Residual Mitral Regurgitation Research Articles

Cardiac computed tomography-based assessment of mitral annular calcification in patients undergoing mitral transcatheter edge-to-edge repair

BackgroundThe role of assessment of mitral annular calcification (MAC) using cardiac computed tomography (CCT) in mitral transcatheter edge-to-edge repair (TEER) remains unclear. The aim of this study was to investigate the association of MAC assessed by CCT with procedural and clinical outcomes in patients undergoing TEER. MethodsWe retrospectively analyzed 275 patients who underwent pre-procedural CCT prior TEER. Mitral calcium volume (MCV) and MAC score were measured by CCT. Functional procedural success was defined as residual mitral regurgitation of ≤2+ with mean transmitral gradient of <5 ​mmHg at discharge. All-cause mortality within two years after TEER was collected. ResultsMAC was present in 115 of 275 patients (41.8 %). The median MCV was 198 ​mm3 (interquartile range [IQR]: 84 to 863 ​mm3), and the median MAC score was 3 (IQR: 2 to 4). Higher MCV and MAC score were inversely related to the rate of functional procedural success, independently of anatomical features of mitral valve. Patients with moderate/severe MAC, defined as MAC score of ≥4, had a lower rate of functional procedural success than those without MAC (56.1 ​% vs. 81.3 ​%; p ​= ​0.002). Moreover, higher MCV and MAC score were associated with a higher risk of all-cause mortality within two years, irrespective of baseline characteristics and functional procedural success. ConclusionsThe presence and burden of MAC assessed by CCT were associated with procedural and clinical outcomes in patients undergoing TEER. The CCT-based assessment of MAC may improve patient selection for TEER.

Echocardiographic Outcomes With Transcatheter Edge-to-Edge Repair for Degenerative Mitral Regurgitation in Prohibitive Surgical Risk Patients

BackgroundThe CLASP IID randomized trial (Edwards PASCAL TrAnScatheter Valve RePair System Pivotal Clinical Trial) demonstrated the safety and effectiveness of the PASCAL system for mitral transcatheter edge-to-edge repair (M-TEER) in patients at prohibitive surgical risk with significant symptomatic degenerative mitral regurgitation (DMR). ObjectivesThis study describes the echocardiographic methods and outcomes from the CLASP IID trial and analyzes baseline variables associated with residual mitral regurgitation (MR) ≤1+. MethodsAn independent echocardiographic core laboratory assessed echocardiographic parameters based on American Society of Echocardiography guidelines focusing on MR mechanism, severity, and feasibility of M-TEER. Factors associated with residual MR ≤1+ were identified using logistic regression. ResultsIn 180 randomized patients, baseline echocardiographic parameters were well matched between the PASCAL (n = 117) and MitraClip (n = 63) groups, with flail leaflets present in 79.2% of patients. Baseline MR was 4+ in 76.4% and 3+ in 23.6% of patients. All patients achieved MR ≤2+ at discharge. The proportion of patients with MR ≤1+ was similar in both groups at discharge but diverged at 6 months, favoring PASCAL (83.7% vs 71.2%). Overall, patients with a smaller flail gap were significantly more likely to achieve MR ≤1+ at discharge (adjusted OR: 0.70; 95% CI: 0.50-0.99). Patients treated with PASCAL and those with a smaller flail gap were significantly more likely to sustain MR ≤1+ to 6 months (adjusted OR: 2.72 and 0.76; 95% CI: 1.08-6.89 and 0.60-0.98, respectively). ConclusionsThe study used DMR-specific echocardiographic methodology for M-TEER reflecting current guidelines and advances in 3-dimensional echocardiography. Treatment with PASCAL and a smaller flail gap were significant factors in sustaining MR ≤1+ to 6 months. Results demonstrate that MR ≤1+ is an achievable benchmark for successful M-TEER. (Edwards PASCAL TrAnScatheter Valve RePair System Pivotal Clinical Trial [CLASP IID]; NCT03706833)

Implications of Mitral Annular Disjunction in Patients Undergoing Transcatheter Edge-to-Edge Repair for Degenerative Mitral Regurgitation

BackgroundLittle is known about mitral transcatheter edge-to-edge repair (TEER) in patients with mitral annular disjunction (MAD). ObjectivesThe authors sought to explore TEER for degenerative mitral regurgitation (MR) according to MAD status. MethodsWe retrospectively analyzed 271 consecutive patients (median age 82 [Q1-Q3: 75-88] years, 60.9% men) undergoing an isolated, first-ever TEER for whom there were viewable preprocedural echocardiograms. Stratified by MAD status at baseline, the cohort was evaluated for all-cause mortality, heart failure hospitalizations, and mitral reinterventions—the composite of which constituted the primary outcome—as well as functional capacity and residual MR, all along the first postprocedural year. ResultsIndividuals with (n = 62, 22.9%) vs without MAD had more extensive prolapse and larger valve dimensions. Although the former's procedures were longer, utilizing more devices per case, technical success rate and residual MR were comparable. MAD presence was associated with higher mortality risk (HR: 2.64; 95% CI: 1.82-5.52; P = 0.014), and increased MAD length—with lower odds of functional class ≤II (OR: 0.65; 95% CI: 0.47-0.88; P = 0.006). Among 47 MAD patients with retrievable 1-month data, MAD regressed in 91.5% and by an overall 50% (Q1-Q3: 22%-100%) compared with baseline (P < 0.001). A greater MAD shortening conferred attenuated risk for the primary outcome. ConclusionsIn our experience, TEER for degenerative MR accompanied by MAD was feasible and safe; however, its postprocedural course was somewhat less favorable. MAD shortening following TEER was observed in most patients and proved prognostically beneficial.

Mitral regurgitation in atrial fibrillation: Is a simple repair enough to tackle a complex problem?

BackgroundClinical and echocardiographic results of valve repair for mitral regurgitation in the setting of atrial fibrillation are poorly studied. MethodsBetween January 2008 and December 2020, 89 patients underwent valve repair for mitral regurgitation in the setting of atrial fibrillation. Clinical and echocardiographic follow-up data were collected and studied. The primary composite endpoint consisted of all-cause mortality or hospitalization for heart failure. ResultsValve repair with true-sized annuloplasty was performed in 83 (93 %) and restrictive annuloplasty in 6 (7 %) patients. Early mortality occurred in 3 (3 %) and residual mitral regurgitation in 1 (1 %) patient. During a median follow-up of 5.4 years (interquartile range 3.4–9.5), 25 patients died, 6 due to end-stage heart failure. Ten patients were hospitalized for heart failure. The estimated event-free survival rate at 10 years was 48.2 % (95 % CI 33.5 %–62.9 %). Recurrent mitral regurgitation was observed in 14 patients and most often caused by leaflet tethering. When analyzed as a time-dependent variable, recurrent regurgitation was related to the occurrence of the primary endpoint (hazard ratio 3.192, 95 % CI 1.219–8.359, p = 0.018). On exploratory sub-analyses, no recurrent regurgitation was observed after restrictive annuloplasty or in patients with paroxysmal atrial fibrillation. Moreover, recurrent regurgitation was observed more often when signs of left ventricular impairment were present preoperatively. ConclusionsDespite good initial results, recurrent regurgitation was a frequent observation after valve repair for mitral regurgitation in atrial fibrillation and had an effect on heart failure related morbidity and mortality. Refinements in the timing of surgery and surgical technique might help improve outcomes.

Mitral valve leaflet stiffness predicts residual mitral regurgitation after transcatheter edge-to-edge mitral valve repair.

Residual regurgitation after transcatheter edge-to-edge mitral valve repair (TMVR) is a predictor of poor prognosis in patients with functional mitral regurgitation (FMR). This study sought to identify the mitral valve (MV) parameters measured by three-dimensional transesophageal echocardiography (3D-TEE) and MV leaflet features that predict residual mitral regurgitation (MR) after TMVR in patients with FMR. Consecutive patients with FMR who underwent TMVR were classified into two groups based on the degree of residual MR just after TMVR:<2+ in the optimal MR reduction group and ≥ 2+ in the suboptimal MR reduction group. The two groups were compared with respect to 3D-TEE parameters and the MV leaflet features, including the following parameters: stiffness, defined as a leaflet that remains at a fixed angle even during diastole, and thickness, measured in both clear and rough zones. Thirty-four of 46 patients (74%) were classified as the optimal MR reduction group. Multivariable analysis showed that anterior mitral leaflet + posterior mitral leaflet length/anteroposterior annulus diameter (p=.044) and MV leaflet stiffness (p=.007) were independent predictors of residual MR. MV leaflet stiffness and the ratio of MV leaflet lengths to the annulus diameter may be good predictors of residual MR after TMVR in patients with FMR.

NYHA class IV in patients with degenerative mitral regurgitation undergoing transcatheter edge-to-edge repair: Results of the worldwide, multicenter PRIME-MR registry

Abstract Background Patients with degenerative mitral regurgitation (DMR) presenting with resting dyspnoea (New York Heart Association [NYHA] class IV), particularly in cases of acute onset or rapid deterioration, constitute a high-risk cohort with significant implications for preprocedural planning. This study aims to assess whether preprocedural NYHA class IV is associated with adverse events and outcomes in DMR patients undergoing Transcatheter mitral edge-to-edge repair (TEER), by analyzing data from the PRIME-MR registry. Methods PRIME-MR, a retrospective, investigator-initiated, multicenter registry, comprises patients who underwent TEER for relevant DMR in 24 high-volumes centres between 2008 and 2022. The primary objective was to evaluate the outcomes of patients with resting dyspnoea (defined as NYHA class IV at baseline) and compare these to patients presenting with NYHA class II or III. Results In this analysis, 1,941 consecutive patients (median age: 81 years [IQR 76; 85]; 46.8% female; mean STS Mortality Score [mitral repair]: 5.0% ± 3.9) with available follow-up data were included (median follow-up time 2.56 years [95%-confidence interval 2.39; 2.47]). Of these patients, 323 (16.6%) presented with NYHA class IV at baseline. There were no differences at baseline in terms of median left ventricular ejection fraction (NYHA IV: 58% [IQR 50; 64] vs. NYHA II/III: 60% [IQR 50; 65]; p=0.30) or right ventricular function, measured by TAPSE (NYHA IV: 19mm [IQR 15; 22] vs. NYHA II/III: 19mm [IQR 16; 23]; p=0.088). DMR severity was comparable between the groups (effective regurgitation orifice area [EROA]: NYHA IV 0.5cm² [IQR 0.4; 0.7] vs. NYHA II/III: 0.4cm² [IQR 0.3; 0.6]; p=0.052). The main pathology differed between both groups, with higher proportions of flails in patients with NYHA IV (57.3% [n=142] vs. NYHA II/III: 48.4% [n=674]; p=0.013). NYHA class IV patients had higher median levels of baseline NT-proBNP (NYHA IV: 3182ng/L [1411; 7966] vs. NYHA II/III: 1875ng/L [IQR 803; 3968]; p&amp;lt;0.001). Functional success rates according to M-VARC criteria (residual mitral regurgitation [rMR] ≤2+, EROA ≤0.15cm², transmitral pressure gradient ≤5 mmHg) were comparable (NYHA IV: 71.4% [n=200] vs. NYHA II/III: 73.5% [n=1060]; p=0.52). Postprocedural efficacy was high in both groups (rMR ≤2+ at discharge in NYHA IV: 87.4% [n=243] vs. NYHA II/III: 90.4% [n=1,344]; p=0.59; Figure 1). However, Kaplan-Meier analysis for all-cause mortality or rehospitalization after two years revealed worse outcomes of patients with NYHA IV (log-rank p=0.002; Figure 2). Conclusion This analysis of the PRIME-MR registry revealed that, despite similar baseline characteristics and high procedural efficacy in both groups, the presence of NYHA class IV at baseline was associated with inferior clinical outcomes in DMR patients undergoing TEER. As such, it represents an important indicator of increased risk of mortality and rehospitalization and may require closer patient follow-up.MR at baseline and dischargeKaplan Meier analysis

Efficacy and evolution of edge-to-edge transcatheter valve repair procedures

Abstract Background Edge-to-edge transcatheter mitral valve repair (M-TEER) has shown safety and efficacy in reducing secondary mitral regurgitation (MR) (1,2) and led to the development of similar devices for transcatheter valve repair (T-TEER) for tricuspid regurgitation (TR) (Fig. 1A). However, T-TEER implementation is challenging due to complex valve anatomy and periprocedural imaging. We sought to understand to which extent procedural success of M-TEER changed over time and possibly impacted T-TEER results. Methods We retrospectively analyzed intraprocedural reduction of secondary MR and TR after release of a valve specific device, between 2018, when M-TEER was implemented in our center, through 2020, when T-TEER procedures started, and up to the end of 2022. We compared results between the 55 T-TEER procedures performed (age 81.8±4.7, 55% females) and 3 M-TEER cohorts: the very first 55 M-TEER, the last 55 M-TEER before T-TEER, and the very last 55 M-TEER (overall mean-age 78.4±8.2, 49% females) (Fig. 1B). Severe MR III/IV was defined by an effective regurgitation orifice area (EROA) of 20-39mm², and IV/IV by EROA ≥40mm², while TR was evaluated using the I/V to V/V classification. Considering that a 5-grade reduction of TR is either not possible or not desirable, the extension of regurgitation reduction for both valves was set on a scale from 1- to 4-grade. Also, optimal results were defined as residual MR 0+ (none or trace) or TR I+ (mild or mild to moderate), while acceptable results were considered MR I+ and TR II+ (moderate or moderate to severe). Results In all groups, regurgitation was successfully and significantly reduced within-group (Fig. 1C). MR reduction to optimal or acceptable levels increased over time from 60% at the start of the M-TEER program to 78% after 12-18 months (p=0.039), and 84% (p=0.005) after approximately 3 years. Accordingly, the extent of regurgitation reduction significantly improved between the first 2 M-TEER cohorts (p=0.016), as well as the first and the last 55 M-TEER (p=0.045), with no significant change from the second to the third population (p=0.267) (Fig. 2). Two years after the first M-TEER, T-TEER with valve specific devices was implemented and achieved 84% optimal or acceptable residual TR, better than initial M-TEER (p=0.005) and similar to the second (p=0.466) and third M-TEER cohorts (p=1.000). In terms of extent of regurgitation reduction, T-TEER also performed similar to the very first (p=0.645) and the very last M-TEER procedures (p=0.076), despite higher mean-EROA (78.5±32.2mm² vs 44.8±16.1mm² in all MR patients, p&amp;lt;0.001), more complex anatomy, more challenging imaging, and sicker patients (mean-EuroSCORE II 8.8±6.6% vs 6.4±5.3% in all MR patients, p&amp;lt;0.001). Conclusions In our center, gain in knowledge and experience, coupled with technological advances, have significantly impacted procedural M-TEER success over time and allowed similar successful implementation of a T-TEER program.Figure 1Figure 2

Early outcomes of the PASCAL P10 and the MitraClip XT transcatheter mitral leaflet approximation devices - A propensity score matched multicentre comparison

Abstract Background The edge-to-spacer PASCAL repair system was recently approved for percutaneous treatment of severe mitral regurgitation (MR). Comparative data with the MitraClip XT device which shows similar size and leaflet grasping features are lacking. Purpose Aim of this study was to compare the procedural and short-term safety and efficacy of two transcatheter mitral leaflet approximation devices, the PASCAL P10 and the MitraClip XT. Methods Overall, 566 patients underwent transcatheter mitral valve repair (TMVR) with PASCAL P10 (n=309) or MitraClip XT (n=257). The PASCAL P10 cohort included patients treated at 10 tertiary care centres in Germany between February and December 2019, while the MitraClip XT cohort consisted of patients treated at three of these 10 centres between May 2018 and September 2022. Propensity score (PS) matching based on the parameters gender, age, left ventricular ejection fraction, NYHA class, left ventricular end-diastolic diameter, left atrial volume index, vena contracta width, MR aetiology, and mean gradient resulted in 191 well balanced patient pairs. Primary efficacy endpoints were technical success, degree of residual MR at discharge and at 30-days as well as device success at 30-days. Primary safety endpoint was the rate of major adverse events (MAE) at 30-days. Results Technical success was 95.8% in the PASCAL group and 95.3% in the MitraClip group (P&amp;gt;0.99). An MR ≤2+ at discharge was numerically more frequent in the PASCAL than in the MitraClip group (PASCAL: 91.5% vs. MitraClip: 85.9%; P=0.101). An MR ≤1+ at discharge was achieved more frequently in the PASCAL group (PASCAL: 68.3% vs. MitraClip: 56.5%; P=0.025). This difference was sustained at 30-days with numerically more patients with residual MR ≤2+ (PASCAL: 89.7% vs. MitraClip: 82.4%; P=0.071) and significantly more patients with MR ≤1+ (PASCAL: 64.7% vs. MitraClip: 51.6%; P=0.021) in the PASCAL group than in the MitraClip group. At 30-days, the mean gradient was similar between the two groups (PASCAL: 3.0 [2.3–4.0] mmHg vs. MitraClip: 3.1 [2.7–4.2] mmHg], P=0.218). Device success at 30 days was achieved with an equal frequency in both groups (PASCAL: 78.8% vs MitraClip: 71.3%; P=0.129). At 30-days, MAE occurred more often in the MitraClip than in the PASCAL group (PASCAL: 3.7% vs. MitraClip: 12.6%; P=0.002). Conclusions In this PS-matched study comparing the PASCAL P10 with the MitraClip XT, safety and efficacy were comparable at 30-days.

Redo transcatheter edge-to-edge mitral valve repair: a single centre experience

Abstract Introduction: Mitral valve transcatheter edge-to-edge repair (TEER) has been established as a therapy for patients with severe symptomatic mitral regurgitation (MR) who are at high surgical risk. Failure to implant a TEER device and the occurrence of residual or recurrent MR ≥3+ are well documented but data regarding outcomes of redo-TEER following initial failure are sparse. Purpose To evaluate the safety and efficacy of redo-TEER following initial failed intervention. Methods We included 16 patients who underwent redo-TEER for symptomatic MR ≥3+ from July 2016 to December 2022. Acute results were assessed by echocardiography prior to discharge and safety was evaluated clinically, according to the occurrence of procedure-related adverse events. Mid- and long-term outcomes were evaluated at three months and one year respectively. Data were obtained retrospectively by chart review. Mortality data were drawn from the national death registry. Results Reasons for redo-TEER include device failure without detachment in nine (56%) patients, device failure due to single leaflet detachment in four (25%) patients and initial implantation failure in three (19%) patients. Median time from index procedure was 167 days (range: 19 – 1457 days). Technical (implantation of a TEER device) and procedural (MR ≤2+ at discharged) success were achieved in 94% and 87.5% of patients undergoing repeat intervention respectively. MR grade was reduced to 1+ in 71% of patients who had successful TEER. No intra-procedural mortality or life-threatening complications were noted. Mean post-TEER hospitalization length was 1.8 ± 1.3 days. No deaths were noted during the first year following redo-TEER. Echocardiography at three months and one year demonstrated MR ≤2+ for all patients in whom TEER was successful. At three months and one-year follow-up, respectively 67% and 50% of patients who underwent successful intervention were in New York Heart Association (NYHA) class I or II and only one had been hospitalized for heart failure. Conclusion Repeat mitral TEER following initial procedural failure is safe and has high acute and mid-term success rates. More research is needed to better characterise patients likely to benefit from repeated intervention.

Impact of transcatheter edge-to-edge repair (TEER) of mitral valve on the clinical outcomes in the management of atrial functional mitral regurgitation

Abstract Background Atrial functional mitral regurgitation (aFMR) has become a novel topic of interest. Data on the safety and efficacy of transcatheter edge-to-edge repair (TEER) of mitral valve among patients with aFMR and ventricular functional mitral regurgitation (vFMR) is scarce and limited to single center studies. Purpose We conducted a systematic review and meta-analysis to assess the safety and efficacy of TEER in the management of aFMR vs vFMR and its impact on clinical outcomes. Methods PubMed/MEDLINE, Cochrane Library and EMBASE databases were queried to identify studies comparing the efficacy of TEER between aFMR and vFMR. The primary outcome of interest was mortality at 1 year and composite of all-cause mortality and heart failure (HF) hospitalizations. Secondary outcomes included mitral regurgitation (MR) reduction, presence of residual MR, improvement in NYHA functional class, postoperatively and at 1-year. Risk ratios (RR’s) and their corresponding 95% confidence intervals (CIs) were calculated using random-effects model. Results We included a total of 3,314 patients from 6 observational studies which met the inclusion criteria (mean age 63.8 ± 3.8 years, 43% male). There were 443 aFMR patients and 2871 vFMR patients with an average follow-up of 12 months. Mortality at 1-year and the composite outcome of all-cause mortality and heart failure hospitalizations were comparable between aFMR and vFMR groups (RR 1.06; 95% CI 0.64 - 1.75; p = 0.81 and RR 0.92; 95% CI 0.75 - 1.14; p = 0.47, respectively). There were no significant differences between aFMR and vFMR groups in terms of MR reduction postoperatively (RR 0.99; 95% CI 0.96 - 1.02; p = 0.53) or at 1-year (RR 1.15; 95% CI 0.96 - 1.38; p = 0.14). Moreover, the presence of residual MR grade ≥ 3+ postoperatively (RR 1.31; 95% CI 0.83 - 2.08; p = 0.25) and at 1-year (RR 0.96; 95% CI 0.44 - 2.11; p = 0.92) was similar between aFMR and vFMR cohorts. Overall, although there was a clinical improvement in symptoms in terms of NYHA functional class at 1 year (grade ≤ 2), there was no statistical significance between the two groups (RR 1.02; 95% CI 0.93 - 1.11; p = 0.74). Conclusion This meta-analysis suggests that transcatheter edge-to-edge repair is likely to be an efficacious and safe option in patients with aFMR and vFMR. Future randomized control trials are needed to fully assess the clinical impact of this procedure in the two MR etiologies.Figure 1Figure 2

Influence of device generations on alternations of mitral annulus after transcatheter edge-to-edge repair: a real-time three-dimensional transesophageal echocardiography study

Abstract Background Alternation of the mitral annulus (MA) after transcatheter edge-to-edge mitral valve repair (TEER) is reported to be associated with a reduction of mitral regurgitation (MR). However, the influence of the new device system with 4 device size options (MitraClip G4) on MA geometry compared to the conventional device (G2) remains unknown. Methods and results A total of 129 patients (mean age 79±10 years, male 66%) including 38 primary MR and 91 secondary MR who underwent TEER guided with three-dimensional (3D) transesophageal echocardiography (TEE) were included. MA area, anterior-posterior (AP) diameter, inter-commissure (CC) diameter, and MA ellipticity before and after MitraClip implantation were measured using 3D TEE images assessed by dedicated software. MitraClip G4 was used in 54 cases (42%). In patients with secondary MR, greater changes in MA area, AP diameter, and MA ellipticity were observed in patients treated with G4 compared to G2 (P=0.001, 0.003, and 0.39, respectively). In contrast, patients with primary MR had no differences in the change of MA parameters between G2 and G4. Patients with significant residual MR had less increase of MA ellipticity after device implantation in secondary MR (P=0.014), but not in primary MR (P=0.062). Conclusion In patients with secondary MR, MitraClip G4 made greater changes in MAA, AP diameter, and MA ellipticity compared to MitraClip G2, but not in CC diameter. The change of ellipticity was associated with a reduction of MR after device implantation in secondary MR. These findings indicated that MitraClip G4 may lead favorable MA alternation than G2, especially in secondary MR.

A novel hemodynamic index characterizing mitral regurgitation undergoing transcatheter edge to edge repair: the mitral pulse pressure fraction

Abstract Objectives Our study sought to investigate the role of invasive hemodynamic monitoring during Transcatheter Edge to Edge Repair (TEER) procedure on top of transesophageal echocardiographic (TEE) guidance. Background Direct hemodynamic impact of residual MR after TEER is not always univocally measured by TEE assessment alone. When analyzing TEER procedure result operators often encounter discrepancy between TEE guidance and invasive hemodynamic monitoring. Methods We analyzed 78 patients with moderate-to-severe or severe mitral regurgitation (MR) who underwent TEER. Mitral pulse Pressure Fraction (MPF) was extracted from intraprocedural continuous left atrial pressure monitoring. 23 patients with the same grade of MR not undergoing TEER were included as a control group. Results TEER had a significant impact reducing MR burden on both TEE guidance and invasive hemodynamic monitoring. Post-TEER MPF was significantly reduced compared to both pre-TEER setting (p &amp;lt; 0.001) and control group (p = 0.004). MR reduction assessed by TEE guidance was not found to be correlated with improved clinical and functional status at follow-up as assessed by New York Heart Association (NYHA) classification (p = 0.424) and 12-items Kansas City Cardiomyopathy Questionnaire (KCCQ) (p = 0.1). On the contrary, a greater reduction in MPF was associated with a significant amelioration of both NYHA classification (p = 0.003) and 12-items KCCQ (p&amp;lt;0.001) during the follow-up period. Conclusions MPF provides an immediate estimate of the real hemodynamic impact of MR and can offer a prompt prediction of the functional improvement after TEER.

Abstract 13106: Two-Year Clinical Outcomes of Staged Transcatheter Mitral Edge-to-Edge Repair After Transcatheter Aortic Valve Replacement

Introduction: Residual significant MR has been linked to an increased risk of adverse clinical events in patients undergoing TAVR. However, the effectiveness of staged TEER after TAVR has been poorly assessed. Hypothesis: To investigate clinical outcomes of staged transcatheter edge-to-edge repair (TEER) for residual significant mitral regurgitation (MR) after transcatheter aortic valve replacement (TAVR). Methods: This observational study included consecutive patients with residual grade 3+ or 4+ MR after TAVR performed at our institution between April 2016 and November 2020. The primary composite outcomes were all-cause mortality and heart failure (HF) hospitalization at 2 years, with HF hospitalization assessed as a secondary outcome for all-cause mortality. Additional analyses, including changes in MR grade and New York Heart Association (NYHA) functional classification, were performed. Results: Among 314 patients, 104 (33.1%) treated with staged TEER and 210 (66.9%) treated with medical therapy alone were enrolled. Patients who underwent staged TEER had a lower rate of primary composite outcomes than those who received medical therapy alone (33.7% vs. 48.1%, p=0.027) (Figure1). However, there was no significant difference in all-cause mortality (11.5% vs. 13.8%, p=0.46) or HF hospitalization (31.7% vs. 42.9%, p=0.061). Staged TEER was associated with a marked improvement in the MR grade and NYHA class from baseline to 2 years. Conclusions: Staged TEER following TAVR was associated with improved clinical outcomes and a reduced MR grade. The findings suggest that TEER should be considered a potential treatment option for significant residual MR in patients who have previously undergone TAVR.

Abstract 12214: Large Left Atrial Infected Myxoma in a Healthy Patient With Intermittent Fever

Introduction: Infected myxomas represent a rare subset of cardiac myxomas. The diagnosis is classified as definite, probable, or possible based on microbiological and pathological findings. Prognosis is often favorable with early diagnosis and intervention. Case description: A 39-year-old female with a history of iron-deficiency anemia presented with three months of fever, poor exercise tolerance, 15-lb unintentional weight loss, and episodes of amaurosis fugax associated with upper extremity paresthesias. Her physical exam revealed tachycardia and a grade 3/6 apical holosystolic murmur. Her laboratory workup was notable for microcytic anemia, elevated inflammatory markers, and Streptococcus sanguinis bacteremia . Echocardiography showed left ventricular and left atrial dilation with normal systolic function and a 6.4x4.3 cm heterogenous left atrial mass adherent to the interatrial septum with prolapse across the mitral valve plane (Figure 1, panel A-B) associated with eccentric mitral regurgitation. She was managed with surgical resection and antibiotics. Pathology revealed myxomatous tissue and prominent plasma cell infiltrates, confirmatory of definite infected cardiac myxoma. Follow-up echocardiography showed residual mitral regurgitation due to mitral annular stretch from myxoma for which surgical intervention was deferred in the acute setting. Discussion: A definite diagnosis of infected myxoma is established with biopsy-proven myxoma, along with microorganism visualization or positive blood cultures with inflammatory cells on histopathology. Rare in occurrence, infected myxomas have been associated with a higher incidence of embolic events, sepsis, and shock compared to uninfected myxomas. Prognosis is favorable with prompt intervention. Increased awareness leading to earlier diagnosis and management is a priority for this subset of patients.

Residual or recurrent mitral regurgitation predicts mortality following transcatheter edge-to-edge mitral valve repair

ObjectiveAlthough regurgitant mitral valves can be repaired through surgical or transcatheter approaches, contemporary comparative outcomes are limited with the impact of residual and recurrent mitral regurgitation (MR) on clinical outcomes being poorly defined. We hypothesized that moderate (2+) or greater residual or recurrent (RR) MR—regardless of type of repair—predicts worse clinical outcomes. MethodsOur institutional experience of 660 consecutive patients undergoing mitral valve repair (2015-2021) consisting of 393 surgical mitral valve repair (SMVr) and 267 transcatheter edge-to-edge mitral valve repair (TEER) was studied. The echocardiographic impact of RRMR (2+) following both SMVr and TEER on death and reintervention was evaluated. ResultsPatients averaged 67.8 ± 14.2 years (SMVr = 63.8 ± 13.3 vs 73.6 ± 13.6, P < .0001) and 62.1% were male. Baseline clinical and demographic data were vastly different between the 2 groups. Residual or recurrent 2+ or greater MR developed in 25% (n = 68) of patients who received TEER compared with 6% (n = 25) of SMVr (P < .0001). Reintervention (9.3% vs 2.4%, P = .002) and death (37.9% vs 10.4%, P < .0001) rates at 3-years were greater among the TEER group versus SMVr group. Given the heterogeneity in baseline characteristics and difference in survival, each cohort was analyzed separately, stratified by RRMR, using multivariable modeling to identify predictors of repeat reintervention and death. There were too few events of RRMR in the SMVr cohort for evaluation. For the TEER subgroups, we observed greater long-term mortality, but not reintervention among those with RRMR., Hypertension was the strongest predictor of death and obesity was for reintervention. ConclusionsPatients undergoing SMVr and TEER are vastly different with respect to baseline patient characteristics and clinical outcomes, with patients who undergo TEER being much greater risk with poorer prognosis. Moderate or greater RRMR predicted worse long-term survival but not reintervention among patients who received TEER. Given the difference in survival among patients with RRMR following TEER, care must be taken to ensure that patients entering clinical trials and receiving TEER should have a high probability of achieving mild or less MR as seen in contemporary surgical results.

Mitral valve repair using leaflet expansion and subpartial annuloplasty in children

ObjectiveMitral valve reconstruction in the pediatric population is a challenge due to the frequent combination of annular dilatation and leaflet restriction and the need for growth. We present a novel strategy using leaflet expansion and subpartial annuloplasty with polytetrafluoroethylene reinforcement. MethodsFrom January 2014 through May 2021, 11 children aged 5 months to 14 years (median, 24 months) underwent elective mitral valve repair due to severe mitral valve regurgitation. The mitral valve abnormalities included congenital malformations (n = 7), postoperative leakage following commissurotomy (n = 1), and functional mitral valve regurgitation due to dilated cardiomyopathy (n = 3). Surgery consisted of leaflet expansions with autologous, untreated pericardium and subpartial annuloplasty with polytetrafluoroethylene reinforcement. ResultsAll children survived their surgeries with uneventful postoperative courses, except for 1 patient who needed an early reoperation to resolve a functional stenosis due to a spinnaker phenomenon. At discharge, mean gradient was 3.5 ± 3.9 mm Hg, with trivial mitral regurgitation in 9 patients (82%). All patients were alive and asymptomatic during the median follow-up of 3 years (range, 1-7 years). Their echocardiographic data showed a mean transmitral gradient of 4.4 ± 1.7 mm Hg and remained unchanged. Residual mitral valve regurgitation was trivial or mild in 9 patients (82%) and moderate in 2 patients (18%). ConclusionsLeaflet expansion with autologous pericardium and subpartial annuloplasty with polytetrafluoroethylene reinforcement for mitral regurgitation in the pediatric population gives stable and satisfactory results both early and at intermediate follow-up, permitting growth of the mitral valve.

Discussion to: Residual or recurrent mitral regurgitation predicts mortality following transcatheter edge-to-edge mitral valve repair

Discussion to: Residual or recurrent mitral regurgitation predicts mortality following transcatheter edge-to-edge mitral valve repair

Prognostic Impact of Residual Moderate Mitral Regurgitation Following Valve-in-Valve Transcatheter Aortic Valve Implantation.

The impact of mitral regurgitation (MR) on valve-in-valve transcatheter aortic valve implantation (VIV-TAVI) in patients with failed bioprostheses remains unclear. The purpose of this study was to assess the prognostic impact of residual moderate MR following VIV-TAVI. We retrospectively analyzed 127 patients who underwent VIV-TAVI between March 2010 and November 2021. At least moderate MR was observed in 51.2% of patients before the procedure, and MR improved in 42.1% of all patients. Patients with postoperative severe MR, previous mitral valve intervention, and patients who died before postoperative echocardiography were excluded from further analyses. The remaining 114 subjects were divided into two groups according to the degree of postprocedural MR: none-mild MR (73.7%) or moderate MR (26.3%). Propensity score matching yielded 23 pairs for final comparison. No significant differences were found between groups before and after matching in early results. In the matched cohort, survival probabilities at one, three, and five years were 95.7% vs. 87.0%, 85.0% vs. 64.5%, and 85.0% vs. 29.0% in the none-mild MR group vs. moderate MR-group, respectively (log-rank P=0.035). Among survivors, patients with moderate MR had worse functional status according to New York Heart Association (NYHA) class at follow-up (P=0.006). MR is common in patients with failed aortic bioprostheses, and improvement in MR-status was observed in over 40% of patients following VIV-TAVI. Residual moderate MR after VIV-TAVI is not associated with worse early outcomes, however, it was associated with increased mortality at five years of follow-up and worse NYHA class among survivors.

Simplified ELASTA-CLIP Before Transapical Mitral Valve Replacement

Residual and recurrent mitral regurgitation after transcatheter edge-to-edge repair are therapeutically challenging. In the present case report, we describe a simplified, transapical electrosurgical laceration and stabilization of clip procedure that represents an alternative and direct approach for electrosurgical laceration of mitral valve leaflets enabling transcatheter mitral valve replacement for recurrent mitral regurgitation after mitral valve transcatheter edge-to-edge repair.

Incidence of systemic inflammatory response syndrome and patient outcome following transcatheter edge-to-edge mitral valve repair.

Systemic inflammatory response syndrome (SIRS) is a common finding after cardiovascular interventions. Data on the incidence of SIRS and its impact on outcome in patients undergoing transcatheter edge-to-edge mitral valve repair (MV-TEER) for mitral regurgitation (MR) is lacking. From January 2013 to December 2020, 373 patients with moderate or severe MR undergoing MV-TEER were included. SIRS was defined as at least two of the following criteria within 48h after the procedure: leucocyte count > 12.0 or < 4.0 × 109/l, respiratory rate > 20 breaths per minute or PaCO2 ≤ 4.3kPa/32mmHg, heart rate > 90bpm and temperature > 38.0°C or < 36.0°C. The primary endpoint was 3-years all-cause mortality. SIRS was observed in 49.6% (185/373) of patients. Patients who developed SIRS presented more frequently with NYHA III/IV at baseline [SIRS: 82.4% (149/185) vs. no SIRS: 79.0% (147/188); p = 0.029]. Patients who developed SIRS spent more days on ICU (p < 0.001) and overall length of stay was longer (p < 0.001). Relevant residual MR, defined as MR ≥ III in-hospital, was present more often in patients who developed SIRS [SIRS: 11.3% (20/177) vs. no SIRS: 3.93% (7/178), p = 0.036]. At 3years, all-cause mortality in the entire population was 33.5% (125/373) with an increased all-cause mortality in patients with SIRS compared to patients without SIRS (HR 1.49, [CI 95% 1.04, 2.13]; p = 0.0264). In the multivariate analysis development of SIRS (HR 1.479 [CI 95% 1.016, 2.154]; p = 0.041) was identified as predictor for 3-years all-cause mortality. SIRS is a common finding after MV-TEER occurring in approximately half of patients. SIRS after MV-TEER was associated with a longer in-hospital stay. In addition, we observed an increased 3-years all-cause mortality in patients with SIRS.