Severe MR Research Articles

Abstract 4129273: Severe Mitral Regurgitation from Impella-associated Mitral Chordae Rupture with Successful Transcatheter Edge-to-edge Repair

Background: Limited data exists describing Impella-related mechanical mitral valve complications. Diagnosis and management can be challenging due to potential underestimation of mitral regurgitation severity from Impella and acute clinical deterioration upon removal. We present a case of successful mitral transcatheter edge-to-edge repair (TEER) for acute severe MR secondary to Impella-related mitral chordae rupture resulting in acute pulmonary edema post-Impella removal. Case Summary: A 37-year-old male smoker presented with chest pain complicated by cardiac arrest due to ventricular fibrillation. Spontaneous circulation could not be restored, requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Coronary angiography revealed total occlusion of the proximal left anterior descending artery, which was successfully stented. Transfemoral Impella CP was placed for left ventricular venting under fluoroscopy (Panel A) with TTE showing no complications. In the intensive care unit, the Impella was advanced under TTE guidance; its tip was found to be positioned deep at the base of the posteromedial pupillary muscle without suction alarms or ventricular arrhythmias on the following day (Panel B). Several days later, TTE revealed new eccentric MR with hyperdynamic left ventricular motion (Panel C). The patient remained hemodynamically stable after VA-ECMO decannulation with Impella at P4. Following Impella removal, he developed repeated flash pulmonary edema despite aggressive fluid removal attributed to acute severe MR secondary to a flail P3 leaflet with ruptured chordae tendineae confirmed by transesophageal echocardiography (Panel D). Given the patient's poor surgical candidacy with a STS score of 13.2%, the team proceeded with mitral TEER, successfully reducing MR severity from severe to mild with a single NT Mitraclip ® across the medial commissure (Panel E). His post-operative cardiac course was uneventful without recurrence of pulmonary edema. Discussion: Irreversible mechanical damage to the mitral valve apparatus caused by Impella placement and repositioning is a rare, potentially fatal complication requiring emergent intervention. Mitral TEER can be a viable salvage option for poor surgical candidates.

Prevalence of multiple native valvular heart disease in TAVR patients: a multicenter study assessing the impact of staged transcatheter edge-to-edge repair

Abstract Background Multiple valvular heart disease (VHD) is associated with poor prognosis in patients undergoing TAVR. Existing research focuses either on mitral or tricuspid regurgitation (MR, TR), without providing comparative analysis of their long-term effects. Moreover, whether staged transcatheter edge-to-edge repair (TEER) improves outcomes in these patients is unknown. Purpose This multicenter study aimed to evaluate the prevalence of multiple VHD within a recent TAVR cohort and to assess and compare the impact of concomitant severe MR and TR on outcomes at both one and five years post-TAVR. Additionally, we aimed to examine the potential impact of staged TEER for severe VHD in patients treated with TAVR. Methods The study cohort consisted of 2,823 patients undergoing TAVR at our Heart Center between 2015 and 2022. This representative cohort was used to investigate the prevalence of multiple VHD in a contemporary TAVR population and to assess and compare the impact of severe MR and TR on outcomes following TAVR. Additionally, this cohort, along with TAVR cohorts from other Heart Centers, was screened for additional valvular intervention. Patients who underwent staged transcatheter edge-to-edge repair for severe MR (n=147) or TR (n=59) were included. Results A concomitant persistent severe VHD was observed in 369 (13.1%) patients, with 208 (7.4%) having a severe MR, and 161 (5.7%) having a severe TR. The one-year mortality was significantly higher in patients with a severe VHD compared to the overall cohort (9.0 vs 5.2 per 100 PY, p<0.01). Notably, the highest one-year mortality was observed in patients with severe TR (13.3 per 100 PY) followed by patients with severe MR (6.4 per 100 PY) and those with no or a mild VHD (3.9 per 100 PY, p<0.01). This difference persisted over five years, with mortality rates of 27.8 per 100 PY in TR patients compared to 16.7 and 10.6 per 100 PY in MR patients and those with no or a mild VHD (p<0.01), Figure 1A. The landmark analysis revealed lower one-year mortality in patients who underwent staged TEER compared to those with severe VHD (4.1 vs 12.1 per 100 PY, p<0.001). This trend continued at the five-year follow-up, with a mortality rate of 11.6 per 100 PY in the staged TEER group versus 25.8 per 100 PY in the group with severe VHD (p<0.001), Figure 1B. The multivariate analyses revealed that concomitant severe TR was independently associated with one-year mortality (HR: 1.75 [95% CI: 1.14 – 2.67], p<0.01). Conclusion A concomitant clinically significant VHD was prevalent among patients with AS undergoing TAVR. The persistence of severe VHD was associated with increased one- and five-year mortality following TAVR. Specifically, severe TR was associated with higher mortality rates compared to severe MR. The potential benefit of an additional staged TEER for concomitant VHD should be carefully considered, as it shows promise in improving outcomes for patients with persistent severe VHD after TAVR.

Impact of left atrial size on outcomes in patients with atrial functional mitral regurgitation

Abstract Background Atrial functional mitral regurgitation (AFMR) is caused by mitral annular enlargement following left atrium (LA) enlargement because of atrial fibrillation and/or heart failure with preserved ejection fraction. However, the distribution and clinical impact of LA size are unknown. Purpose To assess the impact of LA volume index (LAVI) on clinical outcomes in patients with AFMR. Methods We investigated patients with ≥moderate AFMR from the REVEAL-AFMR registry. Patients with ≥moderate aortic valve diseases and/or missing LAVI were excluded. The primary endpoint was a composite of cardiovascular death and heart failure hospitalization. Results Of total 871 patients with AFMR (age 78 ± 9 years, men 45%, atrial fibrillation 80%, severe MR 28%), median LAVI was 75 [58-110] mL/m². LAVI <50, 50-99, 100-149, 150-199 and ≥200 mL/m² were present in 117 (13%), 48 (55%), 162 (19%), 61 (7%) and 48 (6%), respectively. In these subgroups, severe MR was present in 10%, 20%, 38%, 61%, and 69% (Figure A), and NYHA III or IV in 8%, 8%, 13%, 13% and 23%, respectively. During the median follow up of 2.9 [2.0-3.2] years, LAVI ≥200 and 150-199 mL/m² were associated with lower event-free survival compared with <50 mL/m² (Figure B) . In the multivariable analysis, LAVI ≥150 mL/m² was an independent risk factor of adverse events (adjusted hazard ratio [HR] 1.69; 95% CI 1.05-2.73, p=0.030), adjusted for age, sex, body mass index, severe symptoms, chronic kidney disease, anemia, severe MR and tricuspid regurgitation (TR). Variables associated with LAVI ≥150 mL/m² were atrial fibrillation (adjusted OR 5.95; 95% CI 1.79-19.8, p<0.01), severe MR (OR 3.99; 95% 2.49-6.39, p<0.01) , elevated PASP (OR 3.10; 95% 1.80-5.33, p<0.01) and TR (OR; 2.46 95% 1.43-4.21, p<0.01), left ventricular end-diastolic volume (adjusted OR 1.26 per 10mL; 95% 1.17-1.36, p<0.01). Conclusion LAVI was 50-99 mL/m² in nearly a half of patients with AFMR, but enlarged to ≥150 mL/m² in 13%. Patients with larger LAVI more frequently had severe symptoms. LAVI ≥150 mL/m² was associated with worse outcomes, independent of MR severity. Severe MR and left ventricular size were strongly associated with LA enlargement other than atrial fibrillation.Figure AFigure B

Clinical outcomes and impact of mitral valve surgery in atrial functional mitral regurgitation: the REVEAL-AFMR registry

Abstract Background The real-world impact and effective treatment strategies of atrial functional mitral regurgitation (AFMR) are poorly understood. The aim of this study was to investigate the prevalence, clinical characteristics, and the effectiveness of mitral valve surgery in AFMR. Methods The REal-world obserVational study for invEstigAting the prevaLence and therapeutic options for Atrial Functional Mitral Regurgitation (REVEAL-AFMR) was a retrospective cohort study conducted across 26 Japanese centers. All transthoracic echocardiography performed in 2019 were reviewed and patients with moderate or severe AFMR defined by preserved left ventricular function, dilated left atrium, and absence of degenerative valvular changes. The primary composite outcomes were heart failure hospitalization and all-cause mortality. Besides traditional multivariable regression analysis, propensity score-based time-zero matching was performed to account for immortal time bias. Results In 177,235 patients who underwent echocardiography, 8,867 had moderate or severe MR. Within this group, 1,007 were diagnosed with AFMR (mean age 78±10, 56% female, 80% atrial fibrillation). Of these, 113 underwent MV surgery, with 81% receiving concurrent tricuspid valve surgery. Patients who underwent surgery were younger but had more severe MR, larger left heart chambers, and a higher prevalence of heart failure than those who remained under medical therapy. During a median follow-up of 1050 days, 28% experienced the primary outcome, and 18% died. Despite a more severe disease status, only the surgical group showed a decrease in natriuretic peptide levels at follow-up and had significantly lower rate of the primary outcome (hazard ratio 0.43 [0.29-0.64], p<0.001 after adjustment for 25 covariates). Propensity score-based time-zero matching also indicated a lower risk of the primary outcome in the surgical group (hazard ratio 0.39 [0.20–0.78], p=0.007). Multiple sensitivity analyses yielded consistent results. Subgroup analysis suggested a significantly greater benefit of surgery for patients with severe MR than those with non-severe MR (p for interaction=0.044). Conclusions Our registry revealed that patients with AFMR are typically old with predominantly with atrial fibrillation, facing poor outcomes. MV surgery was associated with fewer adverse events, a finding that should be validated in future clinical trials.

Tricuspid regurgitation in the context of severe concomitant left-sided valvular heart disease: patients characteristics and long-term clinical and interventional outcomes

Abstract Background The clinical features, therapeutical management and outcome of patients with significant tricuspid regurgitation (TR) in the context of multiple valvular disease (VD) are poorly defined. Purpose To assess the characteristics, management and long-term prognosis of a large cohort of patients with multiple VD, focusing on the context of significant TR and concomitant severe mitral or aortic disease. Methods Clinical and echocardiographic data were collected in 1183 patients with ≥moderate TR diagnosed at our centers from January 2012 to June 2020: after propensity score matching for age to create matched cohort with < 10% of absolute difference, 975 patients were included in this study and divided in 4 groups as shown in Figure 1. Primary endpoint was all-cause death (ACD), secondary endpoint was the composite of heart failure (HF) hospitalization+any valvular intervention. Results Patients with isolated TR (356, 37%) had more history of atrial fibrillation and were more often asymptomatic and with preserved left-ventricular ejection fraction (LVEF). TR+ severe MR patients (466, 48%) showed higher rates of concomitant coronary artery disease, NYHA class III/IV symptoms and larger left atrial volumes. The group of TR+ severe AS (131 patients, 13%) was characterized by older age, more comorbidities and lower LVEF. Patients with TR and severe AR (22, 2%) were younger, with larger LV dimensions and higher pulmonary pressures. Overall, in 37(4%) patients tricuspid intervention was performed: no differences were found between groups in term of frequency of concomitant or staged tricuspid valve surgical treatment (p=0.444 and p= 0.624, respectively), while left-valve only surgical treatment was more common among patients with TR and severe MR and left-valve transcatheter treatment among patients with TR and severe AS (both p<0.001). After a median follow-up of 2.8 years, the primary endpoint occured in 374 (38%) of patients, and was significantly more frequent in the group of patients with TR and severe AS (p<0.001, Figure 2). In this group, after multivariate analysis, indexed stroke volume remained independenty associated with ACD (OR 0.96, CI 0.93-0.98, p =0.040). Eventually, the secondary endpoint too was more common in patients with TR and severe AS (p<0.001, Figure 2). Conclusions In the context of significant TR, concomitant severe left-sided VD is common, and each subtype presents with different clinical features and echocardiographic phenotypes; in this scenario, TR was profoundly underteated. Long-term, patients with significant TR+ severe AS have considerable worse prognosis.Figure 1Figure 2

FACTORS ASSOCIATED WITH DEVELOPMENT OF SEVERE MR IN PATIENTS WITH HF

FACTORS ASSOCIATED WITH DEVELOPMENT OF SEVERE MR IN PATIENTS WITH HF

Clinical outcomes among patients with mitral valve regurgitation undergoing Impella-supported high-risk PCI

BackgroundMitral valve regurgitation (MR) is associated with worse outcomes in patients undergoing percutaneous coronary intervention (PCI). We sought to evaluate outcomes of Impella-supported high-risk PCI (HRPCI) patients according to MR severity. MethodsPatients from the PROTECT III study undergoing Impella-supported HRPCI were stratified into 4 groups according to MR severity: No or trace MR, mild MR, moderate MR, and severe MR. Immediate PCI-related complications, major adverse cardiovascular and cerebrovascular events (MACCE: all-cause death, myocardial infarction, stroke/transient ischemic attack, and repeat revascularization) at 90 days and death at 1-year were assessed. ResultsFrom March 2017 to March 2020, 631 patients who underwent Impella-supported HRPCI in the PROTECT III study had evaluable MR severity at baseline. Patients with severe MR had lower body mass indices, lower left ventricular ejection fractions (LVEFs), and were more frequently diagnosed with heart failure. The incidence of immediate PCI-related complications was similar between groups. Unadjusted 90-day MACCE and 1-year mortality rates were numerically higher in patients with severe MR compared to the other study groups yet without reaching statistical significance. In multivariable analyses, there was no significant association between the presence of severe MR for 90-day MACCE or 1-year mortality compared with other degrees of MR (adj. HR = 1.71, 95% CI [0.73, 3.98], p = 0.21; adj. HR = 1.79, 95% CI [0.86, 3.74], p = 0.12, respectively). ConclusionsImpella-supported HRPCI patients with moderate or severe MR exhibited a higher prevalence of heart failure, lower LVEF, and longer hospital stays. Patients with severe MR showed numerically higher unadjusted rates of 90-day MACCE and 1-year mortality compared to other groups, however these differences did not reach statistical significance even after adjustment for potential confounders. Clinical trial informationTrial Name: The Global cVAD Study (cVAD)ClinicalTrial.govIdentifier:NCT04136392URL: https://clinicaltrials.gov/ct2/show/NCT04136392?term=cvad&draw=2&rank=2

Clinical Outcomes of Mitral Valve Surgery in Atrial Functional Mitral Regurgitation in the REVEAL-AFMR Registry

The characteristics and treatment strategies of atrial functional mitral regurgitation (AFMR) are poorly understood. To investigate the prevalence, clinical characteristics, and outcomes of mitral valve (MV) surgery in AFMR. This retrospective cohort study, called the Real-World Observational Study for Investigating the Prevalence and Therapeutic Options for Atrial Functional Mitral Regurgitation (REVEAL-AFMR), was conducted across 26 Japanese centers (17 university hospitals, 1 national center, 3 public hospitals, and 5 private hospitals). All transthoracic echocardiography procedures performed from January 1 to December 31, 2019, were reviewed to enroll adult patients (aged ≥20 years) with moderate or severe AFMR, defined by preserved left ventricular function, a dilated left atrium, and an absence of degenerative valvular changes. Data were analyzed from May 8, 2023, to May 16, 2024. Mitral valve surgery, with or without tricuspid valve intervention. The primary composite outcome included heart failure hospitalization and all-cause mortality. In 177 235 patients who underwent echocardiography, 8867 had moderate or severe MR. Within this group, 1007 (11.4%) were diagnosed with AFMR (mean [SD] age, 77.8 [9.5] years; 55.7% female), of whom 807 (80.1%) had atrial fibrillation. Of these patients, 113 underwent MV surgery, with 92 (81.4%) receiving concurrent tricuspid valve surgery. Patients who underwent surgery were younger but had more severe MR (57.5% [n = 65] vs 9.4% [n = 84]; P < .001), a larger mean (SD) left atrial volume index (152.5 [97.8] mL/m2 vs 87.7 [53.1] mL/m2; P < .001), and a higher prevalence of heart failure (according to the New York Heart Association class III [marked limitation of physical activity] or class IV [symptoms of heart failure at rest], 26.5% [n = 30] vs 9.3% [n = 83]; P < .001) than those who remained under medical therapy. During a median follow-up of 1050 days (IQR, 741-1188 days), 286 patients (28.4%) experienced the primary outcome. Despite a more severe disease status, only the surgical group showed a decrease in natriuretic peptide levels at follow-up and had a significantly lower rate of the primary outcome (3-year event rates were 18.3% vs 33.3%; log-rank, P = .03). Statistical adjustments did not alter these findings. The findings of this cohort study suggest that in patients with AFMR, who were typically older and predominantly had atrial fibrillation, MV surgery was associated with lower rates of adverse clinical outcomes. Future studies are warranted to investigate a possible causal relationship to better regulate cardiovascular medicine.

Unsupervised machine learning defines subgroups in ischemic heart disease patients presenting with ventricular tachycardia

Abstract Background Ventricular tachycardia (VT) in ischemic heart disease (IHD) is the leading cause of sudden cardiac death (SCD). Despite the well-defined recommendations, tailoring therapies individually is often a challenge owing to the great heterogeneity in this population. We hypothesized that unsupervised machine learning can uncover hidden patterns to identify patient subgroups with similar characteristics. Aims To use unsupervised machine learning methods on a database of patients with ischemic VT, to discover subgroups with similar characteristics and compare the survival of the identified groups. Methods We collected the data of 566 patients with IHD hospitalized for sustained monomorphic VT, excluding those with acute coronary syndrome. The 17 recorded features included medical history and echocardiography. All-cause mortality was registered with one-year follow-up. We performed dimension reduction using T-distributed Stochastic Neighbor Embedding (TSNE) to produce 3 dimensions of the data. Then, we applied spectral clustering to create three groups within the population. Each group was compared to the rest of the population for each variable. Finally, we compared the survival across the three groups using Kaplan-Meyer analysis, univariate Cox-regression, and Log-rank test. Results We identified three groups with distinct characteristics. Group 1 represented the healthiest population; patients had no previous VT hospitalizations, and none of HD instability, LBBB, SCD, diabetes, VT storm or ICD shocks; additionally, they always had a single VT episode at presentation. They showed better left ventricular ejection fraction (LVEF) (38% vs. 33%, p&amp;lt;0.001) and TAPSE (20 mm vs. 18 mm, p=0.01), less severe mitral and tricuspid regurgitation (MR, TR), smaller left ventricular end-systolic diameter, and longer DT. Conversely, patients in Group 2 (n=349) had more previous VT hospitalizations (30% vs. 18%, p=0,003), more often had diabetes (46% vs. 18%, p&amp;lt;0.001), left bundle branch block (23% vs. 13%, p=0.006), and more often presented with HD instability (47% vs. 28%, p&amp;lt;0.001). Group 3 contained all seriously ill patients with VT storm or incessant VT, more commonly presenting with ICD shocks (34% vs. 21%, p=0.004), SCD (24% vs. 15%, p=0.004), hemodynamic instability (50% vs. 37%, p=0.01). This group had the poorest LVEF (30% vs. 35%, &amp;lt;0.001) and TAPSE (17 mm vs. 19 mm p=0.001), more severe MR and TR, and the shortest DT (140 ms vs. 173 ms p&amp;lt;0.001). Finally, we compared survival across the three groups. Significantly better survival was found in Group 1 (HR: 0.52 CI [0.28 - 0.98]) and Group 2 (HR: 0.61 CI [0.42 - 0.88]), while Group 3 had higher mortality (HR: 2.7 CI [1.83 - 3.97]). Conclusions Using spectral clustering we identified three groups in our cohort of ischemic VT patients. This method delineates the group of ischemic VT patients with the highest risk of mortality who might need more aggressive treatment and closer follow-up.

HCM AT THE CROSSROAD

Abstract Introduction Treatment of oHCM frequently requires difficult choices, especially when it is superimposed on other urgent clinical conditions,such as AMI or mechanical complications. Clinical Case A 52–year–old man with known oHCM, who spontaneously quickly discontinued recommended therapy, presents to theED with a sudden episode of dyspnea and presyncope. A firstECG was essentially normal for pathology. After 1h, the patient experiences a sudden episode of chest pain with rapid hemodynamic deterioration and cardiogenic shock(CS). The ECG shows changes compatible with inferolateral MI. The TTE shows severe LVOTO, SAM, severe MR and a suspicious oval image attached to the anterior mitral leaflet. The patient underwent orotracheal intubation, coronary angiography and TEE. Coronary angiography shows a thrombotic occlusion of the proximal circumflex artery, treated with pPCI. TEE confirms a partial rupture of the papillary muscle head. Treatment:The patient‘s CS can be caused by 2different conditions that require treatments with opposing pathophysiological principles. SevereMR due to papillary muscle rupture, as mechanical complication of MI, requires afterload reduction, hemodynamic stabilization with IABP and emergency transfer to a cardiac surgery center. In contrast, the treatment of the underlying pathology(severe LVOTO and severe rMR due to SAM)requires pharmacological stabilization with depression of cardiac contractility and increase in afterload. In the context of cardiogenic shock a rapid choice was required. To help us make the right choice, an Esmolol test was performed. After iv administration of 2mg Esmolol, heart rate was reduced without reduction in BP. The patient was then treated with esmolol in continuous infusion and norepinephrine. In oHCM the ventriculo–arterial coupling is reduced, less than 1. This treatment favored better V–A coupling, ensuring an increase in afterload and a reduction in myocardial contractility. The patient‘s clinical condition rapidly improved, allowing extubation at48h and early mobilization at96h. Myectomy and mitral repair surgery was scheduled 1 month afterPCI. Conclusions Through the use of a short–lived drug such as Esmolol, it was possible to trace the prevailing mechanism of the patient‘s CS. Differently from other cases of CS, to rebalance the V–Acoupling, it was crucial to reduce myocardial contractility and increase afterload. A pathophysiological pharmacological approach ensured a good outcome.

Thrombin generation, fibrin clot permeation and lysis in patients with severe mitral regurgitation undergoing transcatheter edge-to-edge mitral valve repair: Mitral Fibrin Study.

Intricate management of heart failure (HF), especially in the context of reduced ejection fraction, is further complicated by an elevated risk of thromboembolic events. Studies published so far offer inconclusive insight into the interplay between mitral regurgitation (MR) and the coagulation system. This study aimed to investigate the impact of transcatheter edge‑to‑edge repair (TEER) on specific coagulation parameters in HF patients. A cohort of 31 HF patients with severe MR treated with TEER underwent a systematic evaluation at 3 visits (V1, V2, and V3). Coagulation parameters, including fibrinogen concentration, thrombin generation, fibrin clot permeability, and clot lysis time (CLT) were assessed (n = 27 at V2; n = 25 at V3). TEER induced changes in fibrinogen levels (P = 0.01; V3 vs V2) and improved fibrin clot properties over 50‑day follow‑up (P = 0.01; V3 vs V2). No significant differences were observed between time points in the analyzed blood clot parameters. Correlation analysis showed that baseline CLT was associated with ΔN‑terminal pro-B‑type natriuretic peptide (NT‑proBNP) level (P = 0.049; r = 0.4). Multivariable analysis identified baseline CLT as an independent predictor of early post‑TEER NT‑proBNP change (R2 = 0.55; P = 0.02). We found decreased level of fibrinogen and increased permeation coefficient over a median 50 (interquartile range, 32.5-75.5)-day post‑TEER follow‑up, as compared with early postprocedural assessments. Other blood coagulation parameters remained unchanged from baseline at both follow‑up time points after TEER. Finally, CLT was an independent predictor of early NT‑proBNP increase, emphasizing its role as an indicator of hemodynamic response to TEER.

Case Report: Post-operative mitral valve replacement complicating with a large cardiac mass and role of TEE in decision making

Background Postoperative complications are an integral part of valve surgery. Common complications include hematomas, bleeding, valve dehiscence, paravalvular leak, and acute PV thrombosis. With the available data from published articles, the rate of all valve-related complications is 0.7 to 3.5% per patient annually. [1] The pathology involved is multifactorial, often blood vessel injury leading to bleeding and hematoma. Although postoperative complications are evident, incidental diagnosis of a cardiac mass in an asymptomatic and hemodynamically stable patient postoperatively is crucial, requiring non-invasive imaging for immediate surgical action. Case presentation A woman in her 50s presented with chief complaints of worsening dyspnoea with suddenonset and chest pain. Clinical findings showed apex shifted downward and outward, wide split S2, and a mid systolic murmur radiating to the mid axillary line. Twelve-lead ECG showed LA enlargement, that aligned with X-ray findings. 2D Echocardiography revealed MVP with severe MR and a dilated LV. The patient underwent successful mitral valve replacement as per ACC/AHA class I recommendation. However, postoperative TTE showed a remarkably large mass measuring 5.6 cm*4.6 cm in the RA. Reexploration was performed, followed by mass excision. Plenty of organized clots were seen compressing the RA. TEE showed no evidence of mass. Following stabilization,the patient was discharged considering optimal INR values and prosthetic valve function assessed by echocardiography. The patient’s symptoms improved during the first follow-up. Conclusion Although postoperative cardiac complications are common, appropriate diagnosis with TTE and TEE has benefited surgeons. TEE-guided reexploration aids surgeons in decision-making and strategic approaches. Failure to diagnose such complications in asymptomatic patients can ultimately complicate the procedure. Henceforth, sonographers must be skilled in the detection and identification of unusual complications to guide redo interventions. Such an approach minimizes mortality, redo procedures, and avoids CPB hence reducing long-term prognosis and outcomes with valve replacement.

I prefer the MitraClip in these cases: the 5-year COAPT data.

The COAPT 5-year data demonstrate that compared with medical treatment transcatheter edge-to-edge repair (TEER) with the MitraClip in symptomatic patients with Grade 3+/Grade 4+ secondary mitral regurgitation (SMR) reduced by nearly half the annualized hospitalization risk (33 vs. 57%), by almost 30% the death rate (57 vs. 67%) and achieved significant and durable SMR reduction in 95% of patients. Control patients who crossed over to TEER at 2 years had better prognosis, but nearly half of them died before reaching crossover eligibility. Death or hospitalization for heart failure (HHF) occurred in 73.6% of TEER patients and 91.5% of controls within 5 years, pointing to a need for further study to address left ventricle (LV) dysfunction, the underlying cause of patient's disease. MTRA-FR targeted SMR using the same device and did not improve the composite endpoint of all-cause mortality or HHF at 12 months. Possible reasons for the discrepancy include enrolment of patients with more severe MR and less-advanced LV disease (dilation/dysfunction), less-procedural complications, and higher success in reducing MR in COAPT compared with MITRA-FR. Thus, the ideal patient for MitraClip treatment would be one with severe MR, but with no too severe LV dilation/dysfunction, which is what differentiates COAPT patients from those in MITRA-FR.

Low Field MRI Surveillance 6-24 Months Post-acute COVID-19 Pneumonia: Factors Influencing Severity and Evolution of Lung Opacities

To determine factors influencing low-field MRI lung opacity severity 6-24 months after acute Covid-19 pneumonia. 104 post-acute Covid-19 patients with 167 MRI exams were included. 32 patients had more than one exam, and 63 exams were serial exams. Pulmonary findings were graded on a scale of 0-4 by quadrant, total score ranging from 0 (no opacity) to 16 (opacity > 75%), and score >8 considered moderate and >12 severe opacity. Kruskal-Wallis, Mann-Whitney, and Spearman rank correlation was used to assess the association of clinical and demographic factors with MR opacity severity at time intervals from acute infection. Random coefficients regression was used to assess whether opacity score changed over time. Severity of initial illness was associated with increased MR opacity score at timeframes up to 24 months (p<.05). Among the 167 exams, moderate to severe MR opacities (total opacity score >8) were identified in 33% of exams beyond 6 months: 37% at 6 - <12 months (n=23/63); 31% at 12- <18 months (n=13/42); 25% at 18- <24 months (n=6/24); and 50% at >24 months (n=3/6). No significant change in total opacity score over time was identified by random coefficients regression. Among the 32 patients with serial exams, 11 demonstrated no change in opacity score from initial to final exam, 10 decrease in score (mean 2.3, stdev 1.25, range 1-4), and 11 increase in score (average 2.8, stdev 1.48, range 1-7). Initial Covid-19 disease severity was associated with increased MRI total opacity score at time intervals up to 24 months, and moderate to severe opacities were commonly identified by low-field MRI beyond 6 months from acute illness.

Concomitant interventions in mitral valve surgery - A European perspective.

In recent years, major findings on concomitant procedures and anticoagulation management have occurred in Mitral Valve (MV) surgery. Therefore, we sought to evaluate the current practices in MV interventions across Europe. In October 2021, all national cardio-thoracic societies in the European region were identified following an electronic search and sent an online survey of 14 questions to distribute among their member consultant/attending cardiac surgeons. The survey was completed by 91 consultant/attending cardiac surgeons across 12 European countries, with 78% indicating MV repair as their specialty area. 57.1% performed >150 operations/year and 71.4% had 10+ years of experience.Concomitant tricuspid valve repair is performed for moderate tricuspid regurgitation (TR) by 69% of surgeons and for mild TR by 26.3%, both with annular diameter >40mm. 50.6% indicated ischaemic MV surgery in patients undergoing CABG if moderate mitral regurgitation with ERO >20mm2 and regurgitant volume >30mL, and 45.1% perform it if severe MR with ERO >40mm2 and regurgitant volume >60mL. For these patients the preferred management was: MVR if predictors of repair failure identified (47.2%) and downsizing annuloplasty ring only (34.1%).For atrial fibrillation (AF) in cardiac surgery, 34.1% perform ablation with biatrial lesion and 20% with left sided only. 62.6% perform concomitant Left Atrial Appendage (LAA) Occlusion irrespective of AF ablation with a left atrial clip. A wide variability in anticoagulation strategies for MV repair and bioprosthetic MV valve was reported both for patients in sinus rhythm and AF. These results demonstrate a variable practice for MV surgery, and a degree of lack of compliance with surgical intervention guidelines and anticoagulation strategy.

Non-resectional cordal repair for Barlow mitral valve disease.

The redundant leaflet tissue and annular pathology of Barlow disease can make surgical repair challenging. We examined perioperative and late outcomes of a large cohort of patients with Barlow disease undergoing surgical repair. Patients included in this analysis underwent mitral valve repair from 01/2004-11/2021 by a single surgeon. Of 2798 patients undergoing mitral valve operations, 46% (N.=1292) had degenerative pathology and 7% (N.=184) had Barlow disease. Of the 179 Barlow patients, median age at surgery was 62 (51-70) years; 64% were male (115/179). Rates of non-resectional cordal repair and resectional repair were 86% (154/179) and 14% (25/179). Among patients undergoing non-resectional repair, the median number of cordal pairs inserted on the anterior and posterior leaflets was 2 (2-3) and 4 (3-4). Incidence of return to bypass for systolic anterior motion of the mitral valve, perioperative death, stroke, and renal failure was 2% (4/179), 1% (2/179), 0% (0/179), and 0% (0/179). Rates of clinical and echocardiographic follow-up were 93% (165/177) and 89% (157/177). Median time to latest postoperative clinical and echocardiographic follow-up was 2.4 (0.8-6.1) and 2.1 (0.6-4.7) years. Mitral regurgitation grade at latest follow-up or time of repair failure was none/trace, mild, mild to moderate, and severe in 63% (98/157), 26% (41/157), 8% (12/157), and 4% (6/157); five of six patients with severe MR underwent reoperation. Since 2011 97% (139/144) of patients underwent cordal repair without resection. Non-resectional artificial cordal repair is safe and feasible in almost all patients with Barlow valves and is associated with excellent mid-term results.

The Prognostic Value of Right Ventricle Strain In Patients With Heart Failure With Reduced Ejection Fraction (HFrEF)

Background: RV dysfunction has been recognized as a powerful independent predictor of poor prognosis. Therefore, accurate evaluation of RV function is helpful for risk stratification in patients with HF, so as to guide clinicians to choose the best treatment and improve the prognosis of patients. Therefore, assessment of RV function is clinically important in almost all patients with heart disease. Objective: The main purpose of this study was to evaluate the prognostic value of right ventricular free wall longitudinal strain in patients with heart failure with reduced ejection fraction (HFrEF). Methods: We evaluated a prospective cohort of 126 patients with known or suspected HFrEF referred for echocardiographic evaluation. All underwent measurement of RV free-wall longitudinal strain (RVFWLS) by 2D transthoracic echocardiography. The primary study endpoint was the occurrence of death for any cause or hospitalization for heart failure. Results: From 126 eligible patients with chronic heart failure, 10 (8%) with RVFWLS not suitable for strain analysis were excluded, leaving a final study population of 116 patients. During the follow-up period of 24 months, 44 patients (38%) reached the composite end point: 18 patients died (15%), and 26 patients (22%) were hospitalized for worsening HF. Compared with patients without events, patients who reached the composite end point were older and prevalently men (P &lt;0.05). Patients with events also showed higher LV volumes, lower LVEF%, increased left atrial volume index (LAVI), increased pulmonary artery systolic pressure, and higher prevalence of severe MR and TR than event-free patients. Diastolic RV diameter was also significantly greater in this group. In this study, we found that a RVFWLS less negative of -19.3% was associated to outcomes with 75% sensitivity and 67% specificity P &lt; 0.001. A value of RVFWLS less than -19.3% was strongly associated to outcome with HR 1.9, 95% CI 1.487–2.7; P &lt; 0.001. Conclusion: RV free wall longitudinal strain seems to be more sensitive and accurate for the diagnosis of RV systolic dysfunction in patients with HFrEF, therefore assessment of RV function should be implemented by analysis of RVFWLS in patients with HFrEF, to improve identification of patients who are at high risk for adverse events.

Handgrip echocardiography predicts clinical outcomes in patients with ischemic mitral regurgitation

Abstract Background Mitral regurgitation (MR) is frequent in patients with ischemic heart disease and carries a dismal prognosis. Previous studies already demonstrated the prognostic benefit of bicycle exercise testing in patients with ischemic MR. Thus, current guidelines emphasize the role of exercise testing in patients with valvular heart disease. Isometric handgrip exercise resembles an alternative exercise intervention, that can also be performed in frail, comorbid patients. Until now, there are no data on the prognostic impact of handgrip echocardiography in heart failure patients with ischemic MR. Purpose To assess the prognostic benefit of isometric handgrip testing in heart failure patients with ischemic MR. Methods We prospectively enrolled patients with ischemic cardiomyopathy (left ventricular ejection fraction &amp;lt;50%) and at least mild MR that underwent echocardiography at rest and during handgrip exercise between January 2019 and September 2021. Patients were followed-up for one year to assess clinical outcomes. The combined endpoint included all-cause mortality, heart failure hospitalisation, ventricular assist device implantation (VAD), heart transplantation and mitral valve (MV) surgery/intervention. Results We included 133 patients (mean age was 75±10 years, 21% were female). Seventy patients (53%) presented with mild MR, while 54 patients had moderate MR (41%), and 9 patients (7%) showed severe MR at rest. Twenty-five patients (20%) with non-severe MR at rest, developed severe MR during handgrip exercise. One-year follow-up (median 321 (162-427) days) was complete in 128 patients (96%). Seventy-one patients (56%) experienced an adverse event: 13 patients (10%) died, 33 patients (26%) were re-admitted to hospital due to heart failure symptoms, 30 patients (24%) underwent MV transcatheter edge-to-edge repair, six patients (5%) received MV surgery, one patient (1%) underwent VAD implantation, and another three patients (4%) underwent heart transplantation. According to MR severity at rest, there was no difference in outcomes in patients with mild, moderate and severe MR (p=0.189). As expected, patients with severe MR at rest more often tended to undergo mitral valve surgery/interventions compared to the other groups (p=0.064). However, patients with non-severe MR at rest and exercise-induced severe MR presented with adverse outcomes similar to patients with severe MR at rest (p=0.005). Furthermore, patients with severe MR at rest and patients with dynamic severe MR underwent mitral valve surgery/interventions more frequently than patients with non-severe MR (p&amp;lt;0.001). Conclusion(s) In heart failure patients with ischemic MR, isometric handgrip testing unmasks severe MR in approximately every fifth patient with non-severe MR at rest. These patients showed similar clinical outcomes as compared to patients with severe MR already at rest. Thus, handgrip exercise testing might be a useful tool to guide further therapeutic decision making.

Degenerative or rheumatic: after all, what is the most prevalent etiology of mitral regurgitation in developing countries?

Abstract Introduction Mitral regurgitation (MR) is the most prevalent valve disease in Europe, mostly degenerative. In Brazil, on the other hand, there are few recent epidemiological data and previous studies show a higher prevalence of rheumatic disease. However, a change in the epidemiological profile of valve disease has recently been observed, largely due to the increase in life expectancy and decrease in the incidence of rheumatic fever. This study aims to evaluate patients with MR in a tertiary hospital in Brazil, emphasizing the etiological analysis. Methods Patients with moderate or severe MR on echocardiogram performed between 07/01/2018 and 06/30/2020 in a Brazilian Cardiology hospital were retrospectively evaluated, including 2,017 cases. Clinical data (age, sex, symptoms and comorbidities) were analyzed, in addition to complementary tests, such as electrocardiogram and echocardiogram. Results A total of 2,017 cases were included, of which 1,966 (97.5%) had severe MR. The mean age was 65 years and 52% were female. In this cohort, 924 patients (45.8%) had primary MR, while 1093 (54.2%) had secondary causes. Among the primary etiologies (N=1093), degenerative was the most prevalent, responding to 51.3% (n=474), followed by rheumatic disease, present in 34.5% of the patients (n=319). The other primary etiologies observed were calcific (94 patients = 4.7%), infective endocarditis (15 patients = 0.7%) and congenital (10 patients = 0.5%). In the comparative analysis between degenerative and rheumatic MR, a statistically significant difference was observed in age and gender. Patients diagnosed with rheumatic MR were younger - mean age: 58 years (standard deviation 49-68) compared to 67 years in patients with degenerative mitral disease (standard deviation 58-76 years). Most patients with rheumatic disease were female (N=255, 79.9%), with percentages almost twice as high as those observed in degenerative MR (N=192 - 40.5%). Secondary causes (N=1,093) were composed of dilated etiology in 859 patients (78.6%), ischemic (140 patients - 12.8%) and atrial functional (55 patients - 5%). Conclusion In agreement with the current epidemiological change in valvular heart disease, we could also observe an important change in the etiology of MR in Brazil, with a reduction in the burden of rheumatic disease and greater expressiveness of mitral prolapse.

The impact of unstable results following transcatheter mitral edge-to-edge repair on long-term outcomes

Abstract Background Mitral regurgitation (MR) is associated with reduced quality of life and increased mortality. Mitral edge-to-edge repair (M-TEER) is an alternative for patients (pts) not suitable for open-heart surgery. The severity of residual MR (rMR) following M-TEER is associated with lower long-term survival rates. The prognostic implications of recurrent MR, e.g. an unstable result during follow-up, have not been explored. Purpose This single-center, retrospective study analyzed the incidence of unstable results (defined as worsening rMR during short-term follow-up) and its impact on mid- and long-term outcomes in pts treated with M-TEER. Methods We included a total of 1,030 pts treated by M-TEER between 09/2008 and 11/2019 for either relevant degenerative MR (DMR) or severe functional MR (FMR) at our single center. 467 pts were excluded due to insufficient long-term follow-up data, 134 pts were excluded due to rMR ≥3+ or missing values for rMR at discharge, and one patient with lack of classification into FMR or DMR. Therefore, a total of 428 pts with a median follow-up of 4.61 (95%-confidence interval [95%-CI]: 4.41; 4.96) years were analyzed. Unstable results were defined as an increase in the amount of rMR (≥1+) at 6- or 12-month follow-up compared to discharge. Follow-up was shortened to 5-years for all pts. The primary endpoint was all-cause mortality. Results 428 pts (mean age 74.6 ± 9.1 years, 36.9% female, median STS score 3.6%, DMR in 28.0%, FMR in 72.0%) were stratified according to the presence or absence of an unstable result (FMR: n=101/308 [32.8%] vs. DMR: n=35/120 [29.2%]). The mean left ventricular ejection fraction (LVEF) was 41.6% (± 15), median NT-proBNP was 3,333 pg/ml [interquatile range 1,676; 6,673]. Glomerular filtration rate (GFR) &amp;lt;30mL/min was found in 11.2%. There were no significant differences in baseline characteristics, except for the mean systolic pulmonary artery pressure (SPAP) in the DMR subset of pts (median SPAP: 51.0 mmHg vs. 39.0 mmHg for unstable vs. stable, p=0.009). 171 pts (39.9%) died during follow-up. Kaplan-Meier 12-months analysis for survival demonstrated significant differences for the primary endpoint with superior outcomes for pts presenting with stable results during follow-up (p log rank=0.02, Figure 1). Univariable Cox regression analysis indicated a significant association of an unstable results with increased mortality rates (hazard ratio [HR]=1.44; 95%-CI: 1.05-1.96; p=0.022). The association still proved to be significant following multivariable adjustment for age, LVEF≤30%, anaemia, FMR, GFR&amp;lt;30ml/min, and atrial fibrillation (HR=1.43; 95%-CI:1.03-1.97; p=0.031). Conclusion An unstable result characterized by worsening rMR during the first 12 months after M-TEER appears to be an independent predictor of increased mortality risk. Therefore, predictors of unstable results as well as its impact on functional outcomes should be subject of further investigation.Kaplan-Meier 12-month landmark Analysis