Residual Mitral Regurgitation Research Articles

Cardiac reverse remodeling in primary mitral regurgitation: mitral valve replacement vs. mitral valve repair

BackgroundWhen feasible, guidelines recommend mitral valve repair (MVr) over mitral valve replacement (MVR) to treat primary mitral regurgitation (MR), based upon historic outcome studies and transthoracic echocardiography (TTE) reverse remodeling studies. Cardiovascular magnetic resonance (CMR) offers reference standard biventricular assessment with superior MR quantification compared to TTE. Using serial CMR in primary MR patients, we aimed to investigate cardiac reverse remodeling and residual MR post-MVr vs MVR with chordal preservation. Methods83 patients with ≥ moderate-severe MR on TTE were prospectively recruited. 6-min walk tests (6MWT) and CMR imaging including cine imaging, aortic/pulmonary through-plane phase contrast imaging, T1 maps and late-gadolinium-enhanced (LGE) imaging were performed at baseline and 6 months after mitral surgery or watchful waiting (control group). Results72 patients completed follow-up (Controls = 20, MVr = 30 and MVR = 22). Surgical groups demonstrated comparable baseline cardiac indices and co-morbidities. At 6-months, MVr and MVR groups demonstrated comparable improvements in 6MWT distances (+ 57 ± 54 m vs + 64 ± 76 m respectively, p = 1), reduced indexed left ventricular end-diastolic volumes (LVEDVi; − 29 ± 21 ml/m2 vs − 37 ± 22 ml/m2 respectively, p = 0.584) and left atrial volumes (− 23 ± 30 ml/m2 and − 39 ± 26 ml/m2 respectively, p = 0.545). At 6-months, compared with controls, right ventricular ejection fraction was poorer post-MVr (47 ± 6.1% vs 53 ± 8.0% respectively, p = 0.01) compared to post-MVR (50 ± 5.7% vs 53 ± 8.0% respectively, p = 0.698). MVR resulted in lower residual MR-regurgitant fraction (RF) than MVr (12 ± 8.0% vs 21 ± 11% respectively, p = 0.022). Baseline and follow-up indices of diffuse and focal myocardial fibrosis (Native T1 relaxation times, extra-cellular volume and quantified LGE respectively) were comparable between groups. Stepwise multiple linear regression of indexed variables in the surgical groups demonstrated baseline indexed mitral regurgitant volume as the sole multivariate predictor of left ventricular (LV) end-diastolic reverse remodelling, baseline LVEDVi as the most significant independent multivariate predictor of follow-up LVEDVi, baseline indexed LV end-systolic volume as the sole multivariate predictor of follow-up LV ejection fraction and undergoing MVR (vs MVr) as the most significant (p < 0.001) baseline multivariate predictor of lower residual MR. ConclusionIn primary MR, MVR with chordal preservation may offer comparable cardiac reverse remodeling and functional benefits at 6-months when compared to MVr. Larger, multicenter CMR studies are required, which if the findings are confirmed could impact future surgical practice.

The great performance of the edge-to-edge repair in the anterior leaflet prolapse: a surprise?

In the meta-analysis of Khairallah et al. [1], 2 surgical techniques (the edge-to-edge repair and the neochordal repair) to correct mitral regurgitation (MR) due to isolated anterior leaflet prolapse are compared. A relevant finding is that a lower incidence of recurrent MR was observed in the follow-up when the lesion was corrected using the edge-to-edge repair. The first edge-to-edge mitral valve repair was carried out by us about 30 years ago in a patient with severe MR due to an isolated anterior leaflet prolapse. The functional result was perfect: the newly created double-orifice mitral valve was totally competent, and the global mitral valve area after implantation of a prosthetic ring was well above 3 cm2. At that time (early 1990s), the overall mitral valve repair rate in the surgical community was rather low, particularly in some subsets of lesions due to the complexity and/or ineffectiveness of the available surgical techniques. Triangular resection, chordal transposition and chordal shortening for anterior leaflet prolapse were not uncommonly associated with haemodynamically significant residual or recurrent MR and suboptimal results, even in experienced hands, were repeatedly reported [2–5]. On the contrary, the prolapse of the posterior leaflet, by far the most common lesion in degenerative MR, already at that time was associated with very satisfactory short- and long-term outcomes.

Coaptation Length as Predictor of Recurrent Mitral Regurgitation After Surgical Repair for Degenerative Mitral Valve Disease: Meta-Analysis of Reconstructed Time-to-Event Data

Coaptation Length as Predictor of Recurrent Mitral Regurgitation After Surgical Repair for Degenerative Mitral Valve Disease: Meta-Analysis of Reconstructed Time-to-Event Data

Transesophageal echocardiography for cardiac herniation occurring during robotic-assisted mitral valve repair: a case report

BackgroundCardiac herniation has been reported in thoracic trauma and after pneumonectomy; however, it is sporadic in cardiac surgery.Case presentationA 35-year-old male patient underwent an elective totally endoscopic robotic-assisted mitral valve repair (TERMVR). His hemodynamics were stable after weaning from cardiopulmonary bypass, and no residual mitral valve regurgitation was observed. However, during suturing of the port wound, the patient developed hypotension, which improved with phenylephrine administration. Four-chamber transesophageal echocardiography (TEE) images showed cardiac deformity, and postoperative chest radiography confirmed the dextrocardia. The cardiac herniation was repaired by deflating the left lung and over-inflating the right lung using a double-lumen tube, allowing selective ventilation without re-thoracotomy. The patient was discharged on the sixth postoperative day without complications.ConclusionsThis was a very unusual case of cardiac herniation during TERMVR visualized using distinct TEE images. The cardiac herniation was successfully repaired using a double-lumen tube without re-thoracotomy.

Impact of Residual Functional Mitral Regurgitation After Atrial Fibrillation Ablation on Clinical Outcomes in Patients With Left Ventricular Systolic Dysfunction

Functional mitral regurgitation (FMR) negatively impacts the prognosis in patients with atrial fibrillation (AF) and reduced left ventricular (LV) ejection fraction (LVEF). Although structural reverse remodeling after AF ablation can reduce FMR severity, the prognostic impact of FMR and its evolution remain unclear. Of 491 patients with baseline LVEF <50% who underwent first-time AF ablation, 134 patients (27%) had grade 2 to 4 FMR at baseline. Among them, 88 patients (66%) exhibited FMR improvement to grade 0 to 1 FMR 6months after AF ablation. Conversely, among 357 with baseline grade 0 to 1 FMR, 13 patients (3.6%) exhibited FMR worsening to grade 2 to 4 FMR despite AF ablation. Assessment with multidetector computed tomography revealed that an increase in the left atrial emptying fraction (odds ratio 3.55 per 10% increase; 95% confidence interval 2.12 to 5.95) and a reduction in the LV end-diastolic volume index (1.35 per 10-ml/m2 decrease; 1.04 to 1.76) were identified as contributors to the FMR improvement. During a follow-up of 43months, patients with postprocedural grade 2 to 4 FMR more frequently experienced hospitalizations for heart failure or cardiovascular death than those with grade 0 to 1 FMR (30.5% vs 4.6%, log-rank p <0.001). An age-adjusted multivariate Cox regression analysis including baseline and postprocedural FMR revealed that postprocedural grade 2 to 4 FMR (hazard ratio, 3.24; 95% confidence interval 1.43 to 7.35) was significantly associated with unfavorable events. In conclusion, AF ablation modified and often improved FMR severity in patients with reduced LVEF. Residual grade 2 to 4 FMR 6months after AF ablation was associated with a poor prognosis.

Comparative analysis of mid-term outcomes of Rigid and NeoRing support rings in mitral regurgitation surgery: a prospective randomized trial

Highlights. For the first time, as part of a prospective randomized study, a comparative assessment of the mid-term results of mitral valve annuloplasty using a new biological NeoRing ring (CJSC NeoKor, Kemerovo) and a RIGID ring (CJSC NPP MedInzh, Penza) in patients with connective tissue dysplasia was carried out. Predictors of the conversion of sinus rhythm to atrial fibrillation and residual mitral insufficiency in the medium-term follow-up period were determined.Aim. To analysis and compare mid-term results of mitral valve annuloplasty conducted using NeoRing и RIGID rings.Methods. From November 2019 to March 2022, 62 patients with mitral valve (MV) dysplasia underwent MV annuloplasty using NeoRing semi-rigid rings (CJSC NeoKor, Kemerovo, n = 31) and rigid RIGID rings (CJSC NPP MedInzh, Penza, n = 31). There were no differences between the groups at baseline.Results. Two deaths were registered during inpatient treatment in the RIGID group. Both devices showed a satisfactory outcome during inpatient treatment in the form of restoration of MV function (p&lt;0.001) and the frequency of detected maximum residual mitral regurgitation (MR) up to grade 1 in the NeoRing group 9.7% and in the RIGID group 29%, respectively, no statistically significant intergroup differences were noted (p = 0.292). After 12 months, freedom from ≥2 grade MR in the NeoRing group was 93.5% and 77.4% in the RIGID group (p = 0.147). In the RIGID group, patients had higher values of the transvalvular mitral diastolic gradient – PAV 3.70 [3.00–4.40] mm Hg vs. NeoRing group 2.3 [2.05–2.85] mmHg (p&lt;0.001), as well as a higher transvalvular flow rate – VAV 79 [71–94] cm/sec vs. 70 [64–79] cm/sec (p = 0.017). The analysis of the achievement of composite primary endpoint (recurrence of ≥2 grade MR, MACCE, new onset arrhythmias, reoperations) by the device was carried out. The composite endpoint rate in the RIGID group was 3.067 times higher compared to the NeoRing group, odds differences were statistically significant (p = 0.037, 95% CI: 1.053–8.934).Conclusion. The outcome of MV annuloplasty conducted using rigid and semi-rigid rings revealed no significant differences in long-term survival and recurrence of MR between groups. Given the statistically significant difference in achieving the combined endpoint, lower inpatient and long-term indicators of transmitral pressure gradient, and a positive effect on cardiac chambers reverse remodeling, it was concluded that the use of semi-rigid NeoRing rings for MV annuloplasty when performing valvepreserving operations for connective tissue dysplasia is preferable.

Impact of Gender on Outcomes of Transcatheter edge to edge mitral valve repair: A Meta-analysis.

Background: Gender disparities in outcomes after mitral valve surgery are well known. There are only few studies reporting the influence of gender on outcomes following transcatheter edge to edge repair (TEER) of the mitral valve using MitraClip (MC). In this meta-analysis, we describe outcomes by gender after mitral valve TEER. Methods: Studies reporting gender specific outcomes in patients treated with MC were reviewed from January 2010 to February 2022. Outcomes evaluated include all-cause mortality, New York Heart Association (NYHA) class, readmission for heart failure and residual mitral regurgitation (MR) at the longest follow up. Pooled odds ratio (OR) and 95% confidence interval (CI) were calculated using random effects models. Results: Seventeen studies with 33,747 patients (19,303 males and 14,444 females) were included. There was no difference in all-cause mortality (OR: 1.00, 95% CI: [0.90-1.12], p=0.93), residual MR (OR: 0.59, 95% CI: [0.34-1.02], p=0.06) or readmission for heart failure (OR: 1.04, 95% CI: [0.69-1.57], p=0.83). However, NYHA class III/IV was more frequent in female patients as compared to male patients at the end of follow up (OR: 0.62, 95% CI: [0.51-0.74], p&lt;0.00001). Conclusions: Our meta-analysis, the largest to date, suggests that female patients have worse NHYA functional class after TEER without any difference in all-cause mortality, readmissions for heart failure or residual MR when compared to male patients.

Two Cases of Surgical Correction of Recurrent Mitral Regurgitation due to Failed Catheter- Delivered Mitral Clip (MitraClip).

From April 2018 to February 2021, 150 patients underwent MitraClip implantation for severe functional mitral regurgitation (MR) at our hospital. Two of our patients, an 85-year-old man and an 84-year-old woman, developed a single leaflet device attachment in the acute phase after the implantation and had severe residual MR requiring surgical correction. The recurrent MR was first pointed out on day 5 and day 4, and the duration between MitraClip implantation and surgery was 13 and 55 days, respectively. Due to strong adhesions with the clips and severe valve damage after MitraClip implantation, both cases underwent mitral valve replacement with a good postoperative course. In patients with a high-risk baseline profile, surgical mitral valve replacement after failed MitraClip implantation should be considered at an optimal timing, and a detailed echocardiographic follow-up is required.

680 SINGLE-CENTER EXPERIENCE IN TRANSCATHETER MITRAL VALVE REPLACEMENT WITH THE TENDYNE MITRAL VALVE SYSTEM

Abstract Background Transcatheter mitral valve replacement (TMVR) with the Tendyne System is a therapeutic option for selected patients with severe symptomatic mitral regurgitation (MR) not eligible for either surgical intervention or transcatheter repair. To date, only a few studies have evaluated the short-term and mid-term outcomes of these patients in a real-life scenario. Objectives To describe the baseline features, and the short- and mid-term outcomes of patients undergoing TMVR with the Tendyne System at our Center. Methods Consecutive patients undergoing TMVR with the Tendyne System at our Center from November 2018 and August 2022 were enrolled. The baseline features of the study cohort were collected during the index hospitalization and patients were followed-up for the endpoints of all-cause death, residual MR, and prothesis dysfunction. Results Twenty-two patients (aged 75±6 years, 36% men) with moderate-to-severe or severe MR undergoing TMVR with the Tendyne System were recruited. Many patients were highly symptomatic (45% New York Heart Association [NYHA] functional class III or IV) and the etiology of MR was secondary or mixed in 18 (82%) cases. Prostheses were successfully implanted in all patients, with no peri-procedural residual MR (only two patients had a mild paravalvular leak). One patient died of sepsis during the index hospitalization. Out of 19 patients evaluated at a 30-day follow-up, 18 (95%) had no residual MR, 16 (84%) had an improved functional status (of at least one NYHA grade). Mid-term (&amp;gt;6 months) follow-up was available for 15 patients, 4 of whom were dead (2 died of heart failure, one of sepsis, and one of intestinal ischemia). Among the 10 patients undergoing a mid-term follow-up echocardiography, 8 had no residual MR and 2 had only mild MR. Two valve-related adverse events (i.e., endocarditis) were registered during the follow-up. Conclusions TMVR with the Tendyne System appears to be a safe and promising technique for symptomatic patients affected by signficant MR and not suitable for other procedures. Since experience is still limited, more data including a longer follow-up is warranted to optimize patient selection and outcomes.

177 TRANSCATHETER EDGE-TO-EDGE REPAIR OF SEVERE FUNCTIONAL MITRAL REGURGITATION TO OVERCOME ACUTE DECOMPENSATION IN A YOUNG MAN CANDIDATE TO HEART TRANSPLANTATION.

Abstract Background Chronic severe functional mitral regurgitation (FMR) is common in patients with HF as it reflects left ventricle dysfunction and portends poor prognosis. Case report A 42 years old man with cardiovascular risk factors (former smoker, obesity) but without previous cardiological history presented anterior ST-elevation myocardial infarction (STEMI) treated with primary PCI of the anterior descending artery. He developed severe ventricular dysfunction leading to congestive heart failure (HF) requiring early re-hospitalization for pulmonary edema. Despite optimal medical therapy patient remained symptomatic (NYHA class III, INTERMACS 6) with persistence of left ventricle ejection fraction (LVEF) depression, therefore he received an implantable cardiac defibrillator for primary prevention and was referred to our institution for further evaluation. Trans-esophageal echocardiography showed severe left ventricle dilatation and disfunction (EDD 6.9 cm, iEDV 113 ml/m2, LVEF 24%) and presence of severe FMR with EROA 37 mm2 and RV 44 ml. Right heart catheterization (RHC) revealed combined pulmonary hypertension (mean PA pressure 43 mmHg, PCWP 32 mmHg, PVR 4.6 WU) with severely reduced cardiac index obtained (CO 3.4 l/min, CI 1.9 l/min/m2). After infusion of inodilator (enoximone) a decrease of PA pressure and PVR was reported, concluding for reversible pulmonary hypertension. After screening for non-cardiac contraindications, the patient was listed for heart transplantation. Chances to get a donation with a short waiting list time were low because of patient's high BMI and blood group B. Therefore, after Heart Team evaluation, transcatheter edge-to-edge repair of the mitral valve (TEER) was performed as bridge to transplant. A single NTR clip was used, placed centrally between A2-P2 segments, reducing regurgitation from severe to mild. Patient was discharged on heart transplantation waiting list. At three months follow up he presented clinical improvement with reduction of NYHA class from III to II. RHC was repeated and showed normal filling pressures, reduction of pulmonary pressure (mPAP 20 mmHg) and increased cardiac output (CO 5.2 l/min, CI 2.5 l/min/m2). According to his preferences, the patient was suspended from the waiting list with indication to continue outpatient follow-up. At 1-year control he was stable in NYHA II class and the daily diuretic dose had been reduced, echocardiography showed severe LVEF depression (28%) with mild to moderate residual mitral regurgitation. Conclusions TEER recently emerged as an option for patients with FMR who are not suitable for surgery. Latest guidelines suggest its use in presence of specific criteria (LVEF 20-50%, ESD &amp;lt; 7 cm, sPAP &amp;lt;70 mmHg, hemodynamic stability, absence of right ventricle disfunction and severe TR) rarely fulfilled by patients with advanced HF requiring evaluation for transplant. On the other hand, access to surgical strategies for end stage HF is limited by scarce availability of donors and by temporary or definitive contraindications. Evidences are emerging that in this population TEER can improve hemodynamic profile and lead to reduction of pulmonary hypertension, providing temporary stability before definitive treatment or allowing candidacy. In this setting, TEER might be performed to reduce symptoms. Considering TEER as bridge strategy to transplant, candidacy or decision can expand the number of patients suitable for heart transplantation or delay urgency.

Mitral Valve Transcatheter Edge-to-Edge Repair Using MitraClip or PASCAL: A Multicenter Propensity Score–Matched Comparison

BackgroundSince its introduction in 2003, Abbott’s MitraClip (MC) has become the most established catheter-based treatment for mitral regurgitation (MR). Recent approval of Edwards Lifescience’s PASCAL device has extended the field of TEER. ObjectivesThe aim of this retrospective multicenter study was to compare the PASCAL and MC regarding procedural results and short- and long-term outcomes after mitral valve transcatheter edge-to-edge repair (TEER). MethodsData from 3 high-volume centers were analyzed. The primary endpoint was residual MR at discharge. Secondary endpoints were technical success, MR reduction, and 30-day mortality. After 1 year, all-cause mortality and residual MR were reported. ResultsA total of 412 patients (216 MC, 196 PASCAL) treated between 2018 and 2020 were included. A total of 184 patients (92 in each treatment group) remained after propensity score matching. The rate of baseline MR ≥3 was 98.9% in both groups (P = 1.00). Both TEER systems achieved equally high technical success rates (97.8%; P = 1.00), resulting in residual MR ≤1 in 69.6% vs 77.1% of patients (P = 0.24) and MR reduction by ≥2 grades in 83.7% vs 92.4% of patients (P = 0.13) using the MC and PASCAL, respectively. Thirty-day mortality was 1.1% in both cohorts (P = 0.98), and 1-year follow-up showed similar MR reductions (residual MR ≤1, 78.0% with MC vs 82.3% with PASCAL; P = 0.70) and comparable all-cause mortality (14.1% with MC vs 6.5% with PASCAL; P = 0.14). In multivariate regression analysis, Society of Thoracic Surgeons score independently correlated with an optimal result (MR ≤1), while device choice did not show a significant impact. ConclusionsIn this retrospective multicenter study, the established MC and the novel PASCAL mitral valve TEER systems were safe and offered excellent performance with comparable short- and long-term outcomes.

Early Outcomes of 2 Mitral Valve Transcatheter Leaflet Approximation Devices: A Propensity Score–Matched Multicenter Comparison

BackgroundIn addition to the edge-to-edge MitraClip repair system, the edge-to-spacer PASCAL repair system was approved for percutaneous treatment of severe mitral regurgitation (MR). Comparative data are lacking. ObjectivesThe aim of this study was to compare procedural and short-term safety and efficacy of 2 leaflet-based transcatheter mitral valve repair systems. MethodsProcedural and 30-day outcomes were investigated in a propensity score–matched cohort of 307 PASCAL and 307 MitraClip patients at 10 sites. Matching criteria included sex, age, left ventricular ejection fraction, New York Heart Association functional class, MR etiology, left ventricular end-diastolic diameter, left atrial volume index, and vena contracta width. The primary efficacy endpoints were technical success and degree of residual MR at discharge. The primary safety endpoint was the rate of major adverse events (MAE). ResultsTechnical success was 97.0% in the PASCAL group and 98.0% in the MitraClip group (P = 0.624). MR ≤2+ at discharge was comparable in both groups (PASCAL: 93.8% vs MitraClip: 92.4%; P = 0.527), with more patients exhibiting MR ≤1+ in the PASCAL group (70.5% vs 56.6%; P < 0.001). The postprocedural mean gradient was significantly higher in the MitraClip group (3.3 ± 1.5 mm Hg vs 3.9 ± 1.7 mm Hg; P < 0.001). At 30 days, all-cause mortality and MAE rates were similar (mortality: 1.7% vs 3.3%; P = 0.299; MAE: 3.9% vs 5.2%; P = 0.562). ConclusionsIn this first large propensity score–matched comparison, procedural success rates and MAE did not differ significantly between patients treated with the PASCAL or MitraClip valve repair system. Procedural results with less than moderate MR and no elevated transmitral gradient were more common in the PASCAL group, which might have an impact on long-term outcome.

One stone hits two birds: transcatheter mitral valve edge-to-edge repair for hypertrophic obstructive cardiomyopathy and severe mitral regurgitation.

A 68-year-old woman presented with dyspnoea on exertion and intermittent palpitation followed by near fainting. The transthoracic echocardiography (TTE) revealed asymmetric myocardial hypertrophy with an interventricular septal wall thickness of 15.2 mm at diastole, and elongated anterior leaflet (Panel B) with systolic anterior motion (SAM; Panels A and C, right). Left ventricular outflow tract (LVOT) obstruction with a peak flow velocity (Vp) of 5.18 m/s and a peak pressure gradient (PPG) of 107 mmHg (Panel D) and severe eccentric mitral regurgitation (MR) were observed (Panel E). The transoesophageal echocardiography (TEE) showed MR mostly originated from A2 and A3 (Panel F). The patient was finally diagnosed as hypertrophic cardiomyopathy (HCM). After the Heart Team discussion and share decision-making, the patient then received transcatheter mitral valve edge-to-edge repair (TEER) with MitraClip system and a single XTR clip. The intraoperative TEE displayed residual trace MR (Panel J and TTE Panel I), abolishment of SAM phenomenon (Panel G, right), and an LVOT Vp of 1.84 m/s and PPG of 13 mmHg (Panel H). After the procedure, the left ventricular global longitudinal strain and circumferential strain also increased (pre-operation Panel C, left; post-operation Panel G, left). The patient got rid of prior symptoms immediately after the procedure, and she was then safely discharged home within a week.

Abstract 11879: Von Willebrand Factor Activity and Closure Time With Adenosine Diphosphate During Transcatheter Mitral Valve Repair

Introduction: Residual mitral regurgitation (MR) is associated with worse outcomes after transcatheter edge to edge mitral valve repair (TEER) but is difficult to assess by echocardiography. Shear-stress induced by MR leads to altered Von Willebrand factor activity (vWF:Act), also reflected by increased closure time with adenosine diphosphate (CT-ADP), representing potential ways to screen for residual MR. CT-ADP can be assessed easily during TEER and is known to normalize swiftly after the correction of turbulent flow. Hypothesis: The improvement of CT-ADP is quick enough to allow real-time procedural guidance. Methods: We enrolled 39 patients undergoing TEER. MR severity was assessed by echocardiography during the procedure, 24-hours and 1-month post-TEER. CT-ADP was measured before TEER, 8 minutes after each clip deployment, 1 hour and 24 hours after the procedure. CT-ADP values were related with vWF:Act and MR severity at each time point. Results: Of 39 patients after TEER, 6 (15%) and 8 (21%) patients had residual MR ≥ moderate at 24-hours and 1-month respectively. There was no significant change in CT-ADP values during the procedure. The decrease of CT-ADP was however significant 1-hour post-TEER with stable values at 24-hours (last clip deployment: 136 [110-193]; 1 hour: 99 [82-131] and 24 hours: 95 [82-121] seconds, p&lt;0.001). Concomitant increase in vWF:Act was observed after the procedure (baseline: 1.76 [1.29-2.05]; 1 hour: 1.84 [1.79-1.85] and 24 hours: 2.32 [1.84-2.5] IU/ml, p=0.002). Patients were stratified into 3 groups according to the residual MR grade at 1 month (≤ mild vs. moderate vs. &gt;moderate). CT-ADP was not different among the groups (p=0.74). However, the difference in CT-ADP (1 month vs baseline values) was associated with MR improvement at the same time points (r=0.50; p=0.007). Conclusions: Although CT-ADP decreases after TEER and correlates with vWF:Act and MR improvement at 1 month, this decrease is first observed 1 hour after the procedure and does not seem to be quick enough to provide real-time monitoring of MR severity during TEER.

Residual mitral regurgitation in patients with left ventricular assist device support - An INTERMACS analysis.

Left ventricular assist device (LVAD) placement frequently leads to a reduction in the severity of functional mitral regurgitation (MR). However, a significant number of LVAD supported patients have residual MR. We sought to assess the impact of residual MR in LVAD patient outcomes. Patients in the INTERMACS registry who received a continuous flow LVAD between 2006 and 2017 without a prior mitral valve repair were included for analysis. Residual MR was defined as moderate or severe MR within the first 3 months device support. Baseline characteristics, echocardiographic and hemodynamic variables, and clinical outcomes were comparatively analyzed between those with or without residual MR. A total of 8,364 patients were included in the study, of which 18.8% demonstrated residual MR. Younger age, female gender, and non-ischemic heart failure were predictors of residual MR, as were increased LVEDD, RV dysfunction, severe baseline MR or TR, and elevated right heart pressures. Concomitant mitral valve repair reduced the risk of residual MR. Those with residual MR demonstrated worse LV remodeling, more right ventricular dysfunction, and higher right heart pressures at almost all time points analyzed. Residual MR was associated with increased risk of right heart failure and renal failure, and a trend toward increased mortality on LVAD support. Residual MR is associated with worse clinical outcomes on LVAD support. Strategies to minimize MR including medical and device optimization as well as valve repair should be considered in LVAD patients with residual MR.

Echocardiographic Predictors of Suboptimal Transcatheter Mitral Valve Repair in Patients With Secondary Mitral Regurgitation.

Residual mitral regurgitation (MR) following mitral valve transcatheter edge-to-edge repair (TEER) is associated with worse outcomes. This study sought to identify echocardiographic predictors of suboptimal residual MR after TEER in patients with secondary MR. In this retrospective single-center study, we identified all patients with secondary MR who underwent TEER between 2016 and 2021. Pre- and intraprocedural transesophageal echocardiographic images were reviewed. The primary outcome was suboptimal residual MR, defined as ≥2+ residual MR on postprocedural transesophageal echocardiography. The association of preprocedural echocardiographic parameters with the primary outcome was tested via logistic regression. Sixty-five patients (69 ± 15 years; 49% women) with secondary MR underwent TEER with MitraClip. All patients had moderate-severe or severe (3-4+) MR preoperatively, with an average left ventricular ejection fraction of 35% and New York Heart Association class III symptoms. Procedural success, defined as ≤2+ MR post-TEER, was achieved in 94%. A suboptimal residual MR was observed in 38%. Independent predictors of suboptimal residual MR included bicommissural MR (odds ratio [OR], 7.95; 95% CI, 1.50-42.3; P = .02), 2-dimensional anteroposterior diameter (OR, 6.46; 95% CI, 1.85-22.51 per cm; P < .01), and mitral valve area to left ventricular end-diastolic volume ratio (OR, 0.69; 95% CI, 0.50-0.93 per mm2/mL; P = .02). Certain echocardiographic features, including bicommissural MR, a larger annular diameter, and a smaller ratio of mitral valve area to left ventricular end-diastolic volume, are associated with suboptimal residual MR following TEER. These preprocedural measurements may optimize patient selection in those with secondary MR being considered for TEER.

Mitral Valve Re-Repair Due to Chordal Pseudo-Elongation Through Repeated Right Anterior Minithoracotomy.

We aim to show the step-by-step surgical technique of mitral valve re-repair by means of a repeated right anterior minithoracotomy in a case of a procedure-related early mitral valve repair failure due to left ventricular positive remodeling and chordal pseudo-elongation. The patient was readdressed to our institution for an early severe mitral valve regurgitation, less than a year after performing a right minithoracotomy mitral valve repair (42-mm annular ring implantation, P2 triangular resection, and P2 neochord positioning). The mechanism was attributed to a positive left ventricle remodeling and neochordal pseudo-elongation. Therefore, we decided to perform a mitral valve re-repair in a redo minimally invasive cardiac surgery. We describe in a video-guided step-by-step fashion the surgical procedure, from the reopening of the right anterior minithoracotomy to the surgical strategy chosen to address the re-repair, guided by the mechanism of the previous repair failure. We replaced the previously implanted ring with a smaller one and positioned a new polytetrafluoroethylene 4-0 neochord at the P2 level. The patient was discharged home on the fifth postoperative day after an uneventful hospital stay. Predischarge echocardiogram demonstrated undetectable residual mitral valve regurgitation. At 3-month follow-up, echocardiographic and clinical data were encouraging. At 9-month follow-up, the patient endorsed no recurrence of cardiologic symptoms. Redo minimally invasive cardiac surgery is a viable option even in case of a mitral valve re-repair due to previous repair failure, especially when procedure related in degenerative mitral disease. Combining the benefits of mitral valve re-repair with those of a minimally invasive surgery may optimize short-term and long-term outcomes.

A routine de-airing method for total endoscopic robot-assisted mitral valve repair.

Intraoperative water testing is essential for assessing mitral valve morphology and degree of residual mitral regurgitation during mitral valve repair. However, in some cases, evacuating intracardiac air is challenging. Herein, we report the routine de-airing method during total endoscopic robot-assisted mitral valve repair at our institute and discuss its effectiveness. In brief, our de-airing methods involve the following steps: after restricting the blood flow of the cardiopulmonary bypass, intracardiac air was pushed out into the pulmonary veins by drawing blood from the right ventricle. The left atrium, left ventricle, and ascending aorta were filled with blood to remove air from the root cannula. Retrograde blood flow from the coronary sinus was used to remove air from the coronary arteries. At 10min after cardiopulmonary bypass weaning, transesophageal echocardiography revealed that residual intracardial air was absent in 99% of patients in all three chambers (ascending aorta, left atrium, and left ventricle).

Transcatheter mitral valve repair is feasible and effective in oldest-old patients: results from real-world cohort.

To evaluate the safety and efficacy of transcatheter mitral valve repair (TMVR) using MitraClip® devices in oldest-old patients compared to younger patients. The study retrospectively included 340 consecutive patients who underwent TMVR. Patients were classified according to age into the oldest-old (age ≥ 85 years) patient group or the younger (age < 85 years) patient group. Immediate results of the procedure, intrahospital outcomes and one-year outcomes were compared. Oldest-old patients represented 15.9% (n = 54) of all patients. Procedure success was comparable for the oldest-old patient group and the younger patient group (92.6% vs. 95.8%, P = 0.30), and there was no difference in intrahospital mortality (9.2% vs. 4.2%, P = 0.12). At a one-year follow-up (interquartile range: 6-16 months), there was no significant difference in rehospitalization due to decompensated heart failure (25.5% vs. 34.3%, P = 0.24) or all-cause mortality (29.8% vs. 22.2%, P = 0.26) between the oldest-old patient group and the younger patient group. In patients with available echocardiographic follow-up, severity of residual mitral regurgitation was also comparable between the oldest-old patient group and the younger patient group. TMVR seems to be feasible and effective in oldest-old patients and should be considered for oldest-old patients presenting with symptomatic severe mitral regurgitation and high surgical risk.

Transcatheter mitral valve replacement in native mitral valve with severe mitral annular calcification: Skirting the Sapien 3 to reduce the risk of paravalvular leaks

Mitral annular calcification (MAC) may represent a significant challenge for heart surgeons with an extremely high perioperative risk during mitral valve (MV) surgery. The risk is further increased when patients fail to be eligible for any percutaneous treatment, particularly because circumferential calcifications involving the anterior leaflet suggest a critical obstruction of the left ventricular outflow tract (LVOT). The objective of this study was to evaluate residual mitral regurgitation (MR) after surgical mitral valve replacement using a Sapien 3 Ultra (Edwards Lifesciences, CA, USA) transcatheter aortic valve implantation (TAVI) prosthesis, reinforced with a pericardial skirt, in high-risk selected patients with severe MAC. Since 2020, five high-risk patients (mean age 70 years; 63-76; four women) with severe mitral disease in the context of severe MAC (computed tomography-based mean MAC Score 8.2 ± 1.1) were operated on after we adopted this novel technique. The operations were performed under general anesthesia, using a transapical TAVI delivery system to position the Sapien 3 in the mitral position under direct vision. To reinforce and avoid paravalvular leakages, a pericardial skirt was previously sewn around the prosthesis, securing it to the annulus and perivalvular atrial surface. Sapien 3 Ultra implantation was successful without residual MR in all five patients (mild paravalvular leak in one case). Four patients had a 29-mm valve implanted, while one had a 26-mm valve implanted. Predilatation of the native annulus was never performed. Perfusion and clamping times were 134 ± 53 mins and 108 ± 43 mins, respectively. The presence of the pericardial skirt reduced the risk of leakage between the prosthesis and the rigid calcium surface, with final mean and maximal gradients of the TAVI prosthesis of 4.1 and 10.8 mmHg, respectively. There were no left ventricular outflow tract obstructions (mean LVOT gradient of 8 ± 1 mmHg). All patients were discharged, and neither mortality nor prosthetic dysfunction, nor residual mitral regurgitation was recorded. During follow-up, the last patient treated (MAC Score 10, severe calcification of the mitro-aortic junction) returned to our attention with a significant recurrent jet originating from the anterolateral commissure, currently medically treated, given the prohibitive redo risk. Direct open surgical implantation of the Sapien 3 valve can be safely done in patients with severe MAC in dedicated centers. Reinforcing the TAVI prosthesis by sewing a pericardial skirt led to satisfactory perioperative and early postoperative results, reducing paravalvular leakages. Complex anatomies have a CERTAIN risk of recurrence.