Residual Mitral Regurgitation Research Articles

Elevated mitral valve pressure gradient following transcatheter edge-to-edge repair is independently associated with inferior outcomes in atrial, but not in ventricular secondary mitral regurgitation

Abstract Background In transcatheter mitral valve edge-to-edge repair (M-TEER), the goal of optimizing post-procedural residual mitral regurgitation inadvertently carries the risk of generating relevant mitral stenosis, resulting in an elevated mean mitral valve pressure gradient (MPG). In patients with primary mitral regurgitation, an elevated post-procedural MPG has been found to independently predict impaired outcomes. However, the effect of elevated post-procedural MPG on outcome after M-TEER in patients with secondary mitral regurgitation (SMR) has yet to be fully elucidated. This study investigated the impact of elevated MPG on outcome in the EuroSMR registry, a large, multi-center real-world cohort of patients with SMR. Methods This retrospective study included patients who underwent M-TEER for SMR between 2009 and 2021 in 12 centers. Patients were stratified into two groups based on SMR etiology: (1) ventricular SMR (vSMR), and (2) atrial SMR (aSMR). The etiology was considered as vSMR in patients with a left ventricular ejection fraction (LV-EF) <50% and aSMR in subjects with preserved left ventricular function (LV-EF ≥50%) and a markedly dilated left atrium (Left Atrial Volume Index [LAVi] ≥40ml/m2). According to the proposed M-VARC threshold, post-procedural MPG was assessed by discharge transthoracic echocardiography and was considered elevated if >5 mmHg. The primary endpoint was all-cause mortality after 5 years, with statistical analysis conducted using Kaplan-Meier and uni- and multivariable Cox Regression analysis. Results Among the 1703 patients in the study (vSMR: n=1420; aSMR: n=283), elevated post-procedural MPG was observed in 9.4% (n=133) of vSMR and 19.1% (n=54) of aSMR patients. Atrial fibrillation was significantly more prevalent in aSMR (78.4% vs. 57.1%, p<0.001). Patients with vSMR had a higher median surgical risk assessed by the EuroScore II (aSMR vs. vSMR: 7.0% [IQR 4.0, 13.1] vs. 4.9% [IQR 2.9, 8.5], p<0.001). Kaplan-Meier analyses for all-cause mortality after 5 years demonstrated significant differences in aSMR patients (low vs. elevated MPG: 48.9% vs. 69.8%, log-rank p<0.01), while there was no difference in vSMR patients (55.7% vs. 60.8%, log-rank p=0.66) (Figure 1). This observed effect remained significant even after accounting for common confounding factors: elevated MPG was an independent predictor for all-cause mortality in aSMR patients (HR=1.86; 95%-CI: 1.14-3.02, p=0.013) but not in vSMR patients (HR=1.00; 95%-CI: 0.74-1.35, p=0.99). Conclusion Our findings suggest that elevated post-procedural MPG is an independent predictor of adverse outcomes in patients with aSMR, but not in those with vSMR. This effect may partially be explained by a reduced left atrial function and higher rates of atrial fibrillation.Figure 1.Study flowchart

Calculation of intraprocedural hemodynamics with computational functional dynamic in mitral valve edge-to-edge repair

Abstract Background Hemodynamic outcomes in patients undergoing transcatheter edge-to-edge-repair of the mitral valve (M-TEER) are difficult to predict. Computational functional dynamic (CFD) is frequently used in biomedical engineering to simulate blood flow patterns under various conditions. The authors developed a standardized workflow for individualized analyses and investigated the hemodynamic of mitral regurgitation volumes and gradients by using CFD. Methods 20 patients from two high volume centers who suffered from severe mitral regurgitation (MR) and underwent full cycle cardiac computed tomography (CT) prior procedure were enrolled. Baseline computed tomography and intraprocedural data were analyzed. Based on the specific valve morphology, individualized CFD-simulations were performed to calculate MR volumes prior to intervention and estimate hemodynamics after M-TEER. Results CFD-analyses of 20 patients (mean age 80±4 years, 60% male) showed excellent correlation between baseline PISA method-based MR volumes (45±23ml) measured in transesophageal echocardiography (TEE) and CFD-based calculation (45±26ml; R=0.917; P<0.001) as well as between TEE-measured mean baseline effective regurgitant orifice area (EROA; 27±16mm²) and CFD-measured EROA (24±18mm²; R=0.869; P<0.001)). After device implantation, correlation between intraprocedural TEE-measured and CFD-estimated correlation for residual MR volumes (R=0.949; P<0.001) and EROA (R=0.841; P<0.001) remained robust. Post-interventional mean diastolic pressure gradient (TEE) was 3.6±2.8mmHg which was in close correlation with the CFD estimated gradient (3.0±1.8mmHg, R=0.905; P<0.001). Conclusions This is the first study to use a CFD-standardized workflow for predicting hemodynamic changes in patients undergoing M-TEER using data from two different centers. In the future, CFD-based analyses might serve as a key-diagnostic tool for predicting residual MR volumes and gradients for M-TEER-procedures.Comparison of TEE and CFD flow patternBland-Altman-Blots

Clinical Impact of Baseline Frailty Status and Residual Mitral Regurgitation After Transcatheter Edge-to-Edge Repair: Insights From the OCEAN-Mitral Registry.

The Clinical Frailty Scale (CFS) is a useful frailty marker for predicting clinical outcomes in patients undergoing invasive therapy. However, the clinical impact of CFS after transcatheter edge-to-edge repair in patients with mitral regurgitation (MR) remains unclear. This study aimed to elucidate the association between the baseline frail status defined by the CFS and clinical outcomes with or without postprocedural MR ≥2+ (post-MR ≥2+) after transcatheter edge-to-edge repair. Based on a Japanese multicenter registry (OCEAN [Optimized Catheter Valvular Intervention]-Mitral), data from 2078 patients with MR who underwent transcatheter edge-to-edge repair were analyzed. The patients were classified into 5 groups: CFS 1 to 3, 4, 5, 6, and ≥7. The procedural and clinical outcomes and post-MR ≥2+ were compared among the groups. All-cause mortality for up to 2 years was explored using Cox proportional hazards regression analysis. Although the rates of acute procedural success and post-MR ≥2+ were similar, all-cause mortality at 2 years was significantly increased across the 5 CFS categories (15.5%, 23.8%, 27.7%, 34.6%, and 48.8%, respectively, P<0.001). The incremental CFS categories and post-MR ≥2+ were independent predictive risk factors of all-cause mortality (all P<0.05). Among the patients with 5 CFS categories, the incidence of all-cause mortality was higher in those with post-MR ≥2+ than in those without (all P<0.05). Although prognosis was poor in patients with higher CFS grade after transcatheter edge-to-edge repair, minimizing modifiable factors of residual MR is warranted to improve the clinical outcomes. URL: https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000027188; Unique identifier: UMIN000023653.

Combined Impact of Residual Mitral Regurgitation and GradientAfter MitralValve TranscatheterEdge-to-Edge Repair.

Reducing mitral regurgitation (MR) during mitral transcatheter edge-to-edge repair (M-TEER) may come at the cost of increased mitral valve gradient (MVG). The combined impact of residual MR and MVG on clinical outcomes after M-TEER is unknown. This study sought to evaluate the impact of postprocedure MR and MVG on clinical outcomes after M-TEER. EXPANDed is a pooled, patient-level cohort of the EXPAND (A Contemporary, Prospective Study Evaluating Real-world Experience of Performance and Safety for the Next Generation of MitraClip Devices) and EXPAND G4 studies, which were designed to evaluate real-world safety and effectiveness of the third- and fourth-generation MitraClip TEER Systems. Subjects were categorized by echocardiographic core laboratory (ECL) assessments into 4 groups according to 30-day MR grade and mean MVG: 1) MR≤1+/MVG<5mmHg; 2) MR≤1+/MVG≥5mmHg; 3) MR≥2+/MVG<5mmHg; and 4) MR≥2+/MVG≥5mmHg. A total of 1,723 subjects had evaluable echocardiograms at 30days: 72% had MR≤1+/MVG<5mmHg, 18% had MR≤1+/MVG≥5mmHg, 7% had MR≥2+/MVG<5mmHg, and 3% had MR≥2+/MVG≥5mmHg. MR≤1+ was sustained through 1 year in 93% of patients who achieved 30-day MR≤1+. MVG decreased from 30days to 1 year in subjects with MVG≥5mmHg (6.7 ± 4.0 to 5.5 ± 2.5mmHg MR≤1+/MVG≥5mmHg and 6.5 ± 1.5 to 5.5 ± 1.7mmHg MR≥2+/MVG≥5mmHg). One-year rates of all-cause mortality and heart failure hospitalization were lower for subjects who achieved MR≤1+ at 30days, regardless of MVG. Reduction of MR to mild or less after M-TEER with the latest-generation MitraClip systems was associated with clinical benefit regardless of MVG.

Impact of residual mitral regurgitation after transcatheter edge-to-edge repair in atrial functional mitral regurgitation: Results from MITRA-PRO registry.

Transcatheter edge-to-edge repair (TEER) has emerged to address symptomatic atrial functional mitral regurgitation (aFMR) in patients who are at high operative risk. No clinical data is available on the impact of residual mitral regurgitation (MR) following TEER in aFMR compared to ventricular functional MR (vFMR). In the MITRA-PRO registry, 846 patients with FMR and MitraScore assessment for residual MR quantification were included (722 patients with vFMR and 124 patients with aFMR). Compared to vFMR similar procedural results in regard of residual MR following TEER were found in aFMR patients (MitraScore post TEER 2.5 ± 1.8 vs. 2.7 ± 1.9), while the amount of implanted TEER devices was increased in vFMR. 1-year survival was better in aFMR compared to vFMR regardless of relevant residual MR (MitraScore ≥ 4), while 1-year rehospitalization was comparable for both MR entities. Patients with aFMR and mild residual MR had a lower mortality rate (6.6% vs. 10.3%) and rehospitalization rate (29.1% vs. 46.2%) 1 year after mitral TEER. However, in contrast to vFMR a MitraScore ≥4 was no independent predictor of mortality in aFMR indicating a better tolerance toward residual MR. Residual MR is an independent predictor of 1-year mortality in vFMR patients, whereas in aFMR patients, a MitraScore of ≥4 is associated with higher mortality but is not an independent predictor in multivariate analysis. Therefore, minimizing MR through mitral TEER is crucial for survival in vFMR patients, while aFMR patients tolerate significant residual MR better 1 year after the procedure.

Impact of systolic dominant pulmonary venous flow morphology on outcomes after mitral transcatheter edge-to-edge repair.

The prognostic significance of intraprocedural pulsed-wave Doppler analysis of pulmonary venous flow (PVF) during mitral transcatheter edge-to-edge repair (TEER) remains understudied. We aimed to investigate the prognostic value of systolic dominant-PVF (SD-PVF) morphology post-TEER. In a retrospective analysis from December 2019 to December 2022, patients undergoing mitral TEER were categorized into SD-PVF and systolic blunting (SB)-PVF groups based on post-TEER morphology. The primary endpoint was a composite of all-cause mortality or heart failure hospitalization at 1 year. We investigated the association of PVF morphology post-TEER with the primary endpoint at 1 year using Cox regression and compared the prognostic accuracy of PVF variables through receiver operating characteristic (ROC) curve analysis. Among 187 patients (mean age 76.4 ± 10.5 years, 51.3% primary etiology), residual mitral regurgitation (MR) ≤mild was observed in 147 (82.4%) patients and 105 (56.2%) had SD-PVF post-TEER. Patients with SD-PVF had a lower incidence of >2+ residual MR after clip deployment, at 30 days (2.1% vs. 13.1%; p = 0.005) and at 1 year (1.4% vs. 9%; p = 0.08). SD-PVF post-TEER was independently associated with the primary endpoint (HR = 0.59, 95% CI = 0.39-0.87; p = 0.009). ROC curve analysis of the prognostic accuracy of SD-PVF demonstrated an AUC of 0.64 (95% CI = 0.54-0.73), comparable to other quantitative measures of PVF. Assessing PVF morphology after clip deployment offers a simple prognostic tool for patients undergoing mitral TEER. Multicenter cohorts will be necessary to further investigate its prognostic value.

Impact and limitations of 3D computational modelling in transcatheter mitral valve replacement-atwo-centre Dutch experience.

Transcatheter mitral valve replacement (TMVR) has emerged as aminimally invasive alternative to mitral valve surgery for patients at high or prohibitive operative risk. Prospective studies reported favourable outcomes in patients with annulus calcification (valve-in-mitral annulus calcification; ViMAC), failed annuloplasty ring (mitral valve-in-ring; MViR), and bioprosthetic mitral valve dysfunction (mitral valve-in-valve; MViV). Multi-slice computed tomography (MSCT)-derived 3D-modelling and simulations may provide complementary anatomical perspectives for TMVR planning. We aimed to illustrate the implementation of MSCT-derived modelling and simulations in the workup of TMVR for ViMAC, MViR, and MViV. For this retrospective study, we included all consecutive patients screened for TMVR and compared MSCT data, echocardiographic outcomes and clinical outcomes. Sixteen out of 41patients were treated with TMVR (ViMAC n = 9, MViR n = 3, MViV n = 4). Eleven patients were excluded for inappropriate sizing, 4for anchoring issues and 10for an unacceptable risk of left ventricular outflow tract obstruction (LVOTO) based on 3D modelling. There were 3procedure-related deaths and 1non-procedure-related cardiovascular death during 30days of follow-up. LVOTO occurred in 3ViMAC patients and 1MViR patient, due to deeper valve implantation than planned in 3patients, and anterior mitral leaflet displacement with recurrent basal septum thickening in 1patient. TMVR significantly reduced mitral mean gradients as compared with baseline measurements (median mean gradient 9.5(9.0-11.5) mm Hg before TMVR versus 5.0(4.5-6.0) mm Hg after TMVR, p = 0.03). There was no residual mitral regurgitation at 30days. MSCT-derived 3D modelling and simulation provide valuable anatomical insights for TMVR with transcatheter balloon expandable valves in ViMAC, MViR and MViV. Further planning iterations should target the persistent risk for neo-LVOTO.

Impact of transcatheter edge to edge repair in functional mitral regurgitation and cardiac resynchronization-therapy nonresponders.

Despite optimal medical therapy and cardiac resynchronization therapy (CRT), significant functional mitral regurgitation (MR) persisted in 30% of the patients and labeled as CRT nonresponders. We sought to study the impact of transcatheter edge-to-edge repair (TEER) in patients with symptomatic grade III and IV functional MR despite CRT. A retrospective analysis was conducted of all patients who had prior CRT for at least 6 months and underwent TEER for significant residual functional MR (grade ≥3) and symptomatic heart failure (HF) at our institution. The primary outcomes were the change in New York Heart Association classification (NYHA), MR grade, echo parameters, and NT-ProBNP from baseline to 1-year post-procedure. A total of 28 patients were identified, mean age of 73 ± 6.7 years and 89% males. Procedure success was achieved in all patients. At 1-year follow-up, patients had lower MR grade (median 2, IQR 1 [1,2] vs. 4, IQR 1 [3,4]; p < 0.001), NYHA class (median 2, IQR 1 [2,3] vs. 3, IQR 1 [3,4]; p < 0.001), and NT-ProBNP (7658 ± 11322 vs. 3760 ± 4431; p = 0.035) compared to before the TEER procedure. The left ventricular end-diastolic volume (255 ± 59vs. 244 ± 66 mm; p = 0.016) and the right ventricular systolic pressure (52 ± 14 mmHg vs. 37 ± 13 mmHg, <0.001) decreased. Patients who remain symptomatic after CRT with severe functional MR had improved functional status and MR grade at 1-year following TEER. There was a signal toward reverse remodeling.

550 Robotic Totally Endoscopic Mitral Valve Surgeries Within a Comprehensive Robotic Cardiac Program

BackgroundIn 2013, we initiated a comprehensive multispectrum robotic cardiac surgery program with emphasis on the totally endoscopic approach. We reviewed the outcomes of mitral valve (MV) procedures within this context. MethodsA retrospective review of 1714 robotic endoscopic cardiac surgeries performed at our institution between September 2013 and February 2024 was conducted. Of these, outcomes of 550 consecutive heterogeneous patients undergoing robotic totally endoscopic MV operations were analyzed. Data were collected according to the Mitral Valve Academic Research Consortium definitions. ResultsThe mean age was 63 years, and 217 patients (39%) were female. The mean Society of Thoracic Surgeons risk of mortality was 2.1% (range, 0.15%-19.4%). MV repair occurred in 98% of patients with degenerative mitral regurgitation (MR). Concomitant procedures included Cox-maze cryoablation in 127 (23%) patients, tricuspid valve repair in 54 (9.8%), septal myectomy in 15 (2.7%), totally endoscopic coronary bypass in 6 (1.1%), and aortic valve replacement in 3 (0.5%). Endoaortic balloon occlusion was used in 392 patients (71%), ventricular fibrillatory arrest in 114 (21%), and transthoracic aortic clamp in 44 (8%). Observed to expected 30-day mortality was 0.6. Mean length of hospital stay was 2.8 days. MV repair 30-day surgical success was 95.9% and procedural success was 93.0%. Postoperative echocardiography revealed no or trace residual MR in 95% and mild residual MR in 5%. Five-year freedom from reoperation for recurrent MR was 95.7%. ConclusionsRobotic endoscopic MV surgery is feasible within the context of a comprehensive multispectrum robotic cardiac surgery program.

Recurrent mitral regurgitation after repair of Barlow's disease in a single-center retrospective cohort study.

Barlow's disease (BD) is a common etiology of degenerative mitral valve (MV) disease, often causing significant mitral regurgitation (MR). The pathology of BD is challenging for surgeons performing MV repair (MVR). However, most MVR effectiveness studies have been based on survival and risk of reoperation. The aim of this study was to analyze the safety, efficacy, and durability of MVR in patients with BD and to identify factors that influence recurrent MR. We retrospectively analyzed the clinical outcomes of 274 patients undergoing MVR for BD at a tertiary hospital (Guangdong People's Hospital, Guangzhou, China) between January 2010 and June 2022. To analyze the results of MVR and identify the risk factors for MR recurrence, we defined two groups: a total of 240 patients with MR grade <2+ (group A) and a total of 34 patients who had recurrent MR after MVR (group B; the patients with MR ≥2+). All patients were operated on using standard repair techniques. Recurrent MR was the primary outcome. Secondary outcomes were death and reoperation after MVR. Patients were followed up until March 2023. Patients were followed up by clinic visits, telephone calls, and postal or electronic questionnaires. The median [range] patient age was 46.00 [16-75] years and 186 (67.9%) patients were male. Concomitant procedures were performed in 123 patients: tricuspid valve repair 71 (25.9%), maze or pulmonary vein isolation (PVI) 12 (4.4%), atrial septal defect (ASD) repair 3 (1.1%), and left atrial appendage (LAA) closure 28 (10.2%). Hospital mortality was 0.4%. Long-term complications included radiofrequency ablation in 7 patients (2.6%), pacemaker implantation in 1 patient (0.4%), and stroke in 3 patients (1.1%). The median follow-up was 3.28 (range, 0-12.39) years. Considering the competing risk of mortality, the cumulative incidence of MR progression 2+ or more grades was 2.6%, 5.9%, 14.5%, and 27.7% at 1 month, 1, 5, and 10 years, respectively. Overall survival at 1, 5, and 10 years was 99.3%, 98.6%, and 98.6%, respectively. The immediate postoperative MR area [hazard ratio (HR) =1.723; 95% confidence interval (CI): 1.051-2.824; P=0.031], postoperative left ventricular end-diastolic dimension (LVEDD) (HR =1.149; 95% CI: 1.016-1.300; P=0.027), and postoperative MR grade {HR = Exp[4.500 - 0.544 × ln(t + 20)]; P=0.008} were associated with an increased risk of MR recurrence, whereas a higher left ventricular ejection fraction (LVEF) (HR =0.931; 95% CI: 0.868-0.999; P=0.049) was associated with a decreased risk. MVR in patients with BD can be performed with low mortality and complications and is associated with superior long-term outcomes. However, MVR was associated with a certain risk of MR recurrence, especially in those with high postoperative LVEDD, residual MR >1+, and decreased postoperative LVEF. We recommend MVR for patients with BD, especially for those with early-stage disease. However, future randomized controlled trials are needed to confirm this.

Application of a Novel Mitral Valvuloplasty Strategy in Children with Mitral Regurgitation.

To retrospectively analyze the clinical efficacy of an innovative mitral valvuloplasty strategy in the treatment of mitral regurgitation in children. From January 2018 to December 2022, 140 patients undergoing surgical treatment for mitral regurgitation in our hospital were enrolled. Ninety patients underwent three-step standardized pediatric mitral valvuloplasty (group A) and 50 patients underwent simple annuloplasty (group B). The incidence of primary and secondary study endpoint was compared between the two groups, and the independent risk factors for the primary study endpoint were determined. Our primary study endpoint was a composite endpoint of postoperative functional mitral failure, postoperative heart failure, transplantation, and/or mortality. Secondary end points were defined as perioperative complications. During the follow-up period, there was no all-cause death. Primary endpoint events occurred in 22 patients, including 12 patients in group A and 10 patients in group B. There was no significant difference in the incidence of primary and secondary endpoint events between the two groups. Multivariate Cox proportional hazards regression analysis showed that younger age and residual mitral regurgitation at discharge were independent risk factors for the primary endpoint events, while type of MV repair was not an independent risk factor. Subgroup analysis based on age showed that primary endpoint events occurred in 4 patients in group A and 7 patients in group B in patients < 1year old. The incidence of primary endpoint events in group A was lower than that in group B (6.06% vs. 20.59%, P = 0.041). In patients ≥ 1year old, the primary endpoint event occurred in 8 cases in group A and 3 cases in group B. There was no significant difference in the incidence of primary endpoint events between groups A and B (33.33% vs. 18.75%, P = 0.312). The degree of mitral regurgitation at discharge was significantly improved compared with that before operation in both groups (P < 0.001), and the degree of mitral regurgitation at the last follow-up was not significantly worse than that at discharge (P = 0.090). The mid-term results of mitral valvuloplasty for mitral regurgitation in children are encouraging. The perioperative recovery and postoperative outcomes of three-step standardized mitral valvuloplasty in children are not inferior to those of annuloplasty alone. Three-step standardized pediatric mitral valvuloplasty has better postoperative outcomes than simple mitral annuloplasty, especially for patients younger than 1year old. Children with residual mitral regurgitation at discharge should be followed up regularly to be alert to the occurrence of poor prognosis.

Structural heart transcatheter interventions in orthotopic cardiac transplant and left ventricular assist devices recipients: A nationwide study

BackgroundThe current incidence and outcomes of structural transcatheter procedures in heart transplant (HTx) recipients and left-ventricular assist devices (LVAD) carriers is unknown.Aims: To provide insights on structural transcatheter procedures performed across HTx and LVAD patients in Spain. MethodsMulticenter, ambispective, observational nationwide registry. ResultsUntil May/2023, 36 percutaneous structural interventions were performed (78% for HTx and 22% for LVAD) widely varying among centers (0%–1.4% and 0%–25%, respectively). Percutaneous mitral transcatheter edge-to-edge (TEER) was the most common (n = 12, 33.3%), followed by trancatheter aortic valve replacement (n = 11, 30.5%), and tricuspid procedures (n = 9, 25%).Mitral TEER resulted in mild residual mitral regurgitation in all but one case, mean gradient was <5 mmHg in 75% of them at 1-year, with no mortality and 8.3% re-admission rate. Tricuspid TEER resulted in 100% none/mild residual regurgitation with a 1-year mortality and readmission rates of 22% and 28.5%, respectively. Finally, trancatheter aortic valve replacement procedures (n = 8 in LVADs due to aortic regurgitation and n = 3 in HTx), were successful in all cases with one prosthesis degeneration leading to severe aortic regurgitation at 1-year, 18.2% mortality rate and no re-admissions.Globally, major bleeding rates were 7.9% and 12.5%, thromboembolic events 3.7% and 12.5%, readmissions 37% and 25%, and mortality 22% and 25%, in HTx and LVADs respectively. No death was related to the implanted transcatheter device. ConclusionsMost centers with HTx/LVAD programs perform structural percutaneous procedures but with very inconsistent incidence. They were associated with good safety and efficacy, but larger studies are required to provide formal recommendations.

Island Flap Rotation Technique as a Novel Repair Surgery Method for Severe Degenerative Mitral Valve Regurgitation

Background: The current study was done to assess the efficacy and safety of the island flap rotation technique as a novel method for severe mitral valve regurgitation. Methods: Twenty-three patients were selected to undergo mitral valve repair with the island flap rotational technique. It takes the principle of doing quadrangular resection of the P2 leaflet and flipping the dissected area so that the ruptured primary chordae are replaced with the secondary or tertiary chordae. Transesophageal echocardiography parameters were evaluated before surgery and 1 week after surgery, just prior to discharge. Results: The procedure was done successfully with 100% mitral regurgitation reduction to ≤1+ along with significantly reduced left ventricular end-diastolic diameter (p = 0.001) and left atrial dimension (p = 0.000). The left ventricular ejection fraction was significantly reduced after the procedure (p = 0.000). Older age significantly affects the presence of residual mitral regurgitation (p = 0.02). No thromboembolic adverse events and mortality were observed during the 3-month follow-up. Conclusions: The use of island flap rotation technique as a novel method for severe mitral regurgitation with P2 lesions has been proven to be effective and safe with preserving the valve tissue.

Efficacy and safety of trans-catheter repair devices for mitral regurgitation: A systematic review and meta-analysis

BackgroundSeveral repair strategies emerged as possible treatment for severe mitral regurgitation (MR). A systematic review and meta-analysis was performed to compare the different percutaneous mitral valve repair approaches. MethodsPubMed and Scopus electronic databases were scanned for eligible studies until December 11th, 2023. Clinical efficacy endpoints were all-cause mortality, major adverse cardiovascular events, and post-procedural NYHA functional class <3; the echocardiographic efficacy endpoint was a post-intervention residual MR less than moderate. Safety endpoints and procedural outcome measures were also assessed. ResultsEleven studies were included: 8 [N = 1662 patients, mean follow-up (FUP) 294 days] compared MitraClip® vs Pascal® device, 2 (N = 195 patients) MitraClip® vs Carillon® and 1 study (N = 186 patients) evaluated MitraClip® against Cardioband®. The Pascal®-treated group had lower MR degree compared to the MitraClip®-treated group, without difference in post-intervention mean trans-mitral gradient and in clinical and safety endpoints. A longer procedure time was observed in the Pascal® group, albeit with a lower average number of implanted devices per procedure. The two studies comparing MitraClip® and Carillon® were inconsistent in terms of both efficacy and safety outcomes, while the study evaluating MitraClip® vs Cardioband® showed that the latter might confer a significant clinical benefit, with a similar reduction in MR. ConclusionsPascal® is as safe and clinically effective as MitraClip® in treating patients with MR, with an apparent greater reduction in the magnitude of residual valve insufficiency over the long term. Data on Cardioband® and Carillon® are not robust enough to draw conclusions from the use of such devices.

Two-Year Clinical Outcomes of Staged Transcatheter Mitral Edge-to-Edge Repair After Transcatheter Aortic Valve Replacement

Residual significant mitral regurgitation (MR) can increase the risk of adverse events following transcatheter aortic valve replacement (TAVR). The clinical benefits of staged transcatheter edge-to-edge repair (TEER) post-TAVR remain underexplored. This study aimed to investigate the clinical outcomes of staged TEER for residual significant MR post-TAVR. This observational study included 314 consecutive patients with chronic residual grade 3+ or 4+ MR at 30 days follow-up post-TAVR, with 104 (33.1%) treated with staged TEER (TEER group) and 210 (66.9%) with medical therapy alone (MT group). The primary composite outcomes were all-cause mortality and heart failure (HF) hospitalization at 2 years. Additional analysis, including changes in MR grade and the New York Association (NYHA) functional classification, and subgroup outcome comparisons based on MR etiology were also conducted. In our study, the rate of primary composite outcome was lower in the TEER group than in the MT group (33.7% vs. 48.1%, p = 0.015). Significant improvement in MR grade and NYHA class was observed in the TEER group after 2 years. Subgroup analysis demonstrated that, among patients with degenerative MR, a lower incidence of composite outcome and HF hospitalization was observed in the TEER group (hazard ratio: 0.35; 95% confidence interval: 0.23–0.53, p < 0.001).In conclusion, staged TEER post-TAVR was associated with reduced MR and improved clinical outcomes. The clinical significance of MR post-TAVR should be carefully evaluated, and TEER should be considered for patients with significant residual MR, particularly those with degenerative MR.

Prognostic impact of vasopressor test in transcatheter edge-to-edge repair of secondary mitral regurgitation: The PETIT study.

Vasopressor test (VPT) might be useful in patients with functional mitral regurgitation (MR) and left ventricular dysfunction (MITRA-FR-like patients) during transcatheter edge-to-edge repair (TEER). We aimed to evaluate the prognostic impact of VPT. MR treated with TEER were included in a multicenter prospective registry. VPT was used intraprocedurally in patients with left ventricular dysfunction and/or hypotension. The 1-year echocardiographic and clinical outcomes were compared according to the use of VPT. The primary endpoint was a combination of mortality + heart failure (HF) readmission at 1-year. A total of 1115 patients were included, mean age was 72.8 ± 10.5 years and 30.4% were women. VPT was performed in 128 subjects (11.5%), more often in critically ill patients with biventricular dysfunction. Postprocedurally the VPT group had greater rate of MR ≥ 2+ (46.9% vs. 31.7%, p = 0.003) despite greater number of devices (≥2 clips, 52% vs. 40.6 p = 0.008) and device repositioning or new clip in 12.5%. At 1-year, the primary endpoint occurred more often in the VPT group (27.3% vs. 16.9%, p = 0.002) as well as all-cause mortality (21.9% vs. 8.1%, p ≤ 0.001) but no differences existed in HF readmission rate (14.8% vs. 13.2%, p = 0.610), cardiovascular mortality (4.4% vs. 3.9%, p = 0.713) or residual MR ≥ 2+ (51.1% vs 51.7%, p = 0.371). Dynamic evaluation of MR during TEER procedure through VPT was performed in patients with worse baseline risk who also presented higher all-cause mortality at 1-year follow-up. However, 1-year residual MR, cardiovascular mortality and HF readmission rate remained comparable suggesting that VPT might help in the management of MITRA-FR-like patients.

Association between echocardiographic velocity time integral ratio of mitral valve and left ventricular outflow tract and clinical outcomes post transcatheter edge-to-edge mitral valve repair

BackgroundResidual mitral regurgitation (MR) is frequent after transcatheter edge-to-edge repair (TEER). There is controversy regarding the clinical impact of residual MR and its quantitative assessment by transthoracic echocardiography (TTE), which is often challenging with multiple eccentric jets and artifact from the clip. The utility of the velocity time integral (VTI) ratio between the mitral valve (MV) and left ventricular outflow tract (LVOT), (VTIMV/LVOT), a simple Doppler measurement that increases with MR, has not been assessed post TEER. MethodsBaseline characteristics, clinical outcomes, and TTE data from patients who underwent TEER between 2014 and 2021 across three academic centers were retrospectively analyzed. Post-procedure TTEs were evaluated for VTIMV/LVOT in the first three months after TEER. One-year outcomes including all-cause and cardiac mortality, major adverse cardiac events, and MV reintervention were compared between patients with high VTIMV/LVOT (≥2.5) and low (<2.5). ResultsIn total, 372 patients were included (mean age 78.7 ± 8.8 years, 68 % male, mean pre-TEER ejection fraction of 50.5 ± 14.7 %). Follow up TTEs were performed at a median of 37.5 (IQR 30–48) days post-procedure. Patients with high VTIMV/LVOT had significantly higher all-cause mortality (HR 2.10, p = 0.003), cardiac mortality (HR 3.03, p = 0.004) and heart failure admissions (HR 2.28, p < 0.001) at one-year post-procedure. There was no association between raised VTIMV/LVOT and subsequent MV reintervention. ConclusionHigh VTIMV/LVOT has clinically significant prognostic value at one year post TEER. This tool could be used to select patients for consideration of repeat intervention.

Computational simulation model of transcatheter edge-to-edge mitral valve repair: a proof-of-concept study.

As transcatheter mitral valve (MV) interventions are expanding and more device types and sizes become available, a tool supporting operators in pre-procedural planning and the clinical decision-making process is highly desirable. We sought to develop a finite element computational simulation model to predict the results of transcatheter edge-to-edge repair (TEER) interventions. We prospectively enrolled patients with secondary mitral regurgitation (MR) referred for a clinically indicated TEER. The 3D trans-oesophageal echocardiograms performed at the beginning of the procedure were used to perform the simulation. On the 3D dynamic model of the MV that was first obtained, we simulated the clip implantation using the same clip type, size, number, and implantation location that was used during the intervention. The 3D model of the MV obtained after the simulation of the clip implantation was compared with the clinical results obtained at the end of the intervention. We analysed the degree and location of residual MR and the shape and area of the diastolic MV area. We performed computational simulation on five patients. Overall, the simulated models predicted well the degree and location of the residual regurgitant orifice(s) but tended to underestimate the diastolic mitral orifice area. In this proof-of-concept study, we present preliminary results on our algorithm simulating clip implantation in five patients with functional MR. We show promising results regarding the feasibility and accuracy in terms of predicting residual MR and the need to improve the estimation of the diastolic MV area.

Challenges Regarding the Value of Routine Perioperative Transesophageal Echocardiography in Mitral Valve Surgery.

Transesophageal echocardiography (TEE) is considered an indispensable tool for perioperative evaluation in mitral valve (MV) surgery. TEE is routinely performed by anesthesiologists competent in TEE; however, in certain situations, the expertise of a senior cardiologist specializing in TEE is required, which incurs additional costs. The purpose of this study is to determine the indications for specialized perioperative TEE based on its utility and the correlation between intraoperative TEE diagnoses and surgical findings, compared with routine TEE performed by an anesthesiologist. We conducted a three-year prospective study involving 499 patients with MV disease undergoing cardiac surgery. Patients underwent intraoperative and early postoperative TEE and at least one other perioperative echocardiographic evaluation. A computer application was dedicated to calculating the utility of each type of specialized TEE indication depending on the type of MV disease and surgical intervention. The indications for performing specialized perioperative TEE identified in our study can be categorized into three groups: standard, relative, and uncertain. Standard indications for specialized intraoperative TEE included establishing the mechanism and severity of MR (mitral regurgitation), guiding MV valvuloplasty, diagnosing associated valvular lesions post MVR (mitral valve replacement), routine evaluations in triple-valve replacements, and identifying the causes of acute, intraoperative, life-threatening hemodynamic dysfunction. Early postoperative specialized TEE in the intensive care unit (ICU) is indicated for the suspicion of pericardial or pleural effusions, establishing the etiology of acute hemodynamic dysfunction, and assessing the severity of residual MR post valvuloplasty. Perioperative TEE in MV surgery can generally be performed by a trained anesthesiologist for standard measurements and evaluations. In certain cases, however, a specialized TEE examination by a trained senior cardiologist is necessary, as it is indirectly associated with a decrease in postoperative complications and early postoperative mortality rates, as well as an improvement in immediate and long-term prognoses. Also, for standard indications, the correlation between surgical and TEE diagnoses was superior when specialized TEE was used.

Repeat Mitral Valve Interventions After Transcatheter Edge-to-Edge Repair: The COAPT Trial

The frequency and effectiveness of repeat mitral valve interventions (RMVI) after transcatheter edge-to-edge repair (TEER) for secondary mitral regurgitation (MR) are unknown. We aimed to examine the rate of and outcomes following RMVI after TEER in the COAPT trial.The COAPT tria randomized heart failure (HF) patients with severe secondary MR to TEER with the MitraClipTM device plus guideline-directed medical therapy (GDMT) versus GDMT alone. We evaluated the characteristics and outcomes of patients who had a RMVI during 4-year follow-up. A MitraClip implant was attempted in 293 patients randomized to TEER+GDMT, 10 of whom (underwent a RMVI procedure (9 repeat TEER and 1 surgical mitral valve replacement) after 4-years of follow-up (cumulative incidence 3.90%,95% CI 2.08-7.08; median 182 days after the initial procedure). Patients with RMVI had larger mitral annular diameters, fewer clips implanted and were more likely to have ≥3+ MR at discharge compared with those without RMVI. Reasons for RMVI included failed index procedure due to difficult transseptal puncture (n=2) or tamponade (n=1); residual or recurrent severe MR after an initially successful procedure (n=5); partial clip detachment (n=1); and site-assessed mitral stenosis (n=1). RMVI was successful in 8/10 (80%) patients. Patients who underwent RMVI had higher 4-year rates of HFH but similar mortality compared with those without RMVI. The annualized incidence rates of all HFH in patients who underwent RMVI were 234 events per 100 person years (95% CI 139-395) pre-RMVI and 46 per 100 person years (95% CI 25-86) post-RMVI as compared with 32 events per 100 patient years (95% CI 28-36) among patients not undergoing RMVI. The rate ratio of HFH was reduced after RMVI in patients undergoing RMVI (0.20, 95% CI 0.09-0.45).