Severe Mitral Regurgitation Research Articles

Mitral valve regurgitation followed by blunt chest trauma in a paediatric patient: a case report.

We report a paediatric case where severe mitral valve regurgitation occurred led by blunt chest trauma. Medical treatment was undertaken, and surgical mitral valve repair was postponed until half a year after the initial injury, followed by an uneventful postoperative recovery. We highlight the importance of echocardiographic evaluation for traumatic valve insufficiency. The medical strategy and timing of surgical intervention should be individualised.

Rare Case of Atrial Myxoma with Mitral Regurgitation - Case Report

Atrial myxomas are the most common primary cardiac tumors, typically arising from the left atrium. However, their presentation can vary widely, with mitral regurgitation being a rare but significant complication. This report discusses a rare case of atrial myxoma associated with severe mitral regurgitation in a 45-year-old patient presenting with dyspnea and palpitations. The interatrial septum was connected to a massive, pedunculated mass that prolapsing into the left ventricle during diastole caused considerable regurgitation and occlusion of the mitral valve, as seen by echocardiography. The patient's hemodynamic instability necessitated urgent surgical intervention. The tumor was successfully excised, and mitral valve repair was performed. Histopathological examination confirmed the diagnosis of atrial myxoma. Postoperative recovery was uneventful, with significant improvement in symptoms and echocardiographic findings. The significance of taking atrial myxoma into account while making a differential diagnosis for mitral regurgitation is demonstrated by this instance, particularly in those with unexplained cardiac symptoms. Early diagnosis and prompt surgical management are crucial to prevent potential complications such as embolization, heart failure, or sudden cardiac death. This case also underscores the role of echocardiography as a vital diagnostic tool in identifying and assessing cardiac masses and associated valvular dysfunction.

Left atrial volume assessed by echocardiography identifies patients with high risk of adverse outcome after acute myocardial infarction

BackgroundThe left atrial (LA) volume has been demonstrated to be an important predictor of adverse outcome in patients with various cardiac conditions, including acute myocardial infarction (AMI). However, new treatment strategies in patients with AMI have led to better patient outcomes. We hypothesised that increased LA size could still predict mortality in patients with AMI despite improved treatment strategies.MethodsWe included patients with AMI in a prospective multicenter cohort study and the study patients were enrolled from 2014 to 2022. We recorded echocardiographic and clinical data during their index hospitalisation. Indexed LA volume (LAVi) was assessed in all patients and was used as a continuous variable in the univariate and multivariate Cox regression analysis. The study took place over a period of five years and median follow-up time was 3.8 years (range 3.1 to 5.0 years). The primary study outcomes were all-cause mortality and major adverse cardiac events (MACE). MACE was defined as hospital readmission due to myocardial infarction, cardiac arrest, stroke, heart failure, or onset of new atrial fibrillation.ResultsWe included 487 patients (69 ± 12 years old, 26% female) with AMI. During the follow-up period all-cause mortality was 50 (10.3%) and patients who reached the primary outcomes were 153 (31.4%). The deceased patients had higher LAVi compared to survivors (40.0 ± 12.9 mL/m2 vs. 29.7 ± 11.2 mL/m2, p < 0.001). Factors associated with all-cause mortality and MACE were age, year of enrollment, left ventricular (LV) ejection fraction, LV global longitudinal strain (GLS), LV filling pressure, moderate or severe mitral regurgitation and LAVi. GLS and EF were segregated into two distinct models due to their moderately high correlation (r = 0.57, p < 0.001). LAVi remained as an independent echocardiographic predictor of primary outcomes after adjusting for the covariates above in two separates multivariable Cox regression models (hazard ratio 1.02/1.02 mL/m2 [95% CI 1.01–1.03/1.01–1.03], p = 0.006/0.003).ConclusionsOur study demonstrated that LA dilatation is an independent echocardiographic predictor of mortality and MACE in patients with AMI despite improved treatment strategies. This finding highlights the potential of using LAVi as a marker for prognostication in these patients.

The mitral to aortic/pulmonary velocity-time integral ratio is a simple, feasible and accurate discriminator for echocardiographic evaluation of severe isolated mitral regurgitation.

Echocardiographic quantification of mitral regurgitation (MR) remains challenging, requiring dedicated image acquisition, and is limited by potential error from geometric assumptions of annular dimensions. Volume is a product of area and flow and assuming proportional mitral/aortic areas, an increased mitral-inflow volume compared to LV/RV-outflow semi-quantitatively represents greater MR regurgitant volume. Therefore, we investigated the feasibility and diagnostic performance of the mitral-aortic velocity-time integral(VTI) ratio in isolated MR. We also investigated the use of the mitral-pulmonary VTI ratio as an alternative in clinical situations where the LV outflow tract(LVOT) VTI could not be used. We reviewed 166 consecutive patients (33%, n = 54 severe MR by multi-parameter integrated expert opinion). Pulsed wave Doppler VTI at the mitral leaflet tips and the left ventricular outflow and continuous-wave Doppler of the RV outflow tract were measured individually and independently by blinded readers(expert and trainee status) to derive the ratio. Receiver operator characteristic area under the curve(AUC) comparison was calculated and compared with effective regurgitant orifice area(EROA > 40mm), regurgitant volume(RVol > 60mL), vena contracta(VC > 0.7cm), E-velocity > 1.2cm, systolic flow reversal(SFR), left atrial and ventricular dilatation. Increasing ratio was associated with severe MR(AUC 0.94) with optimal threshold defined at 1.3. This provided significant discrimination for severe MR(AUC 0.81) compared to EROA(0.68), VC(0.52), LV dilatation(0.69), LA dilatation(0.70), SFR(0.73), E-velocity(0.68) all p < 0.05, with sensitivity 82% and specificity 94%. The mitral-pulmonary VTI ratio demonstrated similar discrimination(AUC 0.92) with optimal threshold defined at 1.14. Excellent inter-observer reproducibility(intra-class correlation 0.97) was seen between trainee and expert readers. There was no difference in AUC comparison by MR mechanism or patient rhythm. The mitral-aortic and mitral-pulmonary VTI ratios are simple, geometric-free parameters feasibly reproducible from routine echocardiographic datasets and are excellent discriminative tools for severe MR. Readers should consider integration of this parameter in routine reporting.

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.

Elevated Trans-mitral Pressure Gradient Predicts Surgery in Young People with Moderate-Severe Rheumatic Mitral Regurgitation.

Mitral regurgitation (MR) is the most common lesion in children with rheumatic heart disease (RHD). Progression of RHD results in the need for surgical intervention, the timing of which is dictated by left ventricular dilatation and the onset of heart failure symptoms. We sought to determine whether elevation in trans-mitral pressure gradient (TMPG) in those with moderate or severe rheumatic MR without significant mitral stenosis (MS) could predict the need for future surgical intervention. Echocardiographic studies were reviewed for 116 children and young people with moderate or severe rheumatic MR. Those with significant mitral stenosis or concurrent aortic valve disease were excluded. Trans-mitral pressure gradient was measured at baseline and details of mitral valve surgical intervention were retrieved from a registry database. Time to future surgery (up to six years) was compared between those with TMPG < 5mmHg and TMPG ≥ 5mmHg. Survival curves demonstrated an increased risk of surgery for those with TMPG ≥ 5mmHg with Cox proportional regression analysis providing a hazard ratio of 5.8. The proportion free from mitral valve surgery at one year for the TMPG < 5mmHg group was 0.94 (95% CI 0.86-0.97), compared to 0.62 (95% CI 0.42-0.77) in the ≥ 5mmHg group. Trans-mitral pressure gradient is a strong predictor of future mitral valve surgery in children and young people with significant rheumatic MR without MS. This non-invasive measure could be used to signal the need for more aggressive monitoring in order to optimize the timing of intervention.

Mid- and long-term outcomes of percutaneous balloon mitral valvuloplasty guided solely by echocardiography

Objective: To evaluate the mid-and long-term clinical outcomes of percutaneous balloon mitral valvuloplasty (PBMV) guided solely by echocardiography. Methods: A total of 71 patients with moderate to severe mitral stenosis who underwent PBMV guided solely by echocardiography at Fuwai Hospital, Chinese Academy of Medical Sciences, from January 2016 to December 2022 were retrospectively included. The clinical data and follow-up information were collected and analyzed. Results: Finally, 71 patients (11 males and 60 females) aged (48.6±12.4) years, including 3 pregnant women were included. One patient required surgical intervention due to moderate to severe mitral regurgitation, resulting in a procedure success rate of 98.6% (70/71). The procedural duration was (84.1±40.2) minutes, with the balloon diameter of (26.5±1.1) mm and number of dilatations of 2.9±0.7. The mean mitral transvalvular pressure gradient decreased from (12.6±6.1) mmHg (1 mmHg=0.133 kPa) preoperatively to (5.4±2.4) mmHg postoperatively, while the mitral valve orifice area increased from (0.9±0.2) cm² to (1.7±0.3) cm² (both P<0.001). Before discharge, 16 patients developed new mild mitral regurgitation, five developed new moderate mitral regurgitation, and one patient had a small amount of pericardial effusion absorbed by herself. No severe complications such as death, pericardial tamponade, or thromboembolism occurred during the perioperative period. The average follow-up duration was 12-84 (49.7±21.4) months. At two years postoperatively, the mean mitral transvalvular pressure gradient was (6.2±2.5) mmHg, and the mitral valve orifice area was (1.6±0.3) cm². Eight patients underwent surgical mitral valve replacement at an median of [M(Q1, Q3)] 18 (5, 53) months postoperatively, and one patient died during the follow-up period due to non-cardiac reasons. Conclusion: The mid-and long-term outcomes of PBMV guided solely by echocardiography are favorable.

Imminent risk of LVEF decline in asymptomatic patients with primary mitral regurgitation.

2020 American College of Cardiology/American Heart Association (ACC/AHA) Guidelines state that the ideal time for mitral valve surgery in primary mitral regurgitation (PMR) is when the LV approaches but has not yet reached echocardiographic LV ejection fraction (EF) < 60% or LV end-systolic dimension (ESD) > 40 mm. However, it is difficult to know the imminent risk of crossing this threshold when the surgical outcome is less optimal. Using machine learning and statistical models, we have shown that cardiac magnetic resonance (CMR) LV sphericity index (SI) and LV mid circumferential strain rate (SRcirc) added to LVEF and LVESD predict LVEF < 50% after mitral valve surgery. Here we test the hypothesis that these CMR features predict LVEF < 60% in asymptomatic PMR patients at 18 months. 33 asymptomatic PMR patients with moderate to severe mitral regurgitation had CMR with tissue tagging at baseline and every 6 months for 18 months. Two types of models were employed to predict LVEF < 60% at 18 months: a model using CMR features at a single time point (e.g., baseline) and a model utilizing repeated measurements over time. CMR LVEF decreased below 60% in 13 patients over 18 months. LVEF varied over time with an inverse relation to mean arterial pressure and mean end-systolic wall stress. Random Forest models utilizing LV SI, LV mid SRcirc, LVESD, and LVEF at a single time point (baseline) had a predictive accuracy of 64%. LV SI, LV mid SRcirc, LVESD and LVEF at baseline, 6, and 12 months achieved a higher predictive accuracy of 79%, improved sensitivity from 57% to 85% than baseline alone and identified a threshold of CMR LVEF 63%-64% signaling LVEF < 60%. The variability of LVEF due to blood pressure dependence may require a longitudinal study that incorporates LVEF, LVESD, SRcirc at multiple time points to identify the threshold at which LVEF is at risk for decline to less than 60%.

Ring only repair of bileaflet mitral valve prolapse with mitral regurgitation: Insights from computational modeling

This study evaluates the efficacy of annuloplasty repair as a standalone procedure for treating bileaflet mitral valve prolapse with mitral regurgitation (MR). Various flexible ring bands for MR of different severities were compared to assess their biomechanical impact and treatment outcomes. Computational beating heart models, based on the Living Heart Human Model, were utilized to simulate annuloplasty repairs. Repairs using bands of varying lengths were modeled on moderate and severe MR cases, considering bileaflet mitral valve prolapse. Key parameters, including regurgitant orifice area (ROA), prolapse severity, coaptation length, leaflet position, and deformation, were computed to compare conditions before and after implantation. Annuloplasty repairs effectively reduced the ROA in both moderate and severe MR cases, achieving complete sealing in selective instances. Additionally, annuloplasty repair corrected bileaflet prolapse, with prolapse severity decreasing as the annular size increased. Successful coaptation was indicated by the expansion of each leaflet’s contact area distribution and percentage in contact with the opposing leaflet. The risk of systolic anterior motion, that may obstruct the left ventricular outflow tract, was minimized, as the anterior leaflet was directed towards the posterior position. In conclusion, annuloplasty repair alone can effectively treat MR when an appropriate band length is selected. It facilitates a significant reduction in ROA, correction of bileaflet prolapse, and improvement in leaflet coaptation. These findings have important clinical implications, potentially offering a less complex surgical treatment avenue and reducing complications in the management of MR.

The role of E-wave velocity in predicting early left ventricular dysfunction and significant decline in left ventricular ejection fraction after mitral valve repair for severe chronic primary mitral regurgitation.

Preoperative left ventricular (LV) ejection fraction (LVEF) and LV end-systolic dimension (LVESD) are established predictors of LV dysfunction (LVD) after mitral valve repair (MVr) for mitral regurgitation (MR). Although elevated estimated right ventricular systolic pressure (eRVSP) indicating pulmonary hypertension is the best proposed additional predictor, we hypothesized that transthoracic echocardiography (TTE) parameters more directly reflecting left atrial pressure (LAP) would more accurately predict LVD than eRVSP. Furthermore, predictors of a significant decline in LVEF remain unknown. We retrospectively studied 622 patients, aged 20-87years, who underwent MVr for severe chronic primary MR. As previously reported predictors of postoperative LVD, we collected seven preoperative TTE parameters, including LVESD, LVEF, eRVSP, LV end-diastolic dimension, left atrial volume index (LAVI), early transmitral annular (e') velocity, and atrial fibrillation. Furthermore, as LAP-related TTE parameters, we collected left atrial dimension, E-wave velocity, and E/e' ratio, in addition to eRVSP and LAVI. Using multivariate logistic regression and receiver operating characteristic curve analyses, we explored predictors of early postoperative LVD, defined as LVEF < 50% measured on postoperative day 7. We further explored predictors of a significant decline in LVEF, defined as an absolute decline in LVEF of > 12 percentage points, the third quintile of the data. Incidences of postoperative LVD and a significant LVEF decline were 12.9% and 23.2%, respectively. In addition to LVESD and LVEF, E-wave velocity, but not eRVSP, remained a significant predictor of postoperative LVD. E-wave velocity, LVESD, and LVEF had additive effects in risk prediction. Furthermore, E-wave velocity was the strongest predictor of a significant LVEF decline. E-wave velocities > 121.5cm/s and > 101.5cm/s were associated with increased risks of postoperative LVD (odds ratio [OR], 2.896; 95% confidence interval [95%CI], 1.792-4.681; p < 0.001) and a significant LVEF decline (OR, 6.345; 95%CI, 3.707-10.86; p < 0.001), respectively. After adjustment for multiple TTE parameters, E-wave velocity, but not eRVSP, remained significant predictors of postoperative LVD and a significant LVEF decline after MVr. These results were reproducible in 461 patients who underwent follow-up TTE at 1year, suggesting an important role of E-wave velocity in risk prediction.

'Color Doppler stripes’ make it difficult to diagnose the severity of valvular heart diseases: a report of two cases

BackgroundEchocardiography remains the reference-standard imaging technique for assessing valvular heart disease (VHD), but artifacts like the ‘color Doppler stripe’ can complicate diagnosis. This artifact is not widely recognized and can mimic severe VHD, leading to potential misdiagnoses. We present two cases where color Doppler stripes mimicked severe VHD, highlighting the need for awareness and accurate interpretation in echocardiographic assessments.Case presentationsCase 1: An 85-year-old patient was referred for mitral valve surgery due to suspected severe mitral regurgitation (MR). Upon evaluation, transthoracic echocardiography (TTE) showed mitral valve prolapse (P3) and a high-echoic, vibrating structure attached to the mitral valve, indicative of chordal rupture. Color Doppler echocardiography revealed strong systolic signals in the left atrium, mimicking severe MR. Transesophageal echocardiography (TEE) also detected the vibrating structure and color Doppler stripes in the left atrium, left ventricle, and outside the cardiac chambers. The PISA method on TEE indicated moderate MR and left ventriculography showed Sellers grade II MR. The artifact was identified as color Doppler stripes caused by the vibrating high-echoic structure from the ruptured chorda. Case 2: A 64-year-old patient with severe aortic stenosis, end-stage kidney disease requiring hemodialysis, and a history of coronary bypass grafting presented for routine follow-up. B-mode echocardiography showed a severely calcified tricuspid aortic valve with a vibrating calcified nodule and restricted opening, corresponding to severe aortic stenosis. During systole, color Doppler signals were observed around the aortic, pulmonary, and tricuspid valves, mimicking significant pulmonary stenosis and tricuspid regurgitation. However, pulmonary stenosis was ruled out as the pulmonary valve opening was normal. Mild tricuspid regurgitation was confirmed in the apical view.ConclusionsThese cases highlight the diagnostic challenges posed by color Doppler stripes. Recognizing and understanding this artifact are crucial for the accurate diagnosis and management of VHD, ensuring appropriate treatment and patient outcomes.

8238 Thyroidectomy for Thyroid Storm Complicated by Drug-Induced Hepatotoxicity and Thyrotoxic Cardiopulmonary Disease

Abstract Disclosure: T.A. John: None. A.C. Suarez: None. J. Genkil: None. S. Patil: None. C. Anastasopoulou: None. Case Presentation: A 59-year-old female with hypertension and type 2 diabetes presented with palpitations, and several months of hyperthyroid symptoms, lower extremity swelling, and dyspnea on exertion. On presentation, patient was diaphoretic, tachycardic, volume overloaded and had symmetric swelling of the thyroid gland. Lab results revealed FT4 3.28 ng/dL, total T3 384.59 ng/dL, TSH &amp;lt; 0.01 µIU/mland elevated TSI. Electrocardiogram showed sinus tachycardia. Chest radiography showed pulmonary edema. Echocardiography showed a reduced ejection fraction of 35%, dilation of right ventricle, severe mitral and tricuspid regurgitation, and severely elevated pulmonary artery systolic pressure (55-60 mm Hg). Thyroid ultrasound revealed enlarged, heterogeneous thyroid gland with normal vascularity. The diagnosis of thyroid storm due to Graves' disease was made with a score of 50 on the Burch-Wartofsky Point Scale. Patient was started on propylthiouracil (PTU), metoprolol tartrate and furosemide. Corticosteroid therapy was not utilized due to the risk of worsening heart failure from sodium retention. After two days of PTU, patient developed drug induced liver injury (DILI). Patient was then transitioned to methimazole which was also discontinued thereafter due to progression of DILI. She was started on potassium iodide to suppress thyroid hormone production, and N-Acetyl cysteine (NAC) for DILI. Due to persistent thyrotoxicosis, the patient underwent a total thyroidectomy on hospital day 13 and was started on levothyroxine for post-surgical hypothyroidism. Liver function returned to normal on day 16. A surveillance echocardiogram obtained 3 months later showed recovered biventricular function (ejection fraction 55-60%), mild mitral and tricuspid regurgitation and normal pulmonary pressures. Educational value: Thyroid storm is an uncommon, life-threatening emergency. Thioamides remain the cornerstone of treatment, but rarely, they can result in adverse events such as hepatotoxicity. When thioamides are contraindicated, other agents (e.g., iodine, lithium, potassium perchlorate, cholestyramine, glucocorticoids) can be utilized; however, refractory cases might require total thyroidectomy as definitive treatments. Our patient had marked recovery of cardiac function and resolution of pulmonary hypertension and DILI after timely surgical intervention. Multidisciplinary care is pivotal for the successful management of thyroid storm. Presentation: 6/3/2024

Clinical impacts of concomitant left atrial appendage occlusion during mitral valve surgery in patients with mitral regurgitation

Surgical occlusion of the left atrial appendage (LAA) during cardiac surgery in patients with atrial fibrillation (AF) is known to reduce thromboembolism. However, data on the clinical significance of LAA occlusion (LAAO) in patients with mitral regurgitation (MR) are lacking. A total of 237 AF patients with chronic severe MR who underwent mitral valve (MV) surgery were retrospectively analyzed. Patients were divided into two groups according to concomitant LAAO or LAA preservation. The primary outcome was a composite of all-cause death and thromboembolic events (ischemic stroke or systemic embolism). The LAA was surgically occluded in 98 (41%) patients and preserved in 139 (59%) patients. During the follow-up period (median, 37 months), 29 primary outcomes occurred. In the Kaplan–Meyer analysis, the LAA preservation group showed a greater cumulative incidence of the primary outcome (P = 0.002) and thromboembolic events (P = 0.003) than the LAAO group. In the univariate Cox regression analysis, coronary artery disease, CHA2DS2-VASc score, a cauliflower-shaped LAA, Maze, and no LAAO were significantly associated with the primary outcome. In the multivariate Cox regression analysis, concomitant LAAO was significantly linked to the primary outcome (hazard ratio [HR]: 0.30, 95% confidence interval [CI]: 0.10–0.91, P = 0.033) and thromboembolic events (HR: 0.19, 95% CI: 0.04–0.87, P = 0.032). These benefits from LAAO were consistent, even after propensity score–matched analysis. For patients undergoing surgery for chronic MR who also have AF, concomitant surgical LAAO is associated with favorable clinical outcome.

Effects of Mitral Calcification in Severe Aortic Stenosis with Severe Mitral Regurgitation on Left Heart Remodeling, Surgical Strategy, and Outcomes

To localize and quantify mitral calcification associated with severe aortic stenosis and severe mitral regurgitation and determine its association with cardiac remodeling, operative management, and long-term survival. From July 1998 to July 2010, 158 patients with severe aortic stenosis, severe mitral regurgitation, and mitral calcification underwent surgical aortic valve replacement (SAVR, n=49) or SAVR plus mitral valve repair (SAVR+MVr, n=67) or replacement (SAVR+MVR, n=42). Mitral calcium was localized and quantified on preoperative computed tomography. Random forest methodology was used to correlate calcium volume with cardiac morphology and function. Median follow-up for survival was 4.1 years; 25% were followed ≥14 years. Larger calcium volume was associated with degenerative mitral disease, higher ejection fraction, smaller left ventricular end-systolic volume, and SAVR+MVR (median calcium volume 3.4 cm3) versus SAVR (median calcium volume 1.0 cm3) or SAVR+MVr (median calcium volume 0.41 cm3). Ten-year mortality was higher in patients with more mitral calcification (terciles: 7.1% vs 16% vs 25%), subvalvular involvement (8.1% vs 18%), and SAVR+MVR (5.4% vs SAVR=13% vs SAVR+MVr=26%). Multivariable analysis demonstrated early postoperative mortality was strongly associated with subvalvular mitral calcification, but late mortality was not associated with calcium volume or location. Larger mitral calcium volume is a marker of late-stage cardiac remodeling associated with more extensive mitral valve intervention, but it is not associated with long-term mortality. Quantitative analysis of mitral calcification with computed tomography can aid in patient selection and surgical management decisions in this complex patient population.

Secondary mitral regurgitation surgical management: a narrative review.

The most common valvular heart disease in the US is moderate to severe mitral regurgitation (MR). Function MR or secondary MR comprises many of these cases. Moderate and severe secondary MR are independently associated with increased all-cause mortality and rehospitalization for heart failure. Both ischemic and nonischemic cardiomyopathy can cause secondary MR via similar pathophysiology that leads to inadequate valve leaflets coaptation. The management of secondary MR is complex. The optimal treatment strategy for secondary MR remains controversial, reflected in the vast array of treatment options and the complexity of therapeutic decision-making. Several surgical mitral valve repair techniques have been described in the literature. Many of these aims to facilitate adequate valve leaflet coaptation. In this review, the pathophysiology of MR is described with a focus on evaluating and managing secondary MR. A literature review was performed using PubMed and Google Scholar. Clinical trials, meta-analyses, randomized controlled trials, reviews, and systematic reviews were considered from January 1, 1995 through December 31, 2022. Articles published in languages other than English with limited text availability were excluded. Optimal therapeutic approach in severe secondary MR is complex and several patient factor should be considered. We provide a framework for the surgical management of secondary MR based on echocardiographic parameters, the presence of ischemia, and myocardial viability. Further study is needed to guide the selection of patients most likely to benefit from mitral valve repair or replacement in the setting of secondary MR.

Findings from transoesophageal echocardiographic follow-up after mitral transcatheter edge-to-edge repair.

Transoesophageal echocardiography (TOE) provides accurate evaluation of mitral valve (MV) function following mitral transcatheter edge-to-edge repair (M-TEER) and may better detect complications in case of suboptimal result. We aimed to evaluate midterm anatomical changes and structural complications after M-TEER using TOE and investigate their association with clinical outcomes at 2 years. A follow-up TOE at 6 months was systematically recommended to all patients included in our institutional prospective M-TEER registry until December 2021. We assessed changes in the incidence of mitral regurgitation (MR), MV stenosis (≥5 mmHg), and partial or complete single leaflet device attachment (SLDA) between the index procedure and follow-up and evaluated MV area and annular dimensions in a subset of patients with available three-dimensional (3D) datasets. The clinical endpoint was a composite of mortality and heart failure (HF) rehospitalisation at 2 years. Among the 373 patients included in the registry between February 2012 and December 2021, 128 patients (34%) underwent elective TOE at 6 months. Using TOE, severe MR was observed in 13.3% (n=17) of the patients. The number of patients with an elevated MV gradient increased from 17 (13.3%) after the procedure to 23 (18%) at 6 months, and a new partial or complete SLDA was detected in 7.8% (n=10). Based on 3D TOE measurements, significant increases in MV area, annular area, annular perimeter, and intercommissural (but not anteroposterior) diameter were observed compared to intraprocedural images. A mean MV gradient ≥5 mmHg (hazard ratio [HR] 2.30, 95% confidence interval [CI]: 1.10-4.81; p=0.023) and the presence of severe MR at 6 months (HR 3.26, 95% CI: 1.18-8.99; p=0.023) were associated with the primary endpoint, which was met in 34 (26.6%) patients at 2 years. TOE follow-up allowed the detection of complications that would not be diagnosed using transthoracic echocardiography only and should therefore be used liberally in the patients presenting with a suboptimal result. A mean MV gradient ≥5 mmHg and severe MR, diagnosed at the 6-month TOE follow-up, were associated with adverse clinical outcomes.

Interstitial Fibrosis and Arrhythmic Mitral Valve Prolapse: Unravelling Sex-Based Differences

Interstitial fibrosis as quantified by cardiac magnetic resonance (CMR) has been demonstrated in arrhythmic mitral valve prolapse (AMVP), a condition with known female predominance. Prior studies of interstitial fibrosis in AMVP have only included cases with significant mitral regurgitation (MR) or mitral annular disjunction (MAD), limiting our understanding of alternative arrhythmic mechanisms in MVP. We sought to evaluate the association between interstitial fibrosis and AMVP, regardless of MAD and without severe MR, while also investigating the contribution of sex to this association. We performed research-based contrast CMR in consecutive individuals with MVP between 2019 and 2022. Extracellular volume fraction (ECV%), a surrogate marker for interstitial fibrosis, was quantified using T1 mapping in the basal and mid-LV slices. Replacement fibrosis was assessed using late gadolinium enhancement (LGE). AMVP was defined as MVP with frequent premature ventricular contractions and/or non-sustained/sustained ventricular tachycardia (VT) or fibrillation (VF). We identified 65 MVP cases without severe MR (46% women, 34% no/trace, 44% mild, and 21% moderate MR) and with adequate ECV% measurement. Among these, 38% were classified as AMVP, including two cases of aborted VF arrest, both in premenopausal females. Global ECV% was significantly higher in AMVP versus non-AMVP (31%[27-33] vs 27%[23-30], p=0.002). In the AMVP group, higher segmental ECV% was not limited to the inferolateral/inferior walls, typically subject to myocardial traction by the prolapsing leaflets/MAD but was more diffuse and involved atypical segments such as the anterior/anterolateral walls (p<0.05). The association between AMVP and global ECV% was driven by female sex (32%[30-34] vs 27%[25-30], p=0.002 in females; 28%[23-32] vs 26%[23-30], p=0.41 in males). ECV% remained independently associated with an increased risk of arrhythmic events, including VT/VF (p<0.01), even after adjustment for cardiovascular risk factors, MAD, and LGE (p<0.01). In MVP without significant MR, interstitial fibrosis by CMR is associated with an increased risk of arrhythmic events, suggesting a primary myopathic process. The selective association between interstitial fibrosis and AMVP in females may explain why severe arrhythmic complications are more prevalent among women.

Mitral-specific cardiac damage score (m-CDS) predicts risk of death in functional mitral regurgitation: a study from the National Echo Database of Australia

AimsWe set out to explore associations between a ‘mitral-specific’ cardiac damage score (m-CDS) and survival outcomes in mitral regurgitation (MR) and compare the performance of the m-CDS and an ‘aortic-specific’...

Usefulness of intraoperative color three-dimensional transesophageal echocardiography for detecting treatable residual mitral regurgitation immediately after mitral valve repair

BackgroundResidual mitral regurgitation (MR) immediately after mitral valve (MV) repair is a risk factor for late reintervention. This study aimed to determine the feasibility of color 3-dimensional intraoperative transesophageal echocardiography (3D-IOTEE) for clarifying the mechanism of residual MR and its impact on the conversion rate to MV replacement (MVR). MethodsAmong 767 patients who underwent MV repair at our institute, 92 consecutive patients in whom an immediate second cardiopulmonary bypass (CPB) was performed due to MV repair for residual MR were evaluated. The patients were divided into the re-repair group [i.e. those in whom repair required additional procedures, n = 77 (83.7 %)] and the MVR group [i.e. patients who underwent MVR alone, n = 15 (16.3 %)]. All patients underwent 3D-IOTEE to evaluate the mechanisms of residual MR. The pathomechanisms were classified into the following five categories: Category 1, inter-scallop malcoaptation; Category 2, suture dehiscence; Category 3, prolapse; Category 4, systolic anterior motion of the MV; and Category 5, tethering. Clinical background and outcomes were compared between the two groups based on the five categories. ResultsThe rate of MVR conversion by etiology of residual MR after the first MV repair was 68.8 % (n = 11/16) in Category 1; 0 % (n = 0/22) in Category 2; 2.4 % (n = 1/41) in Category 3; 20 % (n = 2/10) in Category 4; and 33.3 % (n = 1/3) in Category 5. Among the 63 patients with Category 2 and 3 etiologies, 62 patients had complete MV re-repair with additional procedures [Category 2, 100 % (n = 22/22); Category 3, 97.6 % (n = 40/41)]. Meanwhile, MVR was performed owing to difficulty in MV repair after the second CPB in 11/16 patients (68.8 %) with Category 1 etiology. ConclusionsIn the assessment of MR, 3D-IOTEE is useful for lesion localization and determining the origin and severity of MR, which are key factors in selecting the optimal surgical approach in patients undergoing re-repair.

TCT-945 AltaValve System TMVR for the Treatment of Patients With Severe Mitral Regurgitation and Mitral Annular Calcification

TCT-945 AltaValve System TMVR for the Treatment of Patients With Severe Mitral Regurgitation and Mitral Annular Calcification