Severe Ischemic Mitral Regurgitation Research Articles

Abstract 4138545: Mitral Valve Replacement is associated with favourable Functional and Clinical Outcome as compared with Restrictive Mitral Annuloplasty in Patients with Severe Ischemic Mitral Regurgitation. A prospective longitudinal analysis

Background: Restrictive mitral annuloplasty (RMA) and chordal-sparing mitral valve replacement (MVR) are common options for treatment of chronic severe ischemic mitral regurgitation. Research question: in patients with severe ischemic mitral regurgitation the most effective surgical approach remains controversial Aim: to test whether MVR provides superior clinical and functional outcomes compared with RMA. Methods: a prospective longitudinal analysis on 187 patients (age: 66 ± 9 year; EF:35 ± 8 %) undergoing MVR or RMA and CABG for severe ischemic mitral regurgitation. Six-minute walking test and echocardiography were performed at preoperative baseline, at 1 year and at a median FU of 5 year (interquartile range: 2.9). Brain natriuretic peptide levels were also obtained. Mitral regurgitation was defined through a comprehensive and integrative approach. Recurrent mitral regurgitation was defined as a vena contracta ≥ 3 mm at follow-up, in patients with no persistent regurgitation at discharge. The primary outcome was a 5-year composite of all-cause mortality and rehospitalization for heart failure. Survival analysis was performed with Kaplan-Meier method. Cox regression analysis was used to verify any independent predictor of composite end-point Results: Baseline preoperative data were similar between the two group. Mitral valve replacement was performed in 49% of patients (n=92) and RMA in 51 % (n=95). At 5 year patients referred to prostheses showed significant improvement in six-minute walking test as compared to RMA (MVR: 290 ± 70 meters vs MRA: 165± 56 meters) (p > 0.01) ( Figure 1 ). The brain natriuretic peptide values did not differ between the two group at 1 year whereas were significantly lower in the MVR group at 5 years (MVR: 135 pg/ml; interquartile range:100 vs RMA: 486 pg/ml; interquartile range: 68 (p<0.01) ( Figure 2 ). At 5 years freedom from all-cause death and rehospitalization for heart failure was higher in the MVR group as compared to RMA (84 ±8.9% vs 61 ±12%, p<0.01) ( Figure 3 ). According to the Cox analysis recurrent mitral regurgitation was found to be a predictor of clinical outcome (HR:5.4, 95% CI:1.3-23.2, p= 0.023). Conclusions: In patients with severe ischemic mitral regurgitation referred for surgery, chordal- sparing MVR and CABG may improve functional capacity, clinical outcome and brain natriuretic peptide levels, compared with RMA and CABG. The impact of these findings remains to be defined by larger studies on longer term

Association of tricuspid regurgitation with clinical events and quality of life after surgery for severe ischemic mitral regurgitation

BackgroundThe clinical consequences of coexistent tricuspid regurgitation (TR) in patients with severe ischemic mitral regurgitation (IMR) remain unclear. We examined the association of baseline TR severity with outcomes after mitral valve (MV) surgery for IMR. MethodsWe conducted a secondary analysis of a randomized trial evaluating the effectiveness and safety of MV replacement versus repair for severe IMR. Patients were stratified by baseline TR (none/trace/mild vs moderate/severe). The primary endpoint was all-cause mortality. Secondary endpoints included major adverse cardiac and cerebrovascular events (MACCE) and quality of life (QoL) using the Minnesota Living with Heart Failure Questionnaire (MLHFQ). Cox proportional hazards and logistic models were used in the analysis. ResultsOf 251 randomized patients with severe IMR, 246 undergoing MV repair or replacement (123 each) were included in this secondary analysis. Sixty-one patients (25%) had ≥ severe TR, of whom 43% underwent MV repair and 57% underwent MV replacement. The 2-year all-cause mortality was significantly higher for those with moderate/severe TR compared to those with none/trace/mild TR (38% vs 16%; adjusted hazard ratio [aHR], 2.93; 95% confidence interval [CI], 1.59-5.38). MACCE rates were higher in patients with moderate/severe TR (53%) compared to those with none/trace/mild TR (39%) (aHR, 1.91; 95% CI, 1.21-3.03). No significant difference in 1-year QoL, measured as being alive with a 5-point improvement in the MLHFQ, was observed (odds ratio, 0.61; 95% CI, 0.28-1.33). ConclusionsIn patients undergoing surgery for severe IMR, preoperative moderate/severe TR was significantly associated with increased all-cause mortality and MACCE. Whether concomitant TV surgery would improve postoperative outcomes in patients with severe IMR and different degrees of TR should be evaluated in a randomized trial.

Comparisons between the Outcome of Mitral Repair versus Replacement in Patients with Ischemic Heart Disease with Severe Ischemic Mitral Regurgitation and Undergoing Coronary Artery Bypass Grafting (CABG) Surgery: Review Article

Comparisons between the Outcome of Mitral Repair versus Replacement in Patients with Ischemic Heart Disease with Severe Ischemic Mitral Regurgitation and Undergoing Coronary Artery Bypass Grafting (CABG) Surgery: Review Article

The high-risk features among patients undergoing mitral valve operation for ischemic mitral regurgitation: The 3-strike score

ObjectiveIschemic mitral regurgitation is prevalent and associated with high surgical risk. With the less-invasive option of transcatheter edge-to-edge repair, the optimal patient selection for mitral valve operation for ischemic mitral regurgitation remains unclear. We sought to identify high-risk features in this group to guide patient selection. MethodsUsing the Cardiothoracic Surgery Trial Network's severe ischemic mitral regurgitation trial data, we identified patient and echocardiographic characteristics associated with an increased risk of 2-year mortality using the support vector classifier and Cox proportional hazards model. We identified 6 high-risk features associated with 2-year survival. Patients were categorized into 3 groups, each having 1 or less, 2, or 3 or more of the 6 identified high-risk features. ResultsAmong the 251 patients, the median age was 69 (Q1 62, Q3 75) years, and 96 (38%) were female. Two-year mortality was 21% (n = 53). We identified 6 high-risk preoperative features: age 75 years or more (n = 69, 28%), prior sternotomy (n = 49, 20%), renal insufficiency (n = 69, 28%), gastrointestinal bleeding (n = 15, 6%), left ventricular ejection fraction less than 40% (n = 131, 52%), and ventricular end-systolic volume index less than 50 mL/m2 (n = 93, 37%). In patients who had 1 or less, 2, and 3 or more high-risk features, 90-day mortality was 4.2% (n = 5), 9.9% (n = 4), and 20.0% (n = 10), respectively (P = .006), and 2-year mortality was 10% (n = 12), 22% (n = 18), and 46% (n = 23) (P < .001), respectively. ConclusionsWe developed the 3-strike score by identifying high-risk preoperative features for mitral valve surgery for ischemic mitral regurgitation. Patients having 3 or more of such high-risk features should undergo careful evaluation for surgical candidacy given the high early and late mortality after mitral valve operations.

Impact of Mitral Regurgitation Recurrence on Mitral Valve Repair for Secondary Ischemic Mitral Regurgitation.

The current guidelines still do not include specific recommendations on the use of subvalvular repair (SV-r) for treatment of ischemic mitral regurgitation (IMR). Therefore, the objective of our study was to evaluate the clinical impact of mitral regurgitation (MR) recurrence and ventricular remodeling on long-term outcomes after SV-r combined with restrictive annuloplasty (RA-r). We performed a subanalysis of the papillary muscle approximation trial, studying 96 patients with severe IMR and coronary artery disease undergoing restrictive annuloplasty alongside subvalvular repair (SV-r + RA-r group) or restrictive annuloplasty alone (RA-r group). We analyzed treatment failure differences, the influence of residual MR, left ventricular remodeling, and clinical outcomes. The primary endpoint was treatment failure (composite of death; reoperation; or recurrence of moderate, moderate-to-severe, or severe MR) within 5 years of follow-up after the procedure. A total of 45 patients showed failure of the treatment within 5 years, of which 16 patients underwent SV-r + RA-r (35.6%) and 29 underwent RA-r (64.4%, p = 0.006). Patients with significant residual MR presented with a higher rate of all-cause mortality at 5 years compared with trivial MR (HR 9.09, 95% CI 2.08-33.33, p = 0.003). MR progression occurred earlier in the RA-r group, as 20 patients in the RA-r group vs. 6 in SV-r + RA-r group had a significant MR 2 years after surgery (p = 0.002). RA-r remains a surgical mitral repair technique with an increased risk of failure and mortality at 5 years compared with SV-r. The rates of recurrent MR are higher, and recurrence occurs earlier, with RA-r alone compared to SV-r. The addition of the subvalvular repair increases the durability of the repair, thus extending all of the benefits of preventing MR recurrence.

Outcomes of transcatheter edge-to-edge mitral valve repair with percutaneous coronary intervention vs. surgical mitral valve repair with coronary artery bypass grafting.

Patients with severe ischemic mitral regurgitation (IMR) may receive concurrent coronary artery bypass graft (CABG) with surgical mitral valve repair (SMVr) or percutaneous coronary stent implantation (PCI) with transcatheter edge-to-edge mitral valve repair (TMVr). However, there is no consensus on the management of severe IMR in this setting. We aimed to compare the outcomes of combined SMVr with CABG to concurrent TMVr with PCI among patients with IMR in the National Inpatient Sample (NIS) database. The National Inpatient Sample was queried for all patients diagnosed with IMR who underwent SMVr with CABG or TMVr with PCI during the years 2016-2018. Study outcomes included all-cause in-hospital mortality, periprocedural complications, and resources used. A total of 1,360 potentially eligible patients were included in the study. After 1:5 propensity score matching, 133 patients were classified in the SMVr + CABG group and 29 patients in the TMVr + PCI group. Adjusted mortality was higher in the TMVr + PCI group compared with the SMVr + CABG group (13.8% vs. 4.5%, P = 0.034). Perioperative complications were higher among patients who underwent SMVr + CABG including blood transfusions (29.3% vs. 6.9%, P = 0.01) and post-procedural cardiogenic shock (11.3% vs. 0%, P = 0.044). The cost of care was higher (USD$783548.80 vs. USD$331846.523, P = 0.001) and the length of stay was longer (17.9 vs. 15.44 days, P < 0.001) in the TMVr + PCI group. On multivariable analysis, age (OR, 1.039 [95% CI, 1.006-1.072]; P = 0.032), renal failure (OR, 3.465 [95% CI, 1.867-6.433]; P < 0.001), and liver disease (OR, 5.012 [95% CI, 2.578-9.686]; P < 0.001) were associated with in-hospital mortality. TMVr + PCI was associated with higher resource use and in-hospital mortality but with improved perioperative complications compared with SMVr + CABG.

NT-proBNP increase during stress echocardiography predicts significant changes in ischemic mitral regurgitation severity in patients qualified for surgical revascularization.

In many patients, significant changes in ischemic mitral regurgitation (IMR) severity during exercise can be observed independent of the degree of IMR at rest. This study aimed to investigate the correlations between N-terminal fragment B-type natriuretic peptide (NT-proBNP) and echocardiography measurements at rest and at peak exercise in patients with moderate IMR who qualified for surgical revascularization. A total of 100 patients eligible for coronary artery bypass grafting, were included in this prospective study. All patients underwent exercise echocardiography. Additionally, the levels of NT-proBNP were measured at rest and after peak exercise. A positive correlation of absolute NT-proBNP levels with effective regurgitant orifice area (EROA) were observed and with tricuspid regurgitant peak gradient (TRPG) at peak exercise. Absolute ΔNT-proBNP during exercise and the tenting area at rest were independent predictors of severe IMR at peak exercise. The level of absolute ΔNT-proBNP during exercise and coaptation height at rest were the most important predictors of significant increases in TRPG. The best cutoff value for ΔNT-proBNP as a predictor for increases in EROA at peak exercise was 68.9 pg/mL and to predict an increase in TRPG ≥ 50 mmHg at peak exercise was 68 pg/mL. The level of ΔNT-proBNP during exercise was the most important parameter in predicting significant changes in IMR severity and pulmonary pressure. Based on the present data, it can be speculated that integration of the assessment of NT-proBNP at rest and at exercise might improve patient selection for valve surgery.

Abstract 9397: Sex-Based Differences in Outcomes After Mitral Valve Repair for Severe Secondary Mitral Regurgitation

Background: Sex-based differences in outcomes after mitral valve repair for severe secondary ischemic mitral regurgitation (SIMR) is poorly understood. We examined differences in outcomes between men and women after mitral valve repair for severe SIMR. Methods: 96 patients with SIMR were randomized to undergo either papillary muscle approximation (PMA) with restrictive mitral annuloplasty (RMA) or RMA alone to evaluate efficacy and safety. The primary endpoint was death and major adverse cardiac or cerebrovascular events (MACCE) at 5 years. Results: 38 of the 96 enrolled (39.5%) were women. Five-year survival was 68% in women and 78% men (HR 1.48; 95% CI 0.67-3.24). Men and women had similar mortality rates in the PMA (HR 2.64; 95% CI 0.77-9.04) and RMA group (HR 0.93; 95%CI 0.31-2.78). Freedom from MACCE at 5 years was lower among women than men (6% vs 23%; HR 1.89; 95%CI 1.20-2.98). The hazard for MACCE was higher in women in the PMA group alone (HR 3.00; 95% CI 1.50-6.02). Freedom from treatment failure was similar between sexes (55% in women and 69% in men; HR 1.58; 95% CI 0.81-3.06). Similar functional status (26.3% vs 24.1%) and rehospitalization rates (23.7% vs 24.1%) were noted at 5 years. There were no significant differences in the percentage of change over 5 years in LVESD and LVEDD between the sexes. Conclusion: Women with SIMR who underwent mitral valve repair displayed no significant differences in the degree of five-year survival. MACCEs however, recurred more frequently in women.

Combined Pharmacological and Complex and High-risk Coronary Intervention of Chronic Total Occlusion for Ischemic Mitral Regurgitation

Percutaneous coronary intervention for chronic total occlusion is a complex and high-risk intervention (CHIP). Even though persistent ischemia-induced mitral regurgitation is rare, ischemic mitral regurgitation is a frequent complication of an acute coronary crisis. Transcatheter mitral repair has the potential to supplant surgical repair or replacement as the gold-standard treatment for persistent mitral regurgitation. Currently, these interventions are only performed on high-risk surgical candidates, but the indications may eventually be expanded to include low-to-intermediate risk patients as well, in a manner like transcatheter aortic valve replacement. In patients with ischemic cardiomyopathy who still had considerable viable myocardium, combining current guideline-directed pharmacological treatment with interventional complete revascularization decreased hospitalizations for heart failure. We performed a CHIP intervention on the left circumflex artery, which was chronically totally occluded, to address the severe ischemic mitral regurgitation that had been present for a long time.

Treatment of More Than Moderate Ischemic Mitral Regurgitation in Patients Undergoing Left Ventricular Reconstruction

Objective: While evidence-based clinical guidelines recommend chordal-sparing mitral valve replacement, rather than mitral valve repair, in patients with severe ischemic mitral regurgitation (IMR) undergoing coronary artery bypass grafting, there are no similar recommendations for patients undergoing left ventricular reconstruction (LVR). This study aimed to compare the clinical outcomes of mitral valve repair and replacement in patients undergoing LVR complicated by more than moderate IMR. Methods: In this single-center cohort study, a total of 74 consecutive patients who underwent LVR and mitral valve surgery (repair group: 59; replacement group: 15), during the period from March 2000 to March 2021 at Fuwai Hospital (Beijing, China) were retrospectively enrolled. Survival rates were calculated with the Kaplan-Meier method and compared using the log-rank test. Univariate Cox analysis was performed to evaluate possible confounders, followed by adjustment in multivariate analysis. The primary outcome was survival free of major adverse cardiovascular and cerebrovascular events (MACCE). Results: Median follow-up time was 59.4 months. Compared with mitral valve replacement, mitral valve repair was associated with increased risk of perioperative use of ventricular assist device (22.0% vs. 0, P = 0.045). There was no difference in overall survival (hazard ratio (HR), 1.10; 95% confidence interval (CI), 0.31–3.93; P logrank = 0.888) and MACCE-free survival (HR, 1.54; 95% CI, 0.65–3.65; P logrank = 0.319), even after multivariate Cox regression (HR, 1.35; 95% CI, 0.37–4.88; P Cox = 0.646; and HR, 1.41; 95% CI, 0.57–3.44; P Cox = 0.455, respectively). Furthermore, while no differences were observed in ejection fraction and left ventricular end-diastolic diameter on follow-up echocardiography, mitral valve repair was associated with an increased risk of recurrent mitral regurgitation (P = 0.041). Conclusions: In patients undergoing LVR complicated by more than moderate IMR, both concomitant mitral valve repair and replacement can be successfully achieved with comparable overall and MACCE-free survival outcomes; however, mitral valve replacement may be superior to mitral valve repair for persistent correction of mitral dysfunction.

Contemporary Management of Ischemic Mitral Regurgitation at Coronary Artery Bypass Grafting

BackgroundRecent guidelines for the treatment of moderate or severe ischemic mitral regurgitation (IMR) in patients undergoing coronary artery bypass grafting (CABG) have changed. This study assessed the real-world impact of changing guidelines on the management of IMR during CABG over time. We hypothesized that the utilization of mitral valve repair for IMR would decrease over time, whereas mitral valve replacement for severe IMR would increase. MethodsPatients undergoing CABG in a statewide collaborative database (2011-2020) were stratified by severity of IMR. Trends in mitral valve repair or replacement were evaluated. To account for differences of the patients, propensity score–matched analyses were used to compare patients with and without mitral intervention. ResultsA total of 11,676 patients met inclusion criteria, including 1355 (11.6%) with moderate IMR and 390 (3.3%) with severe IMR. The proportion of patients undergoing mitral intervention for moderate IMR decreased over time (2011, 17.7%; 2020, 7.5%; Ptrend = .001), whereas mitral replacement for severe IMR remained stable (2011, 11.1%; 2020, 13.3%; Ptrend = .14). Major morbidity was higher for patients with moderate IMR who underwent mitral intervention (29.1% vs 19.9%; P = .005). In a propensity analysis of 249 well-matched pairs, there was no difference in major morbidity (29.3% with mitral intervention vs 23.7% without; P = .16) or operative mortality (1.2% vs 2.4%; P = .5). ConclusionsConsistent with recent guideline updates, patients with moderate IMR were less likely to undergo mitral repair. However, the rate of replacement for severe IMR did not change. Mitral intervention during CABG did not increase operative mortality or morbidity.

Histopathological maladaptive changes in the explanted human mitral leaflets correlate with changes in echocardiographic leaflet morphology and the severity of ischaemic mitral regurgitation.

Several changes of the mitral valve (MV) morphology have been previously documented in ischaemic mitral regurgitation (IMR) upon macro and microscopic examination. This study aimed to correlate echocardiographic MV thickening with IMR severity and to delineate the histopathological basis of valve thickening from the explanted leaflets. Two hundred and fifty patients were included in the echo-group; of these, 48 patients (19.2%) underwent surgical mitral valve replacement (MVR), including them in the histology-group. By echocardiography, the thickness of the anterior and posterior leaflet was more extensive in moderate to severe IMR, P < 0.001. Histology-group: patients were divided into two groups based on the median thickness: those with cusp thickness <0.42 cm in Group 1, and ≥0.42 cm in Group 2. The thickness of the base and cusp was more significant in Group 2, P < 0.05 in both. Group 2 biopsies were characterized by involvement of the three leaflet segments, myxoid tissue, and fibrosis deposition. Thicker leaflets were associated with a greater degree of mitral regurgitation (MR), P < 0.0001. In the echo-group, a median leaflet thickness of 3.5 mm of the anterior and posterior MV was independently associated with moderate to severe ischaemic MR [odds ratio (OR) 2.88, P < 0.01] and (OR 10.8, P < 0.001), respectively. In ischaemic MR, the thicker the cusps, the worse the MR. Leaflet thickening was due to the myxoid and fibrosis deposition and was detected by echocardiography. Therefore, this method can be helpful in the evaluation of valve remodelling.

Nomogram Predicts Improvement of Ischemic Mitral Regurgitation After Coronary Artery Bypass Grafting

BackgroundDeveloping a nomogram to predict improvement in moderate ischemic mitral regurgitation (IMR) after coronary artery bypass grafting (CABG) is in need. MethodsWe retrospectively collected data from 112 patients with prior myocardial infarction and moderate IMR undergoing CABG between 2010 and 2018. Patients were divided into 2 groups based on IMR degree 1 year after CABG as follows: Improved Group with no or mild IMR (n = 54) and Failure Group with moderate or severe IMR (n = 58). To determine the predictors of postoperative IMR improvement, preoperative clinical and echocardiographic data were compared, and a nomogram was formulated based on all independent predictors. Discriminative ability, calibration, and clinical usefulness of the prediction model were assessed. ResultsIndependent predictors of IMR improvement after CABG constructing the nomogram included duration between infarction and operation, posterior-inferior to left ventricular volume ratio, maximum difference of the time to reach minimum systolic volume of 16 segments, P3 leaflet tethering angle, and annular nonplanar angle. The nomogram exhibited well-fitted calibration curves and excellent discriminative ability. The area under the receiver operating characteristic curve was 0.974. Patients with a score >236 demonstrated a high probability of IMR improvement (sensitivity, 90.7%; specificity, 93.1%). Patients in the Improved Group demonstrated greater actuarial survival rates than those in the Failure Group. ConclusionsThe nomogram combining 5 preoperative clinical and echocardiographic predictors provides an accurate preoperative estimation of moderate IMR improvement after surgery, with excellent discriminative ability. Based on this nomogram, patients with a higher score have predicted higher probabilities of IMR improvement.

MULTI-LOOP TECHNIQUE FOR PAPILLARY MUSCLE RELOCATION IN ISCHEMIC MITRAL REGURGITATION

<h3>BACKGROUND</h3> The appropriate surgical management of ischemic mitral regurgitation (IMR) is still highly debatable: valve replacement is often favoured over repair with ring annuloplasty (RA) because the former is associated with lower MR recurrence. The addition of a sub-valvular intervention, such as papillary muscle relocation (PMR), has been suggested to improve the durability of the mitral repair. Therefore, our aim was to examine the outcomes of a novel technique for PMR involving a multi-loop suture in the treatment of IMR. <h3>METHODS AND RESULTS</h3> Between 2017 and 2020, 9 patients with severe chronic IMR were enrolled into this case series: a multi-loop suture was used to address PMR in addition to ring annuloplasty. In brief, the multi-loop suture was prepared with Gore-Tex sutures, which was then anchored to the posteromedial papillary muscle, and buttressed with pledgets. The sutures attached to the loop were passed through the aspect of the annulus corresponding to the tethered segment, thus, serving as neo-chordae. Length was determined by saline test. Once regurgitation was absent on visual inspection of the saline test, the chordae were secured above the annulus with pledgets on the atrial side. Eight patients also received concomitant coronary artery bypass graft (CABG) procedure. Clinical and echocardiographic outcomes during the perioperative and follow-up periods were assessed. The mean follow-up was 15 +/- 8 months. One patient who had a pre-operative EuroSCORE of 8.25% died within the early post-operative period. The mean transmitral gradient at discharge was 3.8±1.4 mmHg. At follow-up, there was no mortality and cardiac-related readmissions, and only one patient had MR recurrence. The left ventricular end-systolic diastolic dimension was significantly lower at follow-up compared with pre-operative (6.1±4.6mm vs 5.6±0.9mm, P=0.03). A non-significant trend towards improvement was noted at follow-up compared with pre-operative for left ventricular end-diastolic volume (147.9 ± 61.2 ml vs 161.1 ± 46.6 ml, p=0.74), and left ventricular end-systolic volume (84.8 ± 42.6 ml vs 87.3 ± 35.9 ml, p=0.78). Despite the use of an undersized RA, mitral stenosis was not noted at latest follow-up, and the mean transmitral gradient of 3.6 ± 1.4 mmHg. <h3>CONCLUSION</h3> In patients with severe IMR, PMR with a multi-loop suture adjunctive to RA appears to offer excellent clinical and echocardiographic outcomes during follow-up of up to 2 years post-operatively. Nevertheless, these preliminary findings warrant further validation in a larger series of patients.

Early Outcomes of Transection of Secondary Chordae with Downsized Ring Annuloplasty in Low Recurrence Risk Severe Ischemic Mitral Regurgitation

Early Outcomes of Transection of Secondary Chordae with Downsized Ring Annuloplasty in Low Recurrence Risk Severe Ischemic Mitral Regurgitation

Ischemic mitral regurgitation: when should one intervene?

Optimal timing of intervention for ischemic mitral regurgitation remains to be elucidated. This review summarizes the data on the management of ischemic mitral regurgitation, and their implications on current practice and future research. Mechanistically, ischemic mitral regurgitation can present as Type I, Type IIIb or mixed Type I and IIIb disease. Severity of mitral regurgitation is typically quantified with echocardiography, either transthoracic or transesophageal echocardiography, but may also be assessed via cardiac MRI. In patients with moderate ischemic mitral regurgitation, revascularization can lead to left ventricular reverse remodeling in some. In patients with severe ischemic mitral regurgitation, mitral valve replacement may be associated with fewer adverse events related to heart failure and cardiovascular readmissions, compared with valve repair, although reverse remodeling may be better in patients following successful mitral repair. Transcatheter edge-to-edge repair also further complements the treatment of ischemic mitral regurgitation. A tailored approach to patients should be considered for each patient presenting with ischemic mitral regurgitation.

CMR predictors of secondary moderate to severe mitral regurgitation and its additive prognostic role in previous myocardial infarction

BackgroundWe aimed to determine predictors and the additive prognostic role of moderate to severe (MS) ischemic mitral regurgitation (MR) in myocardial infarction (MI). MethodsFour hundred twenty-two patients with previous MI underwent cardiac magnetic resonance (CMR) imaging for the assessment of left ventricular (LV) ejection fraction (EF), end-diastolic (EDV) and end-systolic volume (ESV), sphericity index, wall motion score index (WMSI), and late gadolinium enhancement (LGE). Echocardiography was performed to assess MR. ResultsThirty-eight had from moderate to severe MR (MS-MR group) and 384 did not (No MS-MR group). The S-MR group had higher LV volumes, sphericity index, WMSI, and LGE extent, and lower LVEF. At univariate logistic regression analysis, dilated volumes, SI >0.43, dyskinesia of inferolateral wall, papillary muscle (PM)-LGE, and LGE extent >16% were associated with MS-MR. At multivariate analysis, only SI (OR=5.7) and PM-LGE (OR=3) were independently associated with MS-MR. Considering only patients without LV dilatation, only dyskinesia in the inferolateral wall was a predictor of MS-MR (OR 34.8). Thirty cardiac events (cardiac death, appropriate implantable cardioverter-defibrillator firing, and resuscitated cardiac arrest) occurred during a median follow-up of 1,276 days. After adjusting the prognostic variables at univariate analysis by age (>65 years) and selecting those that were significant (EDV > 95 ml/m2, ESV >53 ml/m2, EF <30%, WMSI >1.65, LGE >12%, S-MR), only WMSI >1.65 and MS-MR remained an independent predictor of cardiac events. ConclusionsIncreased WMSI and PM-LGE in the overall population and inferolateral dyskinesia in patients without ESV dilatation are predictors of MS-MR; MS-MR and elevated WMSI have independent negative prognostic value.

A case of successful percutaneous mitral valve repair for refractory heart failure due to myocardial infarction complicated with severe ischemic mitral regurgitation

A case of successful percutaneous mitral valve repair for refractory heart failure due to myocardial infarction complicated with severe ischemic mitral regurgitation

Mitral Valve Translocation: A Novel Operation for the Treatment of Secondary Mitral Regurgitation

BackgroundConventional annuloplasty repair of secondary (functional) ischemic mitral regurgitation (IMR) is associated with a 60% recurrence of moderate or greater mitral regurgitation at 2 years. We developed a novel repair technique for IMR that addresses the underlying geometric alterations of the mitral valve apparatus and compared outcomes with those of conventional repair in a swine model. MethodsChronic IMR was induced by percutaneous embolization of the circumflex artery. Swine with severe IMR (median 9 weeks after infarction) underwent undersized rigid annuloplasty (n = 5) or translocation repair (n = 6). Translocation repair consisted of detaching the mitral valve en bloc at the annulus, creating a 1 cm wide frustum-shaped pericardial patch, and suturing the outer circumference of the patch to the annulus and inner circumference to the mitral valve. ResultsOperative survival was 92% (11 of 12). All animals had none/trace residual central mitral regurgitation, and mean inflow gradients were similar (1 mm Hg [interquartile range, 1 to 2] vs 2 mm Hg [interquartile range, 1 to 2]; P = .75) in the annuloplasty and translocation groups, respectively. Median coaptation length marginally improved in conventional swine (3 to 4 mm, P = .05), but dramatically improved in translocation swine (3 to 8 mm, P = .003). Posterior leaflet angle increased from 39 to 80 degrees (P = .05) in annuloplasty swine but decreased from 50 to 31 degrees (P = .03) in translocation swine. The posterior leaflet was immobile after annuloplasty but had preserved motion after translocation (excursion, 1 degree vs 24 degrees; P = .045). ConclusionsMitral valve translocation effectively treats mitral regurgitation by relieving leaflet tethering. Compared with annuloplasty, mitral valve translocation creates a larger surface of coaptation and preserves leaflet mobility without compromising diastolic function.

A Nationwide Survey of Surgical Treatment for Severe Ischemic Mitral Regurgitation.

Objective: Mitral subvalvular procedures in addition to restrictive annuloplasty are promising for ischemic mitral regurgitation (IMR). However, the prevalence and efficacy of specific subvalvular repair in severe IMR have not been elucidated. This is the first nationwide survey regarding surgeons’ attitudes toward IMR in Japan.Methods: A questionnaire was sent to 543 institutions. From 2015 to 2019, numbers of elective first-time mitral valve replacement (MVR) with/without complete chordal preservation (CCP)/papillary muscle approximation (PMA) and mitral valvuloplasty (MVP) with/without papillary muscle relocation (PMR)/PMA in patients with severe IMR were collected. Concomitant procedures for coronary artery, tricuspid valve, and arrhythmia could be included but left ventricular reconstruction was excluded.Results: Completed questionnaires were received from 286 institutions (52.7%). The majority (90%) had less than 20 cases within 5 years. The number of MVP (1413, 61.5%) surpassed MVR (886, 38.5%). CCP was performed in half of MVR (50.0%), while PMA was included in only 1.9% of MVR. PMA and PMR were also performed infrequently, in only 7.7% and 10.9% of MVP, respectively.Conclusion: Japanese surgeons aggressively perform MVP for severe IMR. Subvalvular repair was also aggressively performed in addition to MVR, but not to MVP. A multicenter registry study is in progress.