Severe Mitral Regurgitation In Patients Research Articles

The Role of Global Longitudinal Strain in Predicting Left Ventricular Reverse Remodeling After Mitral Valve Replacement Surgery in Patients With Primary Mitral Regurgitation.

This study aimed to identify the utility of global longitudinal strain (GLS) as a reliable parameter that can accurately forecast left ventricle reverse remodeling (LVRR) in patients undergoing valve replacement surgery for severe chronic primary mitral regurgitation (MR), thereby aiding in assessing mortality and morbidity risk. This retrospective observational study involved severe primary MR patients who underwent valve replacement surgery between 2018 and 2023. Pre- and postsurgery echocardiography data were collected, with GLS measurements utilized to assess left ventricular function. Various echocardiography parameters, including MR severity and LV dimensions, were analyzed. Bivariate and multivariate analyses were performed to explore relationships between GLS and LVRR. This study enrolled 103 patients (54.4% male; mean age 45.4 ± 13.6 years). Statistical analyses revealed GLS to be an independent predictor of LVRR, with a threshold of -16.25% showing 89% sensitivity and 50% specificity. Each 1% increase in GLS corresponded to a 1.14-fold (odds ratio [OR]: 1.14; 95% confidence interval [CI]: 1.01-1.31; p<0.05) increased likelihood of LVRR. These findings highlight GLS's potential as a prognostic marker for postsurgical outcomes in severe MR patients.

Risks factors of adverse clinical outcomes in asymptomatic mitral regurgitation patients with preserved ejection fraction: a systematic review and meta-analysis.

Indication for mitral valve (MV) surgery in asymptomatic mitral regurgitation (MR) patients with preserved ejection fraction (EF) remains unclear. This study aims to identify risk factors of adverse clinical outcomes in asymptomatic MR patients with preserved EF for early indication of MV surgery. 3 databases were systematically searched to include studies with asymptomatic MR patients with preserved EF. Risk factors of adverse clinical outcomes (composite outcome of MACE and MV surgery indication), mortality, and left ventricular dysfunction (LVD) are pooled with a meta-analysis of random effect model. A total of 39 observational studies with 9135 asymptomatic moderate to severe MR patients are included. We identified 21 statistically significant risk factors for adverse outcomes. Increased natriuretic peptide, presence of atrial fibrillation, LV GLS > 20%, LVEDD > 35mm, LVESD > 22mm, and LAVI > 55ml/mm2, ERO > 55mm2, and regurgitation volume > 60ml (HR 2.21, 2.07, 4.23, 2.98, 4.05, 1.84, 4.02, 3.30, respectively; p-value < 0.05; I2 0-87%) are associated with greater risk of adverse clinical outcome. Risk factors associated with postoperative LVD are the increase of LVEDD, LVESD, and RVSP. Risk factors associated with mortality are increasing STS score and LV GLS. Several clinical parameters and risk factors can be used to stratify asymptomatic MR patients with preserved ejection fraction who could benefit from early indication for MV surgery.

Mitral valve replacement versus repair for severe mitral regurgitation in patients with reduced left ventricular ejection fraction

ObjectiveThis study compares early and long-term outcomes following mitral valve (MV) repair and replacement in patients with mitral regurgitation (MR) and reduced left ventricular ejection fraction (LVEF). MethodsPatients with primary or secondary MR and LVEF <50% who underwent MV replacement or repair (with/without atrial septal defect closure and/or atrial fibrillation ablation) between 2005 and 2017 at our center were retrospectively analyzed using unadjusted and propensity score matching techniques (42 pairs). ResultsA total of 356 patients with either primary (n = 162 [45.5%]) or secondary MR (n = 194 [54.5%]) and LVEF <50% underwent MV repair (n = 293 [82.3%]) or replacement (n = 63 [17.7%]) during the study period. In-hospital mortality was 0.3% (repair) and 1.6% (replacement) in the unmatched cohort (P = .32); there were no in-hospital deaths after matching. Estimated survival was 72.8% (repair) versus 50.1% (replacement) at 8 years in the unmatched (P < .001), and 64.3% (repair) versus 50.7% (replacement) in the matched groups (P = .028). Eight-year cumulative incidence of reoperation was 7.0% and 11.6% in unmatched (P = .28), and 9.9% and 12.7% in matched (P = .69) repair and replacement groups, respectively. Markedly reduced LVEF (<40%) was among the independent predictors of long-term mortality (hazard ratio, 1.7; 95% CI, 1.2-2.4; P = .002). In secondary MR, MV repair showed an 8-year survival benefit over replacement (65.1% vs 44.6%; P = .002), with no difference in reoperation rate (11.6% [repair] vs 17.0% [replacement]; P = .11). ConclusionsMV repair performed in primary or secondary MR and reduced LVEF provides superior long-term results compared with replacement. Severe LV dysfunction is a significant predictor of reduced survival following MV surgery.

A modified Carpentier classification in transcatheter edge-to-edge repair for mitral regurgitation.

Mitral regurgitation (MR) is the most common heart valve disease, and transcatheter edge-to-edge repair (TEER) has been recommended as a therapy for severe MR patients by guidelines. The classic Carpentier classification used to guide surgical mitral valve repair but is inadequate for mitral TEER (M-TEER). We herein proposed a new modified Carpentier classification named after "type + segment," which is suitable for M-TEER. We shared our strategies in M-TEER procedure for screening and performing the M-TEER according to the new modified Carpentier classification.

SEVERE MITRAL REGURGITATION TREATED WITH TRANSCATHETER AORTIC VALVE IMPLANTATION IN MITRAL RING (TMVIR): A CASE REPORT

Abstract Introduction The increasing prevalence of mitral regurgitation (MR), combined with a growing population of elderly patients at risk of being unsuitable for surgical options, has led to a greater interest in the use of less invasive treatments such as transcatheter heart valve (THV) implantation. This case involves the use of transcatheter aortic valve implantation in a patient with a previous mitral annuloplasty (TMViR). Case Presentation A 77–year–old woman had previously undergone mitral annuloplasty (Physio Ring II 32 mm, Medtronic), Neocord implantation and closure of the posterior commissure for severe MR due to anterior leaflet prolapse. She presented to our attention with worsening dyspnea (NYHA Class III) and a sudden weight gain. Transesophageal echocardiogram (TEE) revealed findings indicative of a previous mitral annuloplasty failure, with residual severe MR along with severe tricuspid regurgitation (TR). The case was discussed in the Heart Team and given the elevated surgical risk and the patient‘s anatomical unsuitability for edge–to–edge therapy, it was decided to perform a TMViR implantation. Under echocardiographic guidance and general anesthesia, right common right femoral vein access was obtained. After transseptal puncture, predilation of the interatrial septum was performed with balloon (Evercross 12 mm, Medtronic). Subsequent access to the left ventricle was achieved with a 6F PigTail catheter, and a stiff exchange guide (Safari S, Boston Scientific) was used to advance the 16Fr Delivery system. With the assistance of TEE, aortic valve implantation on the mitral ring was performed (Sapien 29 mm, Edwards Lifesciences) with rapid pacing via transvenous temporary PM placed in right ventricle (Spikeflow, Fiab). At the end of the procedure, two closure systems (Proglide, Abbott) were used for right femoral vein access. Post–implantation TEE showed a trivial paravalvular leak external to the annulus and a mean transvalvular gradient of 5 mmHg. The postoperative course proceeded without complications, facilitating the patient‘s discharge on the third postoperative day. Currently no further hospitalization in the last 6 months. Conclusion Despite surgical intervention remaining the gold standard in treating severe MR in patients who have undergone a previous annuloplasty, in patients at high surgical risk for a re–operation, who are not eligible for other percutaneous options, TMViR could be a safe and effective option for treatment.

Mitral regurgitation is associated with similar loss of von Willebrand factor large multimers but lower frequency of anemia compared with aortic stenosis

BackgroundVarious cardiovascular diseases cause acquired von Willebrand syndrome (AVWS), which is characterized by a decrease in high-molecular-weight (large) von Willebrand factor (VWF) multimers. Mitral regurgitation (MR) has been reported as a cause of AVWS. However, much remains unclear about AVWS associated with MR. ObjectivesTo evaluate VWF multimers in MR patients and examine their impact on clinical characteristics. MethodsModerate or severe MR patients (n = 84) were enrolled. VWF parameters such as the VWF large multimer index (VWF-LMI), a quantitative value that represents the amount of VWF large multimers, and clinical data were prospectively analyzed. ResultsAt baseline, the mean hemoglobin level was 12.9 ± 1.9 g/dL and 58 patients (69.0%) showed loss of VWF large multimers defined as VWF-LMI < 80%. VWF-LMI in patients with degenerative MR was lower than in those with functional MR. VWF-LMI appeared to be restored the day after mitral valve intervention, and the improvement was maintained 1 month after the intervention. Seven patients (8.3%) had a history of bleeding, 6 (7.1%) of whom had gastrointestinal bleeding. Gastrointestinal endoscopy was performed in 23 patients (27.4%) to investigate overt gastrointestinal bleeding, anemia, etc. Angiodysplasia was detected in 2 of the 23 patients (8.7%). ConclusionModerate or severe MR is frequently associated with loss of VWF large multimers, and degenerative MR may cause more severe loss compared with functional MR. Mitral valve intervention corrects the loss of VWF large multimers. Gastrointestinal bleeding may be relatively less frequent and hemoglobin level remains stable in MR patients.

Quantification of Mitral Regurgitation in Mitral Valve Prolapse by Three-Dimensional Vena Contracta Area: Derived Cutoff Values and Comparison With Two-Dimensional Multiparametric Approach

Echocardiographic grading of mitral regurgitation (MR) in mitral valve prolapse (MVP) is challenging. Three-dimensional (3D) vena contracta area (VCA) has been proposed as a valuable method. However, data defining the cutoff values of severity and validation in the subset of patients with MVP are scarce. The aim of this study was to validate the 3D VCA by 3D color-Doppler transesophageal echocardiography (TEE) in patients with MVP and to define the cutoff values of severity grading. The secondary aim was to compare 3D VCA to the effective regurgitant orifice area estimation by proximal isovelocity surface area (EROA-PISA) method. A total of 1,138 patients with at least moderate MR who underwent TEE were included. Three-dimensional VCA was measured, and the cutoff value and area under the curve (AUC) for the prediction of severe MR were estimated by receiver operating characteristic curve using a guideline-suggested multiparametric approach as the reference standard. In a subgroup of patients, 3D regurgitant volume (RV) and 3D fraction were calculated from mitral and left ventricular outflow tract stroke volumes to further validate 3D VCA against a 3D volumetric reference standard. The optimal 3D VCA cutoff value for predicting severe MR was 0.45cm2 (specificity, 0.87; sensitivity, 0.90) with an AUC of 0.95 using a multiparametric approach as reference. Three-dimensional VCA had a good linear correlation with EROA-PISA (r=0.62, P<.05) with larger values compared to EROA-PISA (0.63cm2 vs 0.44cm2, P<.05). A cutoff of 0.50cm2 (AUC of 0.84; sensitivity, 0.78; specificity, 0.78) predicts an EROA-PISA of 0.40cm2. Three-dimensional VCA had a good linear correlation with 3D RV (r=0.56, P<.01), with an AUC of 0.86 to predict a 3D fraction>50%. The present study suggests 0.45cm2 as the best cutoff value of 3D VCA to define severe MR in patients with MVP, showing an optimal agreement with the reference standard multiparametric approach and 3D RV.

Mitral regurgitation mechanisms related to systolic anterior motion in hypertrophic cardiomyopathy.

Systolic anterior motion (SAM) of the mitral valve can result in mitral regurgitation (MR) and adverse outcomes in patients with obstructive hypertrophic cardiomyopathy (HCM). However, the mechanism and characteristics of MR severity mediated by SAM are unresolved. This study aimed to elucidate the anatomic and hemodynamic associations of MR and the impact of septal myectomy on changes in MR severity in patients with HCM. We retrospectively reviewed patients who underwent septal myectomy with SAM and interpretable imaging between 2017-2022. Significant MR was defined as moderate or more MR. The mitral valve, papillary muscle, and left ventricular geometry were quantitatively evaluated via echocardiography and cardiac computed tomography. Out of 34 patients, two groups were identified: those with preoperative significant MR (n=16) and those without significant MR (n=18). Patients with significant preoperative MR exhibited worse heart failure symptoms at baseline than those without. Following myectomy, these patients showed higher residual left ventricular outflow tract (LVOT) gradients at rest and with provocative measures than those without preoperative MR. Multivariate regression analysis revealed a significant association between the tenting area and MR severity. Additionally, the chordal cutting procedure alleviated the tenting area [2.1 (1.8-2.6) vs. 1.4 (1.2-1.6) cm2] compared to those without it. Our preliminary data suggested that chordal cutting with septal myectomy was associated with an improvement in the tenting area, contributing to MR severity. This procedure may serve as an effective therapy for patients with SAM and significant MR.

Ten-year outcomes of surgical treatment of ischemic mitral regurgitation-a retrospective study

Background: Mitral regurgitation (MR) is a prevalent form of valvular heart disease, affecting millions of people worldwide. Primary MR occurs due to mitral valve dysfunction, while secondary MR is caused by left ventricle remodelling. The study aimed to investigate the long-term outcomes of patients with IMR after undergoing coronary surgeries, including coronary artery bypass graft (CABG) with or without mitral valve repair or replacement. Methods: Retrospective, observational study design was planned. Pre-operative and postoperative data were collected from 68 patients with ischemic MR who underwent coronary artery bypass surgery, with or without Mitral valve replacement or mitral valve repair. (That is CABG only/CABG+MVR/CABG+MVr) in the year between 2001 and 2010. Patients followed up at 3 months, 1 year, and 10 years after the procedure. Results: Significant improvements in New York heart association (NYHA) functional class and MR status were observed for all three surgical groups, namely, a) CABG surgery, b) coronary artery bypass graft surgery with mitral valve replacement (CABG+MVR), and c) coronary artery bypass graft surgery with mitral valve repair (CABG+MVr). After 10 years, redo surgery rates were minimal for CABG only and CABG+MVR groups of patients, while CABG+MVr required 20% redo surgery. Postoperative complications, such as left ventricle failure, were seen in the immediate postoperative period, leading to the death of those patients 3 months following the surgery. After 3 months, complications decreased over time for all groups. Conclusions: Surgical interventions effectively improved functional outcomes and reduced MR severity in patients with ischemic MR. Redo surgery rates were low for most patients, indicating the success of the initial procedures.

Urgent Transcatheter Edge-to-Edge Repair (TEER) of severe mitral regurgitation in patients with cardiogenic shock: A systematic review and meta-analysis of 5,428 patients

Abstract Background Patients presenting with severe mitral valve regurgitation (MR) and cardiogenic shock (CS) demonstrate a poor prognosis and high mortality rate. Transcatheter edge-to-edge repair (TEER) of the mitral valve regurgitation with MitraClip may alter patient management while alleviating hemodynamic instability. Aim To perform a systematic review of the published literature and meta-analysis on the use of MitraClip in patients with severe MR and CS. Methods We performed a systematic review and meta-analysis according to the PRISMA guidelines. We systematically explored published literature in MEDLINE (Pubmed) before January 8, 2023, for studies assessing urgent TEER with MitraClip in patients presenting with severe MR and CS. CS was defined as 1) CS according to ICD-10; 2) inotrope use; or 3) mechanical circulatory support before TEER. The primary outcome was device success and all-cause mortality rates while the secondary outcome was the incidence of myocardial infarction (MI), stroke, and hospitalization for heart failure (HF), during in-hospital/30-days and long-term periods. We calculated I² to test heterogeneity. We used random-effects modeling for the meta-analyses to assess the primary and secondary outcomes. Results In total 25 studies, including 5,428 patients met the predefined eligibility criteria and were included in this meta-analysis. During the in-hospital/30-day period, device success was achieved in 86% (95% CI: 80%-91%, I2 =49%) with MR ≤2+ to be described in 87% (95% CI: 79%-93%, I2 =75.8%) of the cases, while the overall all-cause mortality was 14% (95% CI: 10%-19%, I2 =84%). The incidence of MI and stroke hovered at 4% (95% CI: 1%-13%, I2 =92%) and 2% (95% CI: 1%-2%, I2 =0%), respectively. During a mean follow-up of 10.6 ± 6.4 months, the all-cause mortality was increased to 31% (95% CI: 24%-39%, I2 =92%), while hospitalization for HF is needed in 18% (95% CI: 9%-29%, I2 =80%) of the patients. In the subgroup analysis of patients in CS due to acute MI who underwent urgent TEER, 11 studies and 352 patients were included. Device success was achieved in 92% (95% CI: 75%-100%, I2 =77.8%) and the in-hospital/30-day mortality was 13% (95% CI: 5%-21%, I2 =60%). In a mean follow-up of 10.2 ± 8.3 months, long-term all-cause mortality fluctuated at the same rate of around 11% (95% CI: 2%-23%, I2 =70%). Conclusion The use of MitraClip in patients with MR and concurrent CS is associated with improved in-hospital/30-day and long-term survival. Our findings indicate that using MitraClip in the acute phase is a safe approach that can significantly reduce all-cause mortality, MI, stroke, and re-hospitalization for HF in this patient population.

Eccentric remodeling in patients undergoing mitral valve repair due to severe degenerative mitral regurgitation: impact of relative wall thickness on clinical outcomes

Abstract Background Left ventricular (LV) volume overload in mitral regurgitation (MR) leads to a progressive increase in LV mass. Eccentric hypertrophy is defined as the relative wall thickness (RWT) &amp;lt;0.43, and LV hypertrophy is a frequently observed LV remodeling phenotype in patients with severe MR. However, the prognostic impacts of RWT in these patient groups are not well known. We tested the relationship between RWT and clinical outcomes in severe MR patients undergoing MV repair (MVR). Methods A total of 979 consecutive adult patients with severe degenerative MR and eccentric hypertrophy (55 ± 13 years, 616 males) who underwent MVR were retrospectively analyzed. The study population was stratified by the median RWT value (RWT=0.34) on baseline echocardiography [the lesser RWT group (RWT&amp;lt; 0.34 (n=651)) and the greater RWT group (RWT ≥0.34 (n = 328)). Results The patients in the lesser RWT group were younger (54±13 vs. 57±13, p&amp;lt;0.001) and had a significantly higher prevalence of hypertension and diabetic mellitus than those in the greater RWT group. The greater RWT group had significantly lower indexed LV systolic dimension, thicker ventricular walls, and higher LV ejection fraction as compared with those in the lesser RWT group. In Kaplan-Meier analysis, the greater RWT group had a significantly higher incidence of all-cause death (6.4% vs. 2.3%; log-rank p&amp;lt;0.001) and cardiac death (3.0% vs. 0.9%; log-rank p = 0.01) at five years after MVR than in the low RWT group. RWT≥0.34 was independently associated with higher all-cause and cardiac mortality in the multivariate Cox regression analysis. In subgroup analysis, RWT≥0.34 was associated with worse outcomes in men (P &amp;lt;0.001) but not in women (P = 0.23). Moreover, hypertensive patients in the greater RWT group showed the worst outcomes as compared with the three other groups. Conclusions We concluded that excessive ventricular hypertrophy, manifested as an increased relative wall thickness, is associated with a significantly increased risk of postoperative mortalities after mitral valve repair in patients with severe degenerative MR and eccentric hypertrophy. We also found that eccentric remodeling patterns and clinical outcomes differ according to sex and the presence of hypertension.

Early mitral valve repair surgery versus active surveillance in patients with asymptomatic severe primary mitral regurgitation; insights from the Dutch AMR registry

Abstract Background Management of asymptomatic patients with severe mitral regurgitation (MR) and preserved left ventricular function is still a challenging clinical entity. According to international guidelines, early mitral valve repair (MVR) surgery and active surveillance with facilitated surgery are both possible treatment strategies. Conflicting evidence is available on the number of patients that reach an indication for facilitated surgery during follow-up in the active surveillance strategy group [1, 2]. In the multicenter Dutch AMR registry, asymptomatic MR patients were allocated to either strategy according to the heart team decision [3]. In this registry there was a low threshold to perform additional testing (i.e. cardiac magnetic resonance imaging, holter monitoring and/or cardiopulmonary exercise testing). Purpose To prospectively assess the percentage of MR patients undergoing facilitated surgery during a long-term active surveillance strategy. Methods Since 2013, 99 patients with severe primary MR were included in the Dutch AMR Registry in 5 medical centers. Enrollment for early surgery or active surveillance was based on ESC guidelines and heart team decision. During long term follow-up, we assessed primary endpoints for both groups; occurrence of atrial fibrillation, cerebrovascular accident, heart failure, MVR surgery and cardiovascular/non-cardiovascular death. In particular, we assessed the number and timing of patients that underwent facilitated surgery in the active surveillance group. Results In total, 71 patients were allocated to the active surveillance and 28 to the early surgery group. 39 Patients in the active surveillance group reached a primary endpoint including 3 deaths (2 cardiovascular and 1 non-cardiovascular) (Figure 1). In the early surgery group, 4 patients reached a primary endpoint including 2 cardiovascular deaths. Over a mean follow-up time of 4.4 years, 36 patients (51%) of the active surveillance population underwent facilitated surgery due to either symptomatic or asymptomatic triggers (Table 1). Conclusions In the Dutch AMR registry, 51% of MR patients under active surveillance needed facilitated surgery within 4.4 years. Approximately half of these patients were still asymptomatic when developing an indication for surgery. Cardiovascular mortality rates were similar between the two treatment strategies. This result shows that active surveillance can be safely accomplished in asymptomatic severe MR patients. The Dutch AMR registry will further elucidate 1) whether MR patients can be stratified at baseline to either strategy based on additional testing and 2) whether facilitated surgery is non-inferior to early surgery in terms of surgical outcome, quality of life and long-term survival. For now, the current results support an active surveillance strategy in selected asymptomatic MR patients based on guidelines since half of patients are still free of symptoms without guideline indications for surgery.Figure 1Table 1

Prognostic Impact of Mitral Regurgitation Before and After Transcatheter Aortic Valve Replacement in Patients With Severe Low-Flow, Low-Gradient Aortic Stenosis.

Background There is little evidence about the prognostic role of mitral regurgitation (MR) in patients with low-flow, low-gradient aortic stenosis undergoing transcatheter aortic valve replacement (TAVR). The aim of this study was to assess the prevalence and outcome implications of MR severity in patients with low-flow, low-gradient aortic stenosis undergoing TAVR, and to evaluate whether MR improvement after TAVR could influence clinical outcome. Methods and Results This study included consecutive patients with low-flow, low-gradient aortic stenosis undergoing TAVR at 2 Italian high-volume centers. The study population was categorized according to the baseline MR severity and to the presence of MR improvement at discharge. The primary outcome was the composite of all-cause death and hospitalization for worsening heart failure up to 1 year. The study included 268 patients; 57 (21%) patients showed MR >2+. Patients with MR >2+ showed a lower 1-year survival free from the primary outcome (P<0.001), all-cause death (P<0.001), and heart failure hospitalization (P<0.001) compared with patients with MR ≤2+. At multivariable analysis, baseline MR >2+ was an independent predictor of the primary outcome (P<0.001). Among patients with baseline MR >2+, MR improvement was reported in 24 (44%) cases after TAVR. The persistence of MR was associated with a significantly reduced survival free from the primary outcome, all-cause death, and heart failure hospitalization up to 1 year. Conclusions In this study, the presence of moderately severe to severe MR in patients with low-flow, low-gradient aortic stenosis undergoing TAVR portends a worse clinical outcome at 1 year. TAVR may improve MR severity in nearly half of the patients, resulting in a potential outcome benefit after discharge.

P18 PROGNOSTIC IMPACT OF MITRAL REGURGITATION BEFORE AND AFTER TRANSCATHETER AORTIC VALVE REPLACEMENT IN PATIENTS WITH SEVERE LOW FLOW, LOW GRADIENT AORTIC STENOSIS

Abstract Background There is little evidence about the prognostic role of mitral regurgitation (MR) in patients with low flow, low gradient aortic stenosis (LFLG–AS) undergoing transcatheter aortic valve replacement (TAVR). Aims: The aim of this study was to assess the prevalence and outcome implication of moderately severe to severe MR in patients with LFLG–AS before and after TAVR. Methods This study included consecutive patients with LFLG–AS undergoing TAVR at two Italian high–volume centres. The study population was categorized according to the baseline MR severity and to the presence of MR improvement at discharge. The primary outcome was the composite of all–cause death and hospitalization for worsening heart failure (HF) up to one year. The secondary outcomes were the single components of the primary outcome. Results The study included 268 patients; 57 (21%) patients showed MR&amp;gt;2+. Patients with MR&amp;gt;2+ showed a lower one–year survival free from the primary outcome (Log–Rank &amp;lt;0.001; Figure1), all–cause death (Log–Rank &amp;lt;0.001), and HF hospitalization (Log–Rank &amp;lt;0.001) compared to patients with MR≤2+. At multivariable analysis, baseline MR&amp;gt;2+ was an independent predictor of the primary outcome (p&amp;lt;0.001). Among patients with baseline MR&amp;gt;2+, MR improvement was reported in 24 (44%) cases after TAVR. The one–year survival free from the primary outcome was significantly higher in patients with MR improvement than in those without (Log–Rank = 0.009), and both groups had a significantly lower survival free from the primary outcome when compared with patients with baseline MR &amp;lt;2+ (Figure 2). One–year survival free from the all–cause death (Log–Rank = 0.036) and HF hospitalization (Log–Rank = 0.005) was consistently higher in patients with MR improvement than in those without. Conclusions In this study, the presence of moderately severe to severe MR in LFLG–AS patients undergoing TAVR portend a worse clinical outcome at one year. TAVR may improve MR severity in nearly half of the patients, resulting in a potential outcome benefit after discharge.

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.

Prevalence and Prognostic Implications of Moderate or Severe Mitral Regurgitation in Patients with Bicuspid Aortic Valve

Significant (moderate or greater) mitral regurgitation (MR) could augment the hemodynamic effects of aortic valvular disease in patients with bicuspid aortic valve (BAV), imposing a greater hemodynamic burden on the left ventricle and atrium, possibly culminating in a faster onset of left ventricular dilation and/or symptoms. The aim of this study was to determine the prevalence and prognostic implications of significant MR in patients with BAV. In this large, multicenter, international registry, a total of 2,932 patients (mean age, 48±18years; 71% men) with BAV were identified. All patients were evaluated for the presence of significant primary or secondary MR by transthoracic echocardiography and were followed up for the end points of all-cause mortality and event-free survival. Overall, 147 patients (5.0%) had significant primary (1.5%) or secondary (3.5%) MR. Significant MR was associated with all-cause mortality (hazard ratio [HR], 2.80; 95% CI, 1.91-4.11; P<.001) and reduced event-free survival (HR, 1.97; 95% CI, 1.58-2.46; P<.001) on univariable analysis. MR was not associated with all-cause mortality (adjusted HR, 1.33; 95% CI, 0.85-2.07; P=.21) or event-free survival (adjusted HR, 1.10; 95% CI, 0.85-1.42; P=.49) after multivariable adjustment. However, sensitivity analyses demonstrated that significant MR not due to aortic valve disease retained an independent association with mortality (adjusted HR, 1.81; 95% CI, 1.04-3.15; P=.037). Subgroup analyses demonstrated an independent association between significant MR and all-cause mortality for individuals with significant aortic regurgitation (HR, 2.037; 95% CI, 1.025-4.049; P=.042), although this association was not observed for subgroups with significant aortic stenosis or without significant aortic valve dysfunction. Significant MR is uncommon in patients with BAV. Following adjustment for important confounding variables, significant MR was not associated with adverse prognosis in this large study of patients with BAV, except for the patient subgroup with moderate to severe aortic regurgitation. In addition, significant MR not due to aortic valve disease demonstrated an independent association with all-cause mortality.

Urgent Transcatheter Edge-to-Edge Repair for Severe Mitral Regurgitation in Patients with Refractory Cardiogenic Shock.

Introduction Patients suffering from cardiogenic shock (CS) and mitral regurgitation (MR) demonstrate worse prognosis, with higher mortality rates. We sought to evaluate the effectiveness of urgent valve intervention of the mitral valve, using transcatheter edge-to-edge repair (TEER) procedures in patients presenting with CS in a tertiary Intensive Coronary Care Unit (ICCU). Methods and Results Patients with unremitting CS and severe MR were selected for urgent TEER. Baseline clinical and echocardiographic characteristics were recorded, as well as procedural success (MR severity and hemodynamics), and 30-days and 6-month mortality. Urgent TEER was done in 13 patients, whose average age was 70 years; 12 (92%) of the patients were male. All 13 patients had suffered previous ischemic heart disease—12 (92%) with either acute severe MR or worsening of previously known MR by an acute ischemic event. Using the SCAI criteria, 8 patients (61%) were classified as ‘E’ (Extreme) category; 4 (31%) were classified as ‘C’. At 30 days, 12 out of the 13 patients survived (corresponding to an 8% mortality rate); all of those 12 patients remained alive at 6 months post-admission/procedure. Conclusions The use of TEER was associated with greater 30-day and 6-month survival rates, compared to the worldwide mortality rates of patients admitted with CS. This finding may change the previous paradigm that CS and MR are associated with the worst outcome, and we might be able to offer these patients a safe and effective therapeutic option.

Concomitant mitral regurgitation in patients with low-gradient aortic stenosis: an analysis from the German Aortic Valve Registry

BackgroundPatients with severe aortic stenosis (AS) frequently presented mitral regurgitation (MR), which may interfere with the standard echocardiographic measurements of mean pressure gradient (MPG), flow velocity, and aortic valve area (AVA).AimsHerein we investigated the prevalence and severity of MR in patients with severe AS and its role on the accuracy of the standard echocardiographic parameters of AS quantification.MethodsOf all patients with severe AS undergoing transcatheter or surgical aortic valve replacement enrolled in the German Aortic Registry from 2011 to 2017, 119,641 were included in this study. The population was divided based on the values of left ventricular ejection fraction ([LVEF] > 50%, LVEF 31–50%, and LVEF ≤ 30%] and AVA (0.80 to ≤ 1.00 cm2, 0.60 to < 0.80 cm2, 0.40 to < 0.60 cm2, and 0.20 to < 0.40 cm2).ResultsOverall, 77,890 (65%) patients with mild to-moderate and 4262 (4%) with severe MR were compared with 37,489 (31%) patients without MR. Patients with mild-to-moderate and severe MR presented significantly lower mPG (ΔmPG [95%CI] − 1.694 mmHg [− 2.123 to − 1.265], p < 0.0001 and − 6.954 mmHg [− 7.725 to − 6.183], p < 0.0001, respectively), that increased with LVEF impairment. Conversely, AVA did not differ (severe versus no MR: ΔAVA [95%CI]: − 0.007cm2 [− 0.023 to 0.009], p = 0.973). Increasing MR severity was associated with significant mPG reduction throughout all AVA strata, causing a low-gradient pattern, that manifested since the early stages of severe AS (LVEF > 50%: AVA 0.80 to 1.00 cm2; LVEF 31–50%: AVA 0.60 to 0.80 cm2).ConclusionsIn patients with severe AS, concomitant MR is common, contributes to the onset of a low-gradient AS pattern, and affects the diagnostic accuracy of flow-dependent AVA measurements. In this setting, a multimodality, AVA-centric approach should be implemented.Graphical abstractIn patients with severe aortic stenosis, concomitant mitral regurgitation contributes to the onset of a low-gradient pattern, warranting a multimodality, and AVA-centric diagnostic approach.

Left Atrial Reservoir Function and Outcomes in Secondary Mitral Regurgitation

•LARS is associated with MR severity in patients with more than mild secondary MR.•LARS is associated with mortality in patients with more than mild secondary MR.•LARS provides incremental prognostic value over LA volume and LV GLS. BackgroundLeft atrial (LA) size is a marker of disease severity and is related to worse outcomes in secondary mitral regurgitation (MR). The prognostic value of LA function assessed by LA reservoir strain (LARS), however, remains unknown. The aim of this study was to investigate the prognostic implications of LARS in patients with significant secondary MR.MethodsLARS was evaluated using speckle-tracking echocardiography in patients with more than mild (grade ≥ 2) secondary MR. The population was divided into two groups according to the median LARS value (9.8%). The primary end point was all-cause mortality.ResultsA total of 666 patients (mean age, 66 ± 11 years; 68% men) were included. On multivariable analysis, more severe MR was independently associated with more impaired LARS (LARS < 9.8%; odds ratio, 0.419; 95% CI, 0.249-0.704; P = .001). During a median follow-up period of 5 years (interquartile range, 2-10), 383 patients (58%) died. Patients with LARS < 9.8% had significantly lower survival rates at 1-, 2-, and 5-year follow-up (85%, 70%, and 45%, respectively) compared with patients with LARS ≥ 9.8% (96%, 93%, and 78%, respectively; P < .001). After multivariable adjustment (including LA volume and left ventricular global longitudinal strain), more preserved LARS (≥9.8%; hazard ratio, 0.499; 95% CI, 0.386-0.645; P < .001) was independently associated with lower all-cause mortality. LARS provided incremental prognostic value over LA volume and left ventricular global longitudinal strain.ConclusionsLARS is independently associated with all-cause mortality in patients with significant secondary MR and has incremental prognostic value over LA volume and left ventricular global longitudinal strain. LARS may improve risk stratification of patients with secondary MR. Left atrial (LA) size is a marker of disease severity and is related to worse outcomes in secondary mitral regurgitation (MR). The prognostic value of LA function assessed by LA reservoir strain (LARS), however, remains unknown. The aim of this study was to investigate the prognostic implications of LARS in patients with significant secondary MR. LARS was evaluated using speckle-tracking echocardiography in patients with more than mild (grade ≥ 2) secondary MR. The population was divided into two groups according to the median LARS value (9.8%). The primary end point was all-cause mortality. A total of 666 patients (mean age, 66 ± 11 years; 68% men) were included. On multivariable analysis, more severe MR was independently associated with more impaired LARS (LARS < 9.8%; odds ratio, 0.419; 95% CI, 0.249-0.704; P = .001). During a median follow-up period of 5 years (interquartile range, 2-10), 383 patients (58%) died. Patients with LARS < 9.8% had significantly lower survival rates at 1-, 2-, and 5-year follow-up (85%, 70%, and 45%, respectively) compared with patients with LARS ≥ 9.8% (96%, 93%, and 78%, respectively; P < .001). After multivariable adjustment (including LA volume and left ventricular global longitudinal strain), more preserved LARS (≥9.8%; hazard ratio, 0.499; 95% CI, 0.386-0.645; P < .001) was independently associated with lower all-cause mortality. LARS provided incremental prognostic value over LA volume and left ventricular global longitudinal strain. LARS is independently associated with all-cause mortality in patients with significant secondary MR and has incremental prognostic value over LA volume and left ventricular global longitudinal strain. LARS may improve risk stratification of patients with secondary MR.

Clinical Implications of Functional Mitral Regurgitation Severity in Patients with Heart Failure with Reduced Ejection Fraction (HFrEF).

Background:An estimated 64.3 million people are living with heart failure worldwide. Functional MR in chronic HFrEF reflects primarily the severity of LV dysfunction and is not related to structural alterations of the mitral valvular apparatus. FMR in patients with HFrEF independently of the etiology of HFrEF and its underlying mechanisms, contributes to progression of the symptoms of HF and is independent predictor of worse clinical outcomes.Objective:The purpose of this study was to assess the severity of functional mitral regurgitation (FMR) and its clinical implications in patients with chronic heart failure with reduced ejection fraction (HFrEF).Methods:We enrolled 146 consecutive adult patients with CHF with reduced ejection fraction (HFrEF) who presented to outpatient clinics. All patients underwent clinical and physical examination. Baseline examination included medical history, detailed assessment of current medication, electrocardiogram recording, transthoracic echocardiogram and comorbidities. Heart failure with reduced ejection fraction was defined in line with the new guidelines as history of HF signs and symptoms as well as a LV ejection fraction (LVEF) below 40%. Cardiovascular risk factors were recorded according to the respective guidelines. FMR was defined and graded according to the ESC/EACTS Guidelines for the management of valvular heart disease. The extent of FMR was assessed at baseline and after a median follow-up period of 4 years in 146 consecutive HFrEF patients (left ventricular ejection fraction <40%). All of the patients received the heart failure (HF) medications in agreement with 2016 and 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Major adverse cardiac events were defined as a composite of all-cause death and the need for admission for HF.Results:A total of 146 chronic HFrEF patients (mean age of 63±11 years, 62% male, mean LVEF of 25±11%) of which 19% patients had severe FMR at baseline, with a mean EROA of 31.4±2.7 mm2 and a mean Reg Vol of 45.9±5.3 ml. There was a significant interaction between FMR and NYHA functional class in predicting death or need for hospitalization, (P < 0.0001 for the interaction term FMR NYHA III-IV). During a median follow-up period of 4.2 (IQR) 3.1-5.8) years, the primary endpoint occurred in 52 (36%) patients (21 HF admissions, and 31 deaths). There was a strong graded association between the presence and degree of FMR and risk of death or admission (P <0.0001) at 4 years follow-up period. Regarding HF therapy, 129 patients (88%) received RAAS antagonists, 17 patients (12%) received ARNI, 86 patients (59%) received beta-blockers, 75 patients (51%) were treated with MRA. 31 patients (21%) underwent cardiac resynchronization therapy (CRT) with a response rate of 64%. 24 patients (16%) underwent ICD implantation.Conclusion:Guideline-directed medical therapy is the first-line treatment for chronic HF patients who also have FMR. After this first-line approach, surgical or MitraClip transcatheter therapy can be considered in patients with persistent severe and symptomatic FMR in order to improve symptoms, quality of life and functional status.