Regurgitation In Patients Research Articles

Does the volume overload exaggerate the severity of mitral regurgitation in patients with decompensated heart failure?

Background/aimDiagnosing and managing functional mitral regurgitation (MR) is often challenging and requires an integrated approach including a comprehensive echocardiographic examination. However, the effects of volume overload on the echocardiographic assessment of MR severity are uncertain. The purpose of this study was to weigh the effects of volume overload in the echocardiographic assessment of MR severity among patients with heart failure (HF).Materials and methodsTwenty-nine patients with decompensated HF, who had moderate or severe MR, were included in the present study. The volume status and the N-terminal pro-B-type natriuretic peptide (proBNP) levels were recorded and the echocardiographic parameters were assessed. After the conventional treatment for HF, the proBNP levels and the echocardiographic parameters were assessed again.ResultsThe mean age of the patients was 72 ± 9 years and the average hospitalization time was 10.9 ± 5.9 days. Between the beginning and the end of the treatment, there were significant reductions in the effective regurgitant orifice area (EROA) (0.36 ± 0.09 cm2 to 0.29 ± 0.09 cm2, P < 0.001), vena contracta (VC) (P < 0.001), the regurgitant volume (RV) (P < 0.001), and systolic pulmonary artery pressure (sPAP) (P < 0.001). ConclusionThis is the first study to investigate the relationship of changes in severity of MR with volume-load by monitoring the proBNP levels among patients with HF. The present results demonstrated that volume reduction, as evidenced by a decline in the proBNP levels, was accompanied by a marked reduction in the EROA, VC, and the RV among patients with left ventricular dysfunction.

Midterm results of mitral valve repair for atrial functional mitral regurgitation: a retrospective study

BackgroundAnnular dilation by left atrial remodeling is considered the main cause of atrial function mitral regurgitation. Although acceptable outcomes have been obtained using mitral ring annuloplasty alone for atrial functional mitral regurgitation, data assessing outcomes of this procedure are limited. Therefore, we aimed to assess midterm outcomes of mitral valve repair in patients with atrial functional mitral regurgitation.MethodsWe retrospectively studied 40 patients (mean age: 69 ± 9 years) who had atrial fibrillation that persisted for > 1 year, preserved left ventricular ejection fraction of > 40%, and mitral valve repair for atrial functional mitral regurgitation. The mean clinical follow-up duration was 42 ± 24 months.ResultsMitral ring annuloplasty was performed for all patients. Additional repair including anterior mitral leaflet neochordoplasty was performed for 22 patients. Concomitant procedures included maze procedure in 20 patients and tricuspid ring annuloplasty in 31 patients. Follow-up echocardiography showed significant decreases in left atrial dimensions and left ventricular end-diastolic dimensions. Recurrent mitral regurgitation due to ring detachment or leaflet tethering was observed in five patients and was seen more frequently among those with preoperative left ventricular dilatation. Three patients without tricuspid ring annuloplasty or sinus rhythm recovery by maze procedure developed significant tricuspid regurgitation. Five patients who underwent the maze procedure showed sinus rhythm recovery. Rates of freedom from re-admission for heart failure at 1 and 5 years after surgery were 95 and 86%, respectively.ConclusionsMitral valve repair is not sufficient to prevent recurrent atrial functional mitral regurgitation in patients with preoperative left ventricular dilatation. Tricuspid ring annuloplasty may be required for long-term prevention of significant tricuspid regurgitation.

The prognostic impact of frailty in patients undergoing percutaneous mitral valve repair

Aim: Percutaneous mitral valve repair (PMVR) with MitraClip® has proven to be an effective therapy to reduce mitral regurgitation in patients at high risk for conventional surgery. This population is currently characterized by advance age and high prevalence of comorbidities. Our aim was to evaluate the prevalence of frailty in a cohort of patients undergoing PMVR and its impact on clinical outcomes during follow-up.

S0448 Characterizing Regurgitation and Heartburn Symptoms in Patients Undergoing High Resolution Esophageal Manometry With Esophageal pH-Impedance Monitoring

INTRODUCTION: Studies that characterize GERD often fail to describe regurgitation as well as they do heartburn. The study aims to: 1) describe the frequency and severity of heartburn and regurgitation in patients referred for esophageal function evaluation; 2) describe the esophageal disorders with these symptoms; and 3) investigate the pathophysiology of these symptoms. METHODS: We retrospectively reviewed data from patients undergoing High Resolution Esophageal Manometry with Impedance (HREMI) and Esophageal pH Impedance monitoring (EpHI) between December 2019 and March 2020. Patients filled out the Reflux Disease Questionnaire (RDQ) and the Patient Assessment of Upper GI symptoms (PAGI-SYM). The RDQ evaluates both severity and frequency of heartburn, regurgitation, and dyspeptic symptoms. Mean symptom severity was calculated as (symptom frequency [days per week] x symptom intensity)/7 (scoring is from 0 to 3). RESULTS: Of the 171 patients (average age 55 ± 15 years; 69% female), 164 completed HREMI (7 were unable to tolerate procedure) and 108 completed EpHI. 74 were determined to have GERD by esophageal acid exposure time and/or impedance episodes. Regurgitation movement (RDQ score 0.8; present in 52%) and regurgitation taste (RDQ score 0.6; present in 48.5%) was more prevalent than substernal burning (RDQ score 0.5, present in 35.1%) and substernal pain (RDQ score 0.5, present in 35.1%). Regurgitation taste correlated with regurgitation movement (r = 0.50, P < 0.001), substernal burning (r = 0.53, P < 0.001), and substernal pain (r = 0.39, P < 0.001). Acid exposure time correlated with substernal burning (r = 0.22, P = 0.029) and dyspepsia burning (r = 0.26, P = 0.010). The presence/absence of a hiatal hernia (HH) did not affect regurgitation symptoms. Patients with GERD had similar LES pressures (P = 0.09), hiatal hernia sizes (P = 0.07), and RDQ symptoms. Regurgitation was present in 47% of patients with ineffective esophageal motility, 20% with absent contractility, 33% achalasia, and 39% with no abnormalities (P = 0.21). CONCLUSION: Regurgitation is correlated with heartburn and dyspepsia. It is a common symptom of patients undergoing HREMI and EpHI and is present in many disorders. Additionally, increasing acid exposure was related to substernal burning and dyspepsia burning but was not correlated to regurgitation.(image 3) These results suggest that although acid suppression therapy may be helpful for heartburn, it may not be helpful for treating regurgitation.Table 1Table 2Figure 1

Mitral valve repair for degenerative mitral regurgitation in patients with left ventricular systolic dysfunction: early and mid-term outcomes

BackgroundThis study aims to evaluate the early and mid-term outcomes of mitral valve repair for degenerative mitral regurgitation (MR) in patients with left ventricular systolic dysfunction.MethodsFrom January 2005 to December 2016, the profiles of patients with degenerative MR who underwent mitral valve repair at our institution were analyzed. Left ventricular systolic dysfunction was defined as an ejection fraction < 60% or left ventricular end-systolic dimension > 40 mm. Finally, 322 patients with left ventricular systolic dysfunction were included in this study. The prognosis of left ventricular function during follow-up was evaluated and preoperative factors associated with deteriorated left ventricular systolic function during follow-up were analyzed.ResultsThe in-hospital mortality rate was 1.6%. The rate of eight-year overall survival, freedom from reoperation for mitral valve and freedom from recurrent MR were 96.9, 91.2 and 73.4%, respectively. Intraoperative residual mild MR (hazard ratio 4.82) and an isolated anterior leaflet lesion (hazard ratio 2.48) were independent predictive factors for recurrent MR. During follow-up, 212 patients underwent echocardiography examinations at our institution. Among them, 132 patients had improved left ventricular systolic function, and 80 patients had deteriorated left ventricular systolic. Freedom from recurrent MR was found in 75.9% of the improved left ventricular systolic function group and 56.2% of the deteriorated left ventricular systolic function group (P = 0.047). An age > 50 years (odds ratio 2.40), ejection fraction≤52% (odds ratio 2.79) and left ventricular end-systolic dimension≥45 mm (odds ratio 2.31) were independent risk factors for deteriorated left ventricular systolic function during follow-up.ConclusionsMitral valve repair could be safely performed for degenerative MR in patients with left ventricular systolic dysfunction. Intraoperative residual mild MR and an isolated anterior leaflet lesion were independent predictive factors for recurrent MR. An age > 50 years, ejection fraction≤52% and left ventricular end-systolic dimension≥45 mm were independent risk factors for deteriorated left ventricular systolic function during follow-up.

S0439 Prucalopride Improves Esophageal Contractility Ineffective Esophageal Motility: Prospective Clinical Trial

INTRODUCTION: Ineffective esophageal motility (IEM) is a manometric diagnosis defined by the Chicago Classification (v3.0) as ≥50% of swallows achieving a distal contractile integral (DCI) of < 450 mmHg-cm-s and maybe associated with dysphagia. This pilot study assesses the effectiveness of prucalopride a 5-HT4 enterokinetic drug in IEM patients with dysphagia. METHODS: Symptomatic patients with dysphagia diagnosed with IEM following high-resolution manometry (HRM) with impedance at a tertiary care motility lab were enrolled between August 2017 and September 2019. Patients with uncontrolled GERD (DeMeester score >14.7), endoscopic erosive esophagitis, eosinophilic esophagitis, use of other prokinetic drugs, or narcotics were excluded. Patients received prucalopride 4mg PO once daily for 5 days and then underwent repeat HRM. Outcome measures included pre- and post- prucalopride esophageal HRM values, dysphagia symptom questionnaire (DSQ), and quality of life (Eq5d-3L). These outcomes were compared with paired T-test, Wilcoxon signed ranks test and McNemar test as appropriate. Patients were classified into definite or indefinite for heartburn, acid regurgitation, and GERD based on the MDQ-30 subscale. IRB-approved study (NCT03244553). RESULTS: Twenty-nine patients were enrolled; analysis was performed on twenty-five patients (13M:12F; mean age of 53.3 yrs (±13.97 SD) who completed the study. All patients had symptoms of dysphagia to solids. 76% of patients were on a PPI. The median time and IQR between baseline and post-HRM were 12 [8–18] wks. 18 patients (72%) had an improvement in mean DCI. There was a significant increase in DCI (mean 727.1 ± 548.7 vs 439.5 ± 286.7, P = 0.006), maximum DCI (mean 1198.7 ± 1198.67819.8 ± 540.5, P = 0.013), and decrease in the percentage of failed swallows (median 40 [IQR 25–70] vs 20 [10–50], P = 0.05), and acid regurgitation (P = 0.05) after prucalopride use. No improvement was seen in dysphagia or quality of life. Change in DCI correlated weakly with IRP (Spearman’s r =0.461, P = 0.021). The most common side effects were headaches (48%) and diarrhea (52%). A majority of patients (88%) reported a side effect, leading to discontinuation in 4%. CONCLUSION: In this short duration pilot study, prucalopride significantly improved the DCI, maximum DCI, number of failed swallows, and acid regurgitation in patients with IEM; however, no improvement in dysphagia or quality of life was seen. This pilot study warrants a larger study.Table 1.: Pairwise comparison of manometric values and patient-reported outcomes pre- and post- prucalopride therapyFigure 1.: Representative Pre and post-HRM picture of 3 patients who displayed significant improvement after prucalopride.

Effect of Earlier Atrioventricular Valve Intervention on Survival After the Fontan Operation

Whereas the prevalence and impact of atrioventricular valve (AVV) regurgitation in patients with single ventricle physiology has become increasingly apparent, the optimal timing for valve intervention is unclear. To investigate this, we performed a retrospective review of all 1,167 patients from the Mayo Clinic Fontan database. Thirteen percent (153 patients) had AVV repair or replacement during their staged single ventricle palliation. We found that patients with right ventricular morphology and common AVV were at increased risk for AVV intervention. Patients who underwent AVV intervention had increased risk of death/transplant compared with those who did not (hazards ratio [HR] = 1.75, 95% CI 1.37 to 2.23, p <0.001). With respect to valve intervention timing, whereas AVV intervention before Fontan presented similar risk for death/transplant compared with no AVV intervention (HR = 0.85, 95% CI 0.32 to 2.27, p = 0.74), intervention at time of Fontan had a significantly higher risk (HR = 1.46, 95% CI 1.09 to 1.97, p = 0.01), and intervention after Fontan had a much more substantial risk (HR = 3.83, 95% CI 2.54 to 5.79, p <0.001). AVV repair failure occurred in 11% of patients. In terms of relative risk of valve repair versus replacement, in post-Fontan AVV intervention patients, AVV replacement carried a 2.9 fold risk of death/transplant compared with AVV repair. In conclusion, AVV disease remains a considerable challenge for durable Fontan physiology. This data demonstrates that earlier intervention on valve pathology improves survival with the Fontan circulation. Continued surveillance of single ventricle patients and prompt referral of those with valve pathology can improve outcomes in this challenging population.

Imaging of the mitral valve: role of echocardiography, cardiac magnetic resonance, and cardiac computed tomography.

This article reviews the role of multimodality imaging in the in evaluation of patients with mitral regurgitation referred for transcatheter interventions. Transcatheter therapies for mitral regurgitation in patients with high surgical risk or contraindications for surgery are evolving rapidly. Three-dimensional imaging techniques (transesophageal echocardiography, computed tomography, and cardiovascular magnetic resonance) are key to determine the anatomical suitability for each transcatheter therapy, to accurately quantify mitral regurgitation, and to plan and guide the procedure. Fusion imaging is being implemented in catheterization laboratories to precisely guide the procedure and to maximize safety and optimal results. Transcatheter edge-to-edge mitral valve repair with the MitraClip device (Abbott Vascular, Santa Clara, CA) provides the largest evidence on the safety and efficacy of this minimally invasive therapy and the importance of accurate patient selection to improve outcomes has been recently shown in two randomized trials. Multimodality imaging is key in the work-up of patient with mitral regurgitation undergoing transcatheter therapies. Preprocedural imaging with three-dimensional echocardiography, computed tomography, and cardiac magnetic resonance is important to evaluate the eligibility of patients for transcatheter interventions, whilst three-dimensional transesophageal echocardiography provides soft-tissue information that can be overlaid onto fluoroscopy allowing more accurate guidance of transcatheter interventions.

Impact of right ventricular function on development of significant tricuspid regurgitation in patients with chronic atrial fibrillation

BackgroundChronic atrial fibrillation (AF) can cause significant tricuspid regurgitation (TR), which may result from tricuspid annulus and right atrial enlargement. However, the impact of right ventricular (RV) function on TR development remains unclear. MethodsWe retrospectively examined 175 consecutive patients with lone chronic AF (duration >1 year) without left ventricular dysfunction. TR severity was graded by the jet area and vena contracta, and moderate or severe TR were defined as significant TR. Patients were classified as significant TR (TR group) or without (NTR group) for comparison of clinical factors and transthoracic echocardiographic (TTE) parameters. To explore factors associated with TR development, we also compared previous TTE parameters among patients in TR group who showed no prior significant TR [TR-preTR(−)] and those in NTR group [NTR-preTR(−)]. ResultsThe mean age was 78 years (61% men). Significant TR was observed in 61 patients (35%). Compared with NTR group, the TR group was older, and had longer AF duration and larger right-sided cardiac parameters on index TTE. At previous TTE, the TR-preTR(−) group showed a larger basal RV dimension index (26.8 vs. 22.4mm/m2), reduced RV free wall longitudinal strain (RVLS-FW) (−18.96 vs. −23.23), and lower tricuspid annular diameter change during a cardiac cycle (8.8% vs. 14.1%) than NTR-preTR(−) group. ConclusionSignificant TR was observed in 35% of patients with chronic AF. These patients showed enlarged RV, reduced RVLS-FW, and low tricuspid annular diameter changes before significant TR develops. RV dysfunction may be associated with TR development in chronic AF.

Impact of disproportionate secondary mitral regurgitation in patients undergoing edge-to-edge percutaneous mitral valve repair.

The aim of this study was to evaluate the prognostic role of echocardiographic parameters assessing secondary mitral regurgitation (SMR) severity and left ventricular dimension, including proportionate versus disproportionate SMR, in MitraClip recipients. We analysed 137 patients undergoing MitraClip implantation for SMR at three centres. SMR was classified as proportionate or disproportionate based on the median value of the ratio between effective regurgitant orifice area (EROA) and left ventricular end-diastolic volume (LVEDV). The primary endpoint was a composite of cardiovascular mortality and heart failure hospitalisation at two-year follow-up. Mean age was 70±10 years, 80% were male, and median EuroSCORE II was 5.7%. No differences were observed in the disproportionate compared to the proportionate group except for a more severe NYHA class and their expected higher EROA and lower LVEDV. Number of clips deployed, device success and procedural success were similar between the two groups. Residual mitral regurgitation (MR) >1+ at 30 days was more common among patients with an EROA >0.42 cm2 compared to those with an EROA ≤0.42 cm2 (81.3% vs 58%; p=0.004). The relative risk of the primary endpoint was independent from any echocardiographic parameter, including the presence of disproportionate SMR. The only independent predictors of clinical events were EuroSCORE II >8%, NYHA class and residual MR >1+ at 30 days. Echocardiographic parameters, including the EROA/LVEDV ratio, do not have independent prognostic value in patients undergoing MitraClip implantation. High surgical risk, advanced symptoms and non-optimal MR reduction increase the relative risk of two-year clinical events.

Characteristics and prognostic implications of tricuspid regurgitation in patients with arrhythmogenic cardiomyopathy.

AimsArrhythmogenic cardiomyopathy (AC) is characterized by right ventricular (RV) dilatation and dysfunction and is often seen in combination with tricuspid regurgitation (TR). The aim of this study was to investigate the characteristics and prognostic implications of TR in patients with AC.Methods and resultsClinical, echocardiographic, and cardiac magnetic resonance data of 52 patients with AC fulfilling 2010 Task Force criteria in a single centre were retrospectively evaluated. TR in AC was classified as no/mild, moderate, or severe on the basis of the current guidelines. Significant TR was defined as at least moderate TR. The primary endpoint was a composite of death, heart transplantation, and tricuspid valve surgery. There were seven patients (13.4%) with moderate TR and 13 patients (25.0%) with severe TR at initial diagnosis. Patients with severe TR showed a higher prevalence of atrial fibrillation and a higher mean NT‐pro‐BNP than other groups (68%, P = 0.013; 2423 ± 1578 pg/mL, P < 0.001, respectively). Patients with significant TR revealed a higher incidence of heart failure at initial presentation than did those without significant TR (30.0 vs. 3.1%, P = 0.022). Patients with severe TR showed significantly larger RV and lower RV and left ventricular functional parameters. During a mean follow‐up of 4.2 years, three groups classified by TR severity considerably discriminated clinical outcomes (log rank P = 0.019). Patients with significant TR had a poorer prognosis than those with no or mild TR (42.9 vs. 3.1%, log rank P = 0.005). Cox regression analysis showed significant TR as an independent prognostic factor (hazard ratio 11.41, 95% confidential interval 1.30–99.92, P = 0.028).ConclusionsSignificant TR at initial diagnosis in patients with AC is a poor prognostic factor.

The Tricuspid Valve in Single-Ventricle Patients: Forgotten, Unforgivable, and Indispensable

The Tricuspid Valve in Single-Ventricle Patients: Forgotten, Unforgivable, and Indispensable

Relation of Mitral Annulus and Left Atrial Dysfunction to the Severity of Functional Mitral Regurgitation in Patients with Dilated Cardiomyopathy.

Methods 56 patients (58 ± 17 years, 42 men) with DCM and FMR and 52 controls, prospectively enrolled, underwent 3DTTE dedicated for mitral valve (MV), LA, and left ventricle (LV) quantitative analysis. Results Patients with FMR vs. controls presented increased MA size and sphericity during the entire systole, whereas MA fractional area change (MAFAC) and MA displacement were decreased (15 ± 5 vs. 28 ± 5%; and 5 ± 3 vs. 10 ± 2 mm, p < 0.001). In patients with moderate/severe FMR, MA diameters correlated with PISA radius, EROA, and regurgitant volume (Rvol), as also did the MA area (with PISA radius, EROA, and Rvol: r = 0.48, r = 0.58, and r = 0.47, p < 0.05). MAFAC correlated inversely with EROA and Rvol (r = −0.32 and r = −0.35, p < 0.05), with both active and total LA emptying fractions and with LV ejection fraction as well. In a stepwise multivariate regression model, decreased MAFAC and increased LA volume independently predicted patients with severe FMR. Conclusions Patients with DCM and FMR have MA geometry remodeling and contractile dysfunction, correlated with the severity of FMR. MA contractile dysfunction correlated with both LA and left LV pumps dysfunctions and predicted patients with severe FMR. Our results provide new insights that might help with better selection of patients for MV transcatheter procedures.

Effect of Coronary Artery Bypass Grafting on Chronic Ischemic Mitral Regurgitation in Patients with Coronary Artery Disease

Effect of Coronary Artery Bypass Grafting on Chronic Ischemic Mitral Regurgitation in Patients with Coronary Artery Disease

Adaptive development of concomitant secondary mitral and tricuspid regurgitation after transcatheter aortic valve replacement.

Concomitant secondary atrioventricular regurgitation is frequent in patients with severe aortic stenosis scheduled for transcatheter aortic valve replacement (TAVR). The future implications of leaving associated valve lesions untreated after TAVR remain unknown. Aim of the present study was to characterize the evolution of concomitant secondary atrioventricular regurgitations and to evaluate their impact on long-term prognosis. We prospectively enrolled 429 consecutive TAVR patients. All patients underwent comprehensive clinical, laboratory, and echocardiographic assessments prior to TAVR, at discharge, and yearly thereafter. All-cause mortality was chosen as primary study endpoint. At baseline, severe concomitant secondary mitral regurgitation (sMR) was present in 54 (13%) and severe concomitant secondary tricuspid regurgitation (sTR) in 75 patients (17%). After TAVR 59% of patients with severe sMR at baseline experienced sMR regression, whereas analogously sTR regressed in 43% of patients with severe sTR. Persistence of sTR and sMR were associated with excess mortality after adjustment for our bootstrap-selected confounder model with an adjusted HR of 2.44 (95% CI 1.15-5.20, P = 0.021) for sMR and of 2.09 (95% CI 1.20-3.66, P = 0.01) for sTR. Patients showing regression of atrioventricular regurgitation exhibited survival rates indistinguishable to those seen in patients without concomitant atrioventricular regurgitation (sMR: P = 0.83; sTR: P = 0.74). Concomitant secondary atrioventricular regurgitation in patients with severe AS is a highly dynamic process with up to half of all patients showing regression of associated valvular regurgitation after TAVR and subsequent favourable post-interventional outcome. Persistent atrioventricular regurgitation is a major determinant of unfavourable outcome after TAVR and proposes a window of early sequel intervention.

Single Ventricle With Atrioventricular Valve Regurgitation—Ongoing Challenges

In this issue of The Annals of Thoracic Surgery, the article by Sinha and colleagues1 determined risk factors for death after repair of atrioventricular valve regurgitation in patients with single-ventricle circulation treated at a single institution. Risk factors that emerged included earlier age at atrioventricular valve repair, heterotaxy, and unbalanced atrioventricular septal defect. Transplant-free survival was lowest in patients who underwent repair at the first-stage palliation. In addition, patients with severe dysfunction of the dominant ventricle had lower transplant-free survival.

Management of regurgitation in patients with gastroesophageal reflux disease.

Precision treatment of medically-refractory regurgitation differs from that of heartburn. Regurgitation is an often-overlooked symptom characterized as a bitter taste in the mouth or a sense of fluid moving up from the stomach occurring in approximately 80% of gastroesophageal reflux disease (GERD) patients with varying severity. Its response to standard medical therapy is significantly less than heartburn while significantly lessening quality of life in 10-20% of GERD patients. The therapeutic gain of proton pump inhibitors (PPIs) above placebo averages 17% for regurgitation compared with 41% for heartburn. Increased dosing of medication is commonly, yet futilely, used. The symptom is probably mediated more by fluid volume than by the acidity of the refluxate. PPIs significantly decrease gastric acid secretion and to some extent volume of gastric juice. Significantly, doubling the PPI dose does not incrementally decrease gastric juice volume though it may decrease gastric acid secretion further. Studies on refractory regurgitation using some of the newer antireflux procedures (magnetic sphincter augmentation and transoral fundoplication) demonstrated success in over 85% of patients whereas increased PPI dosing helped in approximately 15%. Precision care of regurgitation should recognize the low-therapeutic impact of acid control, while antireflux procedures are very successful.

In-hospital outcomes of percutaneous mitral valve repair in patients with chronic obstructive pulmonary disease: insights from the national inpatient sample database.

We aimed to assess the in-hospital outcomes in patients with mitral regurgitation treated with percutaneous mitral valve repair (PMVR) among patients with chronic obstructive pulmonary disease (COPD). There is lack of data on the outcomes of PMVR for mitral regurgitation in patients with COPD. We analyzed the national inpatient sample (NIS) database from January 2012 to December 2016. A total of 9125 patients underwent PMVR in the period between January 2012 and December 2016, of whom 2,495 (27.3%) patients had concomitant COPD. Comparing COPD patients to non-COPD patients, COPD patients had higher proportion of females (48.3% vs. 46.6%, p = .16), were younger (75.8 ± 10.0 years vs. 76.4 ± 12.2 years; p = .04), had higher prevalence of peripheral vascular disease (17.4% vs. 13.5%; p < .01) and renal failure (39.3% vs. 37%; p < .01). After propensity matching, there was no significant difference in mortality among the COPD group versus non-COPD patients (2.6% vs. 2.9%; p = .6). Patients with COPD had higher proportion of in-hospital morbidities including St-segment elevation myocardial infarction (1.8% vs. 1.0%; p = .02), cardiogenic shock (1.4% vs. 0.4%; p < .01), vascular complications (2% vs. 0.8; p < .01), pneumothorax (1% vs. 0.4%; p < .01), and septic shock (1.2% vs. 0.4%; p < .01). Moreover, surrogates of severe disability (mechanical intubation and non-home discharges), cost of hospitalization, and length of stay were higher in the COPD group. There was no difference in mortality between the COPD and non-COPD patients after PMVR. Moreover, we observed higher rates of in-hospital morbidities, surrogates of severe disability, and higher resources utilization by the COPD group.

Higher preoperative left atrial volume index predicts lack of mitral regurgitation improvement after transcatheter aortic valve replacement.

Moderate-to-severe mitral regurgitation is present in 20-35% of patients undergoing transcatheter aortic valve replacement (TAVR) and the current literature lacks simple echocardiographic parameters, which can predict post-TAVR changes in mitral regurgitation. The aim of this study is to investigate the echocardiographic predictors of improvement or worsening of mitral regurgitation in patients undergoing TAVR with moderate-to-severe mitral regurgitation. This retrospective study included 113 patients who underwent TAVR with preoperative mitral regurgitation grade at least 2. Patients with concomitant coronary artery disease requiring treatment were excluded. Mitral regurgitation was related to the annular dilatation or tethering mechanism in all patients. Preoperative and postoperative echocardiographies were compared in terms of mitral regurgitation and other commonly measured parameters. After TAVR, a reduction in mitral regurgitation was observed in 62.8% of cases. On the basis of the difference between postoperative and preoperative echocardiograms, 71 patients had improved mitral regurgitation, whereas 42 patients had stable or worsened mitral regurgitation. After analyzing preoperative echocardiographic parameters with regard to this group difference, left atrial volume index (LAVI) was the only variable that was different between groups (33.4 ± 4.8 ml/m in improved mitral regurgitation vs. 39.8 ± 3.0 ml/m in not improved mitral regurgitation, P < 0.001). In a multivariable logistic regression model, a LAVI increase was associated with lack of an acute reduction in mitral regurgitation (odds ratio = 1.41, P < 0.001) after adjustment for age and preoperative serum creatinine. Higher preoperative LAVI is a determinant predictor of lack of an acute reduction in mitral regurgitation after TAVR, and LAVI could be used as a stratifying tool to tailor the treatment strategy and the timing of the procedures. However, validation of these results and long-term outcomes are warranted to support those conclusions.

Secondary valve regurgitation in patients with heart failure with preserved ejection fraction, heart failure with mid-range ejection fraction, and heart failure with reduced ejection fraction.

Secondary mitral regurgitation and secondary tricuspid regurgitation due to heart failure (HF) remain challenging in almost every aspect: increasing prevalence, poor prognosis, notoriously elusive in diagnosis, and complexity of therapeutic management. Recently, defined HF subgroups according to three ejection fraction (EF) ranges (reduced, mid-range, and preserved) have stimulated a structured understanding of the HF syndrome but the role of secondary valve regurgitation (SVR) across the spectrum of EF remains undefined. This review expands this structured understanding by consolidating the underlying phenotype of myocardial impairment with each type of SVR. Specifically, the current understanding, epidemiological considerations, impact, public health burden, mechanisms, and treatment options of SVR are discussed separately for each lesion across the HF spectrum. Furthermore, this review identifies important gaps in knowledge, future directions for research, and provides potential solutions for diagnosis and treatment. Mastering the challenge of SVR requires a multidisciplinary collaborative effort, both, in clinical practice and scientific approach to optimize patient outcomes.