HTX (group 1), aortic valve replacement, AVR, for severe aortic stenosis (group 2), mitral valve replacement, MVR, for severe primary regurgitation (group 3) and elective coronary artery bypass graft (CABG) (group 4). We excluded patients with other previous cardiac surgery, active pacemakers, BMI > 30, abnormal LV global function, more than mild regurgitation and/or stenosis, major post-operative complications absent informed consent. None of the HTX patients had previous history of rejection or coronary artery disease. All the surgical procedures required a median sternotomy and on-pump approach. All echocardiograms were performed between the 5th and the 12th postoperative day or within 2-3 months after HTX. For all patients, data regarding standard echo, GLS and MW parameters were collected and compared. One-way analysis of variance (ANOVA) and Bonferroni post-hoc tests were used to compare the variables among groups. Any independent predictor was tested to MW values reduction. Results Final population included 202 patients (137 males, 67%) with median age of 62 [50-86] years: 82 HTX, 40 AVR, 42 MVR and 40 CABG. MW-derived global work index (GWI), global constructive work (GCW) and global work efficiency (GWE) were significantly lower in group 2, 3 and 4 compared to HTX patients while having comparable global wasted work (GWW) (Table 1). Multivariate regression analysis showed significant relationship between all MW indices and GLS and blood pressure, as expected. GWI was also related to E/e’ ratio (b=0,131 p=0,033), GCW and GWW with LV end-diastolic volume, EDV (b=-0,177 p=0,012 and b=-0,261 p=0,030 respectively), GWE with EF (b=0,245 p=0,009) and EDV (b=0,210 p=0,027). Conclusions GLS and MW indices are lower after HTX than healthy general population. However, the transplanted heart has better MW indices compared to other post-operative patients. These preliminary results can suggest that the impact of surgical procedure on transplanted hearts might be only partially related to abnormal deformation and needs further characterization.

Comparison of quantitative echocardiographic parameters for grading of mitral regurgitation severity for prediction of clinical outcome

Abstract Introduction Current recommendations favour the use of quantitative parameters for the assessment of mitral regurgitation (MR) severity and the effective regurgitant orifice area (EROA) derived from the proximal isovelocity surface area (PISA) method has been demonstrated as a predictor of outcome. Purpose The aim of our study was to compare the long-term predictive value of quantitative echocardiographic parameters, derived from the PISA method and volumetric method on clinical endpoints. Methods We retrospectively analysed 298 patients who consecutively underwent echocardiographic examination at out department in 2018 and had been diagnosed with more than mild MR. From the echocardiographic measurements we calculated the quantitative parameters (EROA, regurgitant volume (Rvol) and regurgitant fraction (RF)) by the PISA method and volumetric method (based on the Rvol calculated as a difference between total left ventricular stroke volume derived from the Simpson’s biplane planimetry and forward stroke volume assessed by the pulsed-wave Doppler left ventricular outflow tract method). The clinical outcome was death from any cause, hospitalization due to heart failure or mitral valve intervention in the period from the echocardiographic examination to the end of 2022. Results The study cohort comprised 169 (56%) patients with secondary MR, 103 (35%) with primary MR and 26 (9%) with combined etiology. Clinical endpoints were observed in 198 (66%) patients. Median time to the event was 732 (121-1578) days. Quantitative parameters by the PISA method better predicted the clinical outcome compared to quantitative parameters by the volumetric method (Figure A). RF-PISA had the biggest area under the curve (AUC 0.633, p < 0.001), followed by the EROA-PISA (AUC 0.626, p < 0.001), while the predictive values of quantitative parameters by the volumetric method were not significant (EROA: p= 0.109, Rvol: p=0.153, RF: p=0.156). By the PISA method, patients with RF≥50% had more adverse outcome compared to those with RF<50% (Figure B). By the volumetric method, however, the outcome was similar for both patients with RF≥50% or <50% (Figure B). In our cohort, the best cut-off value for the prediction of the clinical event was RF-PISA >46% (sensitivity 48%, specificity 76%) and EROA-PISA > 0.24 cm2 (sensitivity 41%, specificity 78%). Conclusions Quantitative parameters for grading MR severity by the PISA method provide better diagnostic accuracy for predicting the clinical outcome in comparison to quantitative parameters by the volumetric method. RF-PISA turned out as a good predictor for clinical outcome. Our results show that the fraction of regurgitation better defines the clinical significance of MR than the absolute values of quantitative parameters. Therefore, the RF should be reported as part of the quantitative assessment of MR severity.

Right ventricular function outcomes of percutaneous balloon mitral valvuloplasty: a 3-dimensional echocardiography and 2-dimensional speckle tracking analysis

Abstract Background Rheumatic heart disease (RHD) is a significant cause of mitral stenosis (MS), particularly affecting young adults in developing regions. Percutaneous Balloon Mitral Valvuloplasty (PBMV) is a recognized intervention for severe symptomatic mitral stenosis with favorable morphology. However, its impact on various cardiac parameters needs thorough evaluation by new imaging techniques to increase measurement accuracy and decrease inter-observer variability. Purpose This study aims to evaluate the impact of PBMV on cardiac function and structure among patients with severe rheumatic mitral stenosis, focusing on mitral valve function, Pulmonary artery systolic pressure (PASP) and right ventricular (RV) parameters. Methods A prospective study was conducted involving 30 patients (80% female, mean age 33.1 years) diagnosed with severe rheumatic mitral stenosis. All participants underwent PBMV. Pre- and 30 days post-procedure assessments included conventional echocardiographic parameters, three-dimensional (3D) RV assessment and two-dimensional (2D) strain RV analysis. Statistical analyses were performed to determine significant changes post-PBMV. Results Echocardiographic evaluation showed a decrease in trans-mitral mean pressure gradient and Pressure Half Time (both P<0.001). Improvements were also noted in 2D and 3D mitral valve planimetry values (P<0.001). However, mitral regurgitation (MR) severity increased in some cases (P=0.022). Regarding right ventricular analysis, significant reductions were observed in RV basal, mid and longitudinal diameters (P<0.001 for all). RV Fractional Area Change (FAC%) increased significantly (P<0.001). TAPSE also showed a significant increase (P<0.001), reflecting improved RV functional performance. PASP and TR severity both showed marked reductions (P<0.001), whereas a subgroup analysis indicated that patients with atrial fibrillation (AF) had a less pronounced decrease in PASP compared to those with sinus rhythm. Strain analysis revealed substantial improvements in RV strain parameters, with significant increases in basal, mid, apical, and mean (RVFW) free wall strain (P<0.001) and RV global longitudinal strain (RV GLS) (P<0.001). 3D echocardiography demonstrated significant decreases in RV end-systolic volume (P=0.004) and marked increases in RV EF ejection fraction (P<0.001) and stroke volume (P<0.001), while end-diastolic volume showed no significant change (P=0.061). the study demonstrates that the decline in PASP can significantly predict improvements in both 2D and 3D RV function parameters following PBMV. Conclusion RV performance showed substantial improvement early post-PBMV, as evidenced by marked increases in 3D right ventricular ejection fraction (3DRVEF), right ventricular free wall (RVFW) strain, and RV global longitudinal strain. These enhancements were significantly predicted by the reduction in pulmonary artery systolic pressure (PASP). RV conventional Echocardiographic Parame RV 3D echocardiography and 2D speckle tr

Low forward stroke volume index after transcatheter edge-to-edge repair for secondary mitral regurgitation predicts a worse prognosis in a 2-year follow-up

Abstract Background Transcatheter edge-to-edge repair (TEER) is an established treatment for patients with heart failure (HF) and significant secondary mitral regurgitation (SMR). While TEER often reduces mitral regurgitation (MR) severity, alleviating symptoms and improving prognosis, some patients do not experience these benefits. The absence of improvement in forward stroke volume may underlie this lack of response. Aim To evaluate the prognostic significance of forward stroke volume index (FSVi) following TEER for SMR. Methods We retrospectively analysed data from consecutive patients referred for TEER in our academic hospital from October 2016 to June 2023. The inclusion criteria were: symptomatic moderate to severe and severe SMR, anatomical suitability for TEER, and optimal medical therapy. Transthoracic echocardiograms (TTE) were performed before (up to 3 months pre-TEER, TTE-0), within 48 hours (TTE-1), and 6 months post-procedure (TTE-2). The FSVi was calculated by multiplying the left ventricular outflow tract area by the left ventricular outflow tract velocity-time integral. Patients were followed for a mean of 2 years. The composite endpoint was all-cause mortality or hospitalisation due to HF. Results Out of 67 patients treated with TEER, we included 50 patients who had follow-up at our hospital, TEE-0, and at least one of TEE-1 or TEE-2. Six patients with primary MR were excluded. Thus, 44 patients (mean age 69.7±8.2 years, 77% male) were included in the study. These patients were in NYHA class II to IV, with a median EuroSCORE II of 13% (IQR 7, 23), and a median LVEF of 31% (IQR 26, 36), 77% had ischaemic cardiomyopathy. The mean follow-up was 1.6±0.7 years. No patients were lost to follow-up. There were 22 composite endpoints including 12 deaths. At baseline patients in the group with composite endpoint were most often diabetic, had higher NYHA class, and lower 6-minute walking test distance. Echocardiographic parameters were similar in both groups. Median FSVi in TTE – 0 was 29 mL/m2 (22, 34) vs 31 mL/m2 (25, 36), p=0.2 (in the group with and without composite endpoint). After TEER, FSVi was significantly lower in the group with versus without a composite endpoint in TTE -1 [32 mL/m2 (27, 34) vs 38 mL/m2 (33, 43), p=0.005] and TTE -2 [32 mL/m2 (22, 33) vs 40 mL/m2 (34, 48), p=0.001]. The group with composite endpoint had higher NYHA class, lower 6-minute walking test distance, lower LVEF, and higher resting heart rate 6 months after TEER. The optimal cut-off value for the FSVi in TTE – 1 after TEER for predicting the composite endpoint was 35 ml/m2 (AUC 0.76, 80% sensitivity, 70% specificity, PPV 0.73, NPV 0.78). A significant difference in the composite endpoint occurrence was observed between groups with FSVi > 35 ml/m2 and ≤ 35 ml/m2 (TTE – 1) during the follow-up (Figure). Conclusions FSVi in early postprocedural TTE predicts death or rehospitalisation for HF in patients treated with TEER for SMR. Kaplan-Meier curves

Mitral regurgitation evolution after transcatheter tricuspid valve interventions; a sub-analysis of the TriValve registry.

Abstract Background Transcatheter tricuspid valve interventions(TTVI) are increasingly used to treat patients with significant tricuspid regurgitation(TR).[1] The evolution of concurrent mitral regurgitation(MR) severity after TTVI is currently unknown. Increasing severity of TR is associated with declining cardiac output, while a significant increase in left ventricular preload and cardiac index have been observed in patients undergoing successful tricuspid valve surgery with functional improvement.[2,3] Physiological studies, instead, have demonstrated MR worsening in response to preload augmentation especially in the setting of left ventricular systolic disfunction; however, it is unknown whether increased left ventricular preload might translate into clinically relevant MR worsening after successful TTVI.[2,4] Gaining insights regarding the trajectories of MR severity after TTVI may significantly contribute to clinical decision-making. Indeed, it would help to define whether patients undergoing TTVI may benefit from a concurrent transcatheter procedure on the mitral valve. Purpose The aim of this study was to assess the evolution of MR after TTVI and to identify predictors of MR worsening and improvement. Methods This analysis is a substudy of the Trivalve Registry, an international registry designed to collect data on TTVI.[5] This substudy included all patients with echocardiographic data on MR evolution and excluded those with a concomitant tricuspid and mitral transcatheter valve intervention or with a history of mitral valve intervention. The co-primary outcomes were MR improvement and worsening at two timepoints: pre-discharge and 2-month follow-up. Results The graphical abstract is presented in Figure 1. This analysis included 359 patients with severe TR, mostly(80%) treated with tricuspid transcatheter edge-to-edge repair(T-TEER). MR improvement was found in 106(29.5%) and 99(27%) patients, while MR worsening in 34(9.5%) and 33(9%) patients at pre-discharge and 2-month follow-up, respectively. The type of transcatheter procedure has a significant impact on MR worsening and improvement. Annuloplasty and heterotopic replacement were associated with MR worsening. Independent positive predictors of MR improvement were T-TEER, acute procedural success, TR reduction, LVEDD>60 mm and beta-blocker therapy while atrial fibrillation was a negative predictor. Patients with moderate-to-severe/severe MR following TTVI showed significantly higher death rates while the stratification according to MR evolution was not prognostically relevant(Figure 2). Conclusions MR degree variation is common after TTVI, with most cases showing improvement. Clinical and procedural characteristics may predict the MR evolution, in particular procedural success and T-TEER play key roles in MR outcomes. An effective TTVI with significant TR reduction may prevent MR worsening and possibly trigger an improvement, differently from the common belief. Figure 1. Graphical abstract. Figure 2. Death rates.

Acute tricuspid valve annulus remodeling after transcatheter edge-to-edge repair with Triclip

Abstract Background Right ventricular (RV) adverse remodeling together with RV dysfunction, and not only tricuspid regurgitation (TR) severity, are independently associated with survival in patients with medically treated significant TR. Nevertheless, changes in RV dimensions and function after transcatheter tricuspid valve intervention and their association with outcomes remain largely unexplored, as well as tricuspid valve annulus (TVA) reverse remodeling. Aim of our study is to assess acute remodeling of TVA after tricuspid transcatheter edge-to-edge repair (T-TEER) with the TriClip device (Abbott Vascular, Santa Clara, CA, USA) using intraprocedural trans-esophageal echocardiography (TEE). Materials and methods This prospective, single-center study, conducted at Fondazione Policlinico Universitario Campus Bio-Medico of Rome, enrolled 60 consecutive symptomatic patients referred with the diagnosis of at least severe TR who underwent T-TEER from March 2021 to June 2024 with the TriClip System. Intraprocedural TEE was performed using Siemens Acuson SC2000 (Siemens Medical Systems, Pleasanton, CA, USA) at the beginning, and then using Philips EpiQ CVx (Philips Medical System, Andover, MA). A full-volume 3D echocardiographic data set was acquired during the procedure for each patient before and after the grasping. The following parameters were assessed using a multiplanar reconstruction analysis performed off-line using a 3D dataset: septal-lateral (SL) and antero-posterior (AP) annulus diameters; annulus area; annulus perimeter and eccentricity index. Results The mean age of the study cohort was 77,77 ± 6,18 years, and 77% were female. Twenty-eight patients (46,7%) had severe (3+), twenty-four patients (40%) massive (4+) and eight patients (13,3%) torrential (5+) tricuspid regurgitation. The majority of them had atrial functional tricuspid regurgitation, mostly due to annular dilatation. The acute procedural success was achieved in 82.22%. We observed an acute reduction in SL (from a median of 45 to 38 mm, p<0.0001), AP (from a median of 47.5 to 45.8 mm, p<0.0001), area (from a median of 18.4 to 16.2 cm2, p<0.0001), perimeter (from a median of 149 to 141 mm, p<0.0001) and eccentricity index (from 0.92 to 0.87, p <0.0001). The TV annulus was larger in patients with residual TR >2+. Analysis of the subgroups according to procedural success showed an acute inverse remodeling of the TV annulus independent of residual TR grade. We observed a significative reduction of TVA three-dimensional measurements immediately after the procedure. Conclusions In our study we observed that the reduction of TVA begins immediately after TriClip implantation, proving that T-TEER is effective in reducing TR and in inducing reverse remodeling of the TV apparatus. Concurrently, the baseline TV geometry influences the procedural results. Our data are gathered during T-TEER procedure, follow up data are needed for monitoring right ventricular performance. tva measures using mpr tr grade at baseline and after t-teer

Analysis of 15 cases of critical pulmonary stenosis with intact ventricular septum in neonates treated by antegrade venous-arterial loop interventional therapy

Objective: To evaluate the clinical efficacy of percutaneous balloon pulmonary valvuloplasty (PBPV) via antegrade venous-arterial loop in neonates with critical pulmonary stenosis with intact ventricular septum (CPS-IVS). Methods: A retrospective case review was conducted. Fifteen neonates with CPS-IVS who underwent PBPV via antegrade venous-arterial loop at the Women and Children's Hospital, Qingdao University between September 2020 and September 2023 were included. Pre-and post-operative right ventricular functional parameters, surgical complications, and follow-up outcomes were analyzed. Paired-sample t-test was used to compare changes in right ventricular systolic pressure (RVSP), percutaneous oxygen saturation (SpO2), and echocardiographic findings pre-and post-operatively, as well as during the follow-up period. Results: Among the 15 neonates (9 males and 6 females) with CPS-IVS, the surgical age was (3.6±0.5) d. All neonates underwent successful PBPV via antegrade venous-arterial loop under general anesthesia. The immediate post-operative trans-pulmonary valve pressure gradient was (35±6) mmHg (1 mmHg=0.133 kPa), with a significant reduction in RVSP from (96±16) mmHg to (59±14) mmHg (t=6.70, P<0.001). SpO2 (with an inspired oxygen concentration of 0.48) increased from 0.86±0.07 pre-operatively to 0.97±0.03 post-operatively (t=4.81, P<0.001). One month postoperatively, SpO2 (without oxygen supplementation) normalized in all patients, with a statistically significant difference compared to pre-operative values (t=0.16, P<0.001). Immediately postoperative, mild to moderate diastolic pulmonary valve regurgitation was observed in 8 patients, with no cases of severe regurgitation. Additionally, the severity of tricuspid valve regurgitation decreased from severe to mild-to-moderate in 6 patients. Three months postoperatively, one patient underwent a second PBPV due to an increased trans-pulmonary valve pressure gradient of 74 mmHg, which decreased to 27 mmHg immediately after the procedure, with subsequent good recovery. Over a one-year follow-up period, all 15 patients demonstrated improvements in right ventricular indices. The Z-score of the tricuspid valve annulus significantly improved from -1.9±0.8 pre-operatively to -0.4±0.1 post-operatively (t=6.88, P<0.001). At the last follow-up, mild to moderate pulmonary valve regurgitation was observed in 3 patients, and mild tricuspid regurgitation in 2 patients, with no cases of moderate or severe regurgitation. Conclusion: Intervention via antegrade venous-arterial loop for the treatment of CPS-IVS in neonates is safe and effective.

Evaluating the Sapien® XT Valve in Native Right Ventricular Outflow Tracts After Tetralogy of Fallot Repair: Mid- and Long-Term Results.

Although the long-term outcomes of the surgical grafts are well defined and reported, the data regarding the mid-and long-term results of the balloon-expandable percutaneous valves in the native right ventricular outflow tract (RVOT) is limited. We retrospectively evaluated 42 patients who underwent PPVI (Sapien® XT valve) to native RVOT due to severe pulmonary regurgitation (PR) and/or moderate to severe pulmonary stenosis (PS) between August 2015 and November 2020. The median patient age at the time of PPVI was 13.4years (6.1-36.5years). The median body weight of the patients was 42kg (15-110kg). The rate of patients who were followed up without the need for percutaneous or surgical intervention was 97.4% at the end of year 1, 89.3% at the end of year 3, and 85.8% at the end of year 5. At the end of year 6, the proportion of patients requiring no procedure remained constant, with year 5 at 85.8%, but decreased to 70.2% at the end of year 7. Although the early results are very encouraging, it is seen that PPVI in patients with RVOT in the long term brings some problems. The most important of these is tricuspid valve problems, which were not considered before the procedure. Patients requiring reintervention due to pulmonary regurgitation show similar characteristics to surgical valves' long-term results.

Does an Unrestricted Atrial Septal Defect Alter the Pulmonary Venous Doppler Flow Profile and Downgrade the Severity of Mitral Regurgitation?

Does an Unrestricted Atrial Septal Defect Alter the Pulmonary Venous Doppler Flow Profile and Downgrade the Severity of Mitral Regurgitation?

Transcatheter edge-to-edge repair of severe atrioventricular valve regurgitation in unrepaired functionally univentricular heart with dextroversion.

Transcatheter edge-to-edge repair of severe atrioventricular valve regurgitation in unrepaired functionally univentricular heart with dextroversion.

Right Ventricular Outflow Tract Obstruction: Transcatheter Correction In Tetralogy Of Fallot: A Pilot Study.

This study evaluated transcatheter approach for relieving right ventricular outflow tract (RVOT) obstruction using combined non-compliant balloon dilatation of the RVOT and conal artery occlusion in patients with Tetralogy of Fallot (TOF), both uncorrected and post-intra-cardiac repair (ICR) restenosis. A prospective study was conducted from January 2022 to June 2023, including 40 symptomatic patients aged over 12 years with RVOT obstruction in TOF. Exclusion criteria included moderate to severe pulmonary regurgitation. The procedure involved two steps: non-compliant balloon dilatation of the RVOT and conal artery embolization using alcohol or coils or both. Clinical and echocardiographic assessments were performed pre-procedure, immediately post-procedure, and at 1-year follow-up. Thirty-five patients completed the study. Mean age was 19.8 (±4.2) years, with a male-to-female ratio of 4:3. Twenty-five patients had uncorrected TOF, and ten were post-ICR. Post-procedure, uncorrected patients showed a significant increase in oxygen saturation from 84.7 (±1.4) % to 94.6 (±1.2) %. Procedural success was 91.4%, with three patients experiencing significant restenosis. No procedural complications were observed. There were no arrhythmic events till the 1st year of follow up. At 1-year follow-up, the mean RVOT pressure gradient was significantly reduced, and all patients remained symptom-free. In conclusion, combined balloon pulmonic valvuloplasty and conal artery occlusion is a safe and effective method for alleviating RVOT obstruction in TOF patients, showing promising intermediate-term outcomes with minimal complications.

Predictive value of CMR feature tracking analysis of myocardial deformation in repaired tetralogy of fallot with severe pulmonar regurgitation

Predictive value of CMR feature tracking analysis of myocardial deformation in repaired tetralogy of fallot with severe pulmonar regurgitation