Severe MR Research Articles

Quantification of regurgitation in mitral valve prolapse with automated real time echocardiographic 3D proximal isovelocity surface area: multimodality consistency and role of eccentricity index

Three-dimensional transthoracic echocardiography (3D-TTE) provides a semi-automated proximal isovelocity surface area method (3D-PISA) to obtain quantitative parameters. Data assessing regurgitation severity in mitral valve prolapse (MVP) are scarce, so we assessed the 3D-PISA method compared with 2D-PISA and cardiovascular magnetic resonance (CMR) and the role of an eccentricity index. We evaluated the 3D-PISA method for assessing MR in 54 patients with MVP (57 ± 14 years; 42 men; 12 mild/mild-moderate; 12 moderate-severe; and 30 severe MR). Role of an asymmetric (i.e. eccentricity index ≥ 1.25) flow convergence region (FCR) and inter-modality consistency were then assessed. 3D-PISA derived regurgitant volume (RVol) showed a good correlation with 2D-PISA and CMR derived parameters (r = 0.86 and r = 0.81, respectively). The small mean differences with 2D-PISA derived RVol did not reach statistical significance in overall population (5.7 ± 23 ml, 95% CI − 0.6 to 12; p = 0.08) but differed in those with asymmetric 3D-FCR (n = 21; 2D-PISA: 72 ± 36 ml vs. 3D-PISA: 93 ± 47 ml; p = 0.001). RVol mean values were higher using PISA methods (CMR 57 ± 33 ml; 2D-PISA 73 ± 39 ml; and 3D-PISA 79 ± 45 ml) and an overestimation was observed when CMR was used as reference (2D-PISA vs. CMR: mean difference: 15.8 ml [95% CI 10–22, p < 0.001]; and 3D-PISA vs. CMR: 21.5 ml [95% CI 14–29, p < 0.001]). Intra- and inter-observer reliability was excellent (ICC 0.91–0.99), but with numerically lower coefficient of variation for 3D-PISA (8%–10% vs. 2D-PISA: 12%–16%). 3D-PISA method for assessing regurgitation in MVP may enable analogous evaluation compared to standard 2D-PISA, but with overestimation in case of asymmetric FCR or when CMR is used as reference method.

Prevalence of brain MRI findings in children with nonacquired growth hormone deficiency: a systematic review and meta-analysis.

To verify and integrate the prevalence and phenotype of abnormalities in the sellar region in patients with growth hormone deficiency (GHD) using MRI data. We searched PubMed and EMBASE up to December 14, 2020. The inclusion criteria were as follows: (1) pediatric patients diagnosed with nonacquired GHD and (2) detailed data sufficient to assess the proportion of sellar and parasellar abnormalities on brain MRI scans. Finally, thirty-two studies with 39,060 children (mean or median age, 3.4-14.1 years) were included. The number and type of MRI findings from all included studies were pooled by two authors. The heterogeneity across studies was evaluated with the Q test or the inconsistency index (I2) statistic. Subgroup analyses were performed according to the type of GHD (isolated GHD [IGHD] vs. multiple pituitary hormone deficiency [MPHD]), MRI magnet, geographical region, and cutoff serum growth hormone (GH) level. The pooled proportion of sellar and parasellar abnormalities was 58.0% (95% CI, 47.1-68.6%; I2, 98.2%). The MPHD group showed a higher proportion of sellar and parasellar abnormalities and pituitary stalk interruption syndrome than the IGHD group (91.4% vs. 40.1%, P<0.001; 65.3% vs. 20.1%, P<0.001). The patients in studies with low peak GH levels on stimulation tests were more associated with severe MR abnormalities (cutoff GH ≤ 5 μg/l vs. cutoff GH = 10 μg/l; 72.8 % vs. 38.0%; P<0.001). The types and incidence of MRI abnormalities of the sellar region differ significantly between the IGHD and MPHD groups.

Cardiac remodelling and heart failure symptoms in patients with apical hypertrophic cardiomyopathy

Abstract Funding Acknowledgements Type of funding sources: None. Background Although earlier publications suggested a more benign clinical course for patients (pts) with apical hypertrophic cardiomyopathy (ApHCM), recent studies report increased morbidity and mortality, comparable to the prognosis of other HCM variants. Moreover, information regarding cardiac remodelling and its relationship with symptoms in pts with ApHCM is scarce. The aim of our study was to assess left ventricular (LV), right ventricular (RV) and left atrial (LA) remodelling in pts with ApHCM in comparison with non-apical variants of HCM (nonApHCM), and the impact of cardiac remodelling on heart failure symptoms. Methods One hundred fifty-one consecutive pts with HCM (52 ± 16 yrs, 47% men) in sinus rhythm and with preserved LV ejection fraction (16 pts with ApHCM and 135 pts with nonApHCM), were prospectively enrolled. Comprehensive echocardiography was performed in all, including the measurement of maximal LV wall thickness (LVWT), RV free wall thickness (RVWT) and maximal LA volume indexed to body surface area (LAVi). Global LV strain (ɛ), RVɛ, LAɛ and end-diastolic LA strain rate (ASr) were measured using speckle-tracking echocardiography (STE). The ratio of E to average e’ was used to estimate LV filling pressure. The degree of mitral regurgitation (1/2/3) has also been assessed. Heart failure symptoms were defined according to the New York Heart Association (NYHA) classification. Results Forty-eight pts in nonApHCM group had intraventricular obstruction. There were no significant differences between pts with and without ApHCM regarding: age (58 ± 20 vs 52 ± 16 yrs), gender distribution, RVWT, LVɛ (-14.9 ± 2.7 vs -13.9 ± 3.5 %), RVɛ (-19.6 ± 3.6 vs -10.0 ± 5.0%), LAɛ (19.2 ± 5.8 vs 16.4 ± 7.1%)(p &amp;gt; 0.05 for all). Pts with ApHCM had lower values for LVWT (17.2 ± 1.9 vs 21.4 ± 5.2 mm, p = 0.002), E/e’ (12.0 ± 5.8 vs 17.6 ± 8.5, p = 0.02) and LAVi (48 ± 16 vs 61 ± 25, p = 0.03) compared to pts with nonApHCM. Pts with ApHCM had slightly better LA contractile function as assessed by ASr (-1.23 ± 0.50 vs -0.97 ± 0.49 sec-1, p = 0.05). Mitral regurgitation was more often severe in nonApHCM pts (56/42/31 vs 10/4/0, p &amp;lt; 0.001). There was no significant difference between the percentage of symptomatic pts (NYHA class ≥2) in ApHCM vs nonApHCM group (p = 0.3). In the ApHCM group, symptomatic pts had significantly lower ASr compared to asymptomatic pts (-0.98 ± 0.35 vs -1.61 ± 0.46 sec-1, p = 0.01). Conclusions Despite of lower LVWT values, less severe MR and no obstruction, pts with apical HCM have similar prevalence of heart failure symptoms, and similar LV, RV and LA dysfunction compared to pts with non-apical HCM. Symptomatic pts with apical HCM have worse LA contractile function compared to asymptomatic pts.

Role of the tricuspid annulus in functional tricuspid regurgitation development after early isolated mitral valve surgery: is it an old story?

Abstract Funding Acknowledgements Type of funding sources: None. Background. Functional Tricuspid Regurgitation (FTR) has been described as a common condition after isolated mitral valve (MV) surgery, affecting patients’ prognosis. Thus, in cases without significant tricuspid regurgitation (TR) but tricuspid annular (TA) dilatation, TV annuloplasty is currently recommended. Studies suggesting the currently used cut-off for definition of TA dilatation were based on 2D echocardiography (2DE) and included patients treated with MV surgery with heterogeneous MV disease, degree of cardiac remodeling and heart rhythm. As the management of severe MR has moved towards an earlier surgical treatment, few data are available about the incidence of FTR in the population undergoing early isolated MV surgery without TR, but 2DE satisfying criteria for TA dilatation. Aims. To test, in patients treated with early isolated MV surgery for MV prolapse (MVP), without TR and either normal or dilated TA (i) if the currently used 2D TA cut-off is predictive of FTR and cardiac events development (ii) how right chambers’ remodeling assessed by 3D echocardiography (3DE) affects TA dimension. Methods. We studied 159 patients (age 61 ± 11) treated with early isolated MV surgery between 2010 and 2017. Eligible patients were those with 3DE images; normal left and right ventricular (LV and RV) function; sinus rhythm; normal or elevated right ventricular systolic pulmonary artery pressure (sPAP); normal or dilated TA by 2DE; absent TR. The decision to not perform TV annuloplasty in patients with TA dilatation was based on the surgical inspection. All patients underwent a complete 2DE, 3DE analysis was performed using custom software, including LV, RV, left atrial (LA) and right atrial (RA) assessment. 3D TA dimension were obtained using MPR. Clinical and 2DE follow-up was performed at 36 ± 6 months after surgery, major adverse cardiac events (MACEs, including cardiac hospitalization, cardiac death, arrhythmias) and FTR were recorded. Results. Based on 2DE TA dimensions, patients were divided in group 1 (N = 68, 43%, TA≥21 mm/m²) and group 2 (N= 91, 57%, normal TA). Patients in group 1 showed larger RA volume, RV basal diameter and TA area (p &amp;lt; 0.05) by 3DE compared to group 2 (Table). At the multivariate analysis, only the 3D RA volume, RV basal diameter and RV function were independently correlated to the TA area (p &amp;lt; 0.05). At the follow-up, no differences were noted between groups in FTR development and MACEs at the Kaplan-Meier analysis (Fig.). At the COX analysis, 2DE TA dilatation failed to result a predictor of cardiovascular events (model’s X2, p &amp;gt; 0.05). Conclusions. In patients undergoing early MV surgery, the currently defined TA dilatation by 2DE may not necessarily evolve in FTR, and a larger cut-off may be needed. In this population, the evaluation of right chambers’ dimension and function may better define the probability to develop FTR. Abstract Figure. Fig

Tricuspid annular dimensions in patients with severe mitral regurgitation without severe tricuspid regurgitation

Concomitant TV repair during mitral valve (MV) surgery based on tricuspid valve annulus (TVA) dilation, rather than the degree of tricuspid regurgitation (TR), is beneficial and supported by the valve guidelines. We sought to determine TVA geometry and dimensions in controls and assess the changes that occur in patients with severe primary (PMR) and secondary (SMR) mitral regurgitation without TR. We analyzed cardiac computed tomographic angiography (CCTA) of 125 consecutive subjects: 50 controls with normal coronary CCTA and no valvular dysfunction, 50 PMR patients referred for robotic repair, and 25 SMR patients referred for transcatheter therapy. Patients with >2+ TR on echocardiography were excluded. Annular measurements were performed using dedicated software and compared. Correlations and determinants of TVA dimensions were analyzed. Patients with SMR were older and had significantly more comorbidities. In controls, the TVA was larger and more planar and eccentric compared to the MV annulus (all P<0.01). Dimensions of both annuli correlated significantly (r≥0.5; P<0.001 for all dimensions) in controls and patients with severe MR. In both PMR and SMR, the TVA enlarged in all dimensions (P<0.01) with a trend towards becoming more circular. On multivariable regression, the MV annular area was the primary determinant of the TVA area (adjusted β=0.430, P<0.001). Substantial changes in TVA dimensions are encountered in patients with severe MR even in the absence of severe TR such that TVA and MVA dimensions remain correlated. Close attention to the TVA in patients with severe MR is warranted.

RISK STRATIFICATION OF HEART FAILURE BY ISCHEMIC MITRAL REGURGITATION IN PATIENT WITH MYOCARDIAL INFARCTION

One of the important complications which causes the increase of mortality and economic burden on patient is the ischemic MR. Its main pathophysiology is the remodeling of the LV after MI which causes the hemodynamic load and heart failure. However, the data on relationship between ischemic MR and duration of heart failure is very few. We prospectively studied 300 patients who admitted for acute myocardial infarction in our hospital. All patients were assessed by echocardiography and graded MR as mild, moderate, and severe according to regurgitant jet area which is less than 20%, 20 – 40%, and more than 40% of the left atrial area, respectively. The median duration of follow up was 1 year (range 6-12 months). Mild and moderate or severe ischemic MR was present in 40.2 and 6.4% of patients respectively. The hazard ratios for HF were 2.9 (95% condence interval (CI), 1.9–4.3; P&lt;.001) and 3.7 (95% condence interval (CI), 2.1-6.5; P&lt;.001) in patients with mild and moderate or severe ischemic MR respectively, with compared to patients without ischemic MR, after adjusting for ejection fraction and other clinical variables like age, sex, Killip class, previous infarction, hypertension, diabetes mellitus, anterior wall infarction, ST elevation infarction and coronary revascularization. In patients with mild ischemic MR, the adjusted hazard ratio for death was 1.1 (95% CI 0.7-1.7; P=.42), where as in moderate or severe ischemic MR it was 2.1 (95% CI 1.3-3.5; P=.02).

Prognostic comparison of atrial and ventricular functional mitral regurgitation

ObjectiveAtrial functional mitral regurgitation (A-FMR) has been suggested as a new aetiology of functional MR (MR); however, its prognosis and prognostic predictors are not fully elucidated. Aim of this study...

Epidemiological profile, management and outcomes of patients with acute coronary syndrome: Single centre experience from a tertiary care hospital in North India

BackgroundCardiovascular disease is the leading cause of death in India. Our aim is to study the clinical, epidemiological profile and in-hospital outcomes of patients presenting with acute coronary syndrome. MethodsWe did a prospective single center observational study of the 1203 patients presenting with ACS to a tertiary referral center in North India over a period of one year (July 2018–June 2019). ResultsThe mean age of study population was 58.4 ± 12.5 years. STEMI and NSTE-ACS accounted for 69.9% and 31.1% respectively. 62.1% of our patients were from rural background. The median time to hospital admission was 600 min for STEMI patients, thrombolysis was performed in 52% of cases. Cardiogenic shock at presentation was noted in 18%. Coronary angiography and percutaneous coronary intervention were done in 1062 (88.3%) and 733 (60.9%) patients respectively. The overall in-hospital mortality was 7.6%. STEMI patients had higher mortality than NSTE-ACS (8.9% vs 4.5% p < 0.001). Female gender (OR−3.306 C.I. 1.87–5.845), severe MR (OR−4.65, C.I.−1.187–18.18), acute kidney injury (AKI) at admission (OR-5.15, C.I.−2.5–10.63), higher Killip class (class III/IV) (OR−3.378,C.I.−1.292–8.849), AF (OR−3.25, C.I.−1,18–8.92), complete heart block (CHB) (OR−4.44,C.I.−2.09–9.43) and right bundle branch block (RBBB) (OR−2.86, C.I.−1.2–6.8) were significant predictors of in hospital mortality. ConclusionsOur study represents the predominance of STEMI as the initial ACS presentation with a considerable delay in first medical contact and higher prevalence of cardiogenic shock (CS). STEMI patients had higher mortality. Female sex, severe MR, AKI, higher Killips class, AF, CHB, RBBB being predictors of high in-hospital mortality in ACS patients.

IMMEDIATE RESULTS OF PERCUTANEOUS TRANS-MITRAL COMMISSOROTOMY IN JUVENILE MITRAL STENOSIS

Objectives: Immediate result of PTMC in juvenile (5-12 years) rheumatic mitral stenosis.&#x0D; Study Design: Observational descriptive and retrospective study.&#x0D; Place and Duration of Study: Institute of Cardiology, Multan from 2009 to Jun 2020.&#x0D; Methodology: This is an observational descriptive and retrospective study carried out at Institute of Cardiology, Multan from 2009 to Jun 2020. Patients with clinical evidence of significant mitral stenosis were undergone transthoracic echocardiography. Mitral stenosis was defined as mitral valve area &lt;1.0 cm2 . Mean mitral valve gradient was calculated by mitral valve inflow velocities. Patients with Wilkins score &lt;8 were included. Patients with significant MR, left atrial or atrial appendage clot, infective endocarditis, significant aortic regurgitation or any other indication for bypass surgery were excluded. Patients with Wilkins score &gt;8 were also excluded from the study. Variables recorded on a performa were age, weight, left atrial size, mean mitral valve gradient, preprocedure MR. Reduction of mitral valve mean pressure gradients to less than &lt;50% of the initial value was defined as success (without significant or moderate MR). After the procedure, variables recorded on performa were mean left atrial pressures in mmHg (on angio), mean mitral valve gradients and degree of MR (mild, mild to moderate, moderate or severe MR) on transthoracic echocardiography. Paired t-test of significance (p&lt;0.05) was evaluated using SPSS (version 20).&#x0D; Results: Forty three juvenile patients were included the in the study (2009 to June 2019). Mean age was 10.8 ± 1.4 (range 7-12) years. Mean weight was 28.9 ± 5.2 (20-37) kg. Mean mitral valve gradient (on TTE) before the procedure was 20 ± 6 mmHg. Mean left atrial size and mean area of mitral valve were 42 ± 5 mm and 0.8 ± 0.2 cm2 respectively. Balloon sizes used were 26 mm (n=19) and 24 mm (n=24). After PTMC, mean mitral valve reduced to 7 ± 2 mmHg (p&lt;0.005) and left atrial pressure to 18 ± 7 mmHg. Post procedure transthoracic echocardiography showed 4.7% (n=2/43) patients developed moderate to severe or severe MR. So the success rate was 95.3% (n=41/43).&#x0D; Conclusion: PTMC is safe and effective procedure for juvenile patients with mitral stenosis. Long term follow-up is needed to find out period of re-intervention/surgery free duration from the time of PTMC.

Paroxysmal Severe Mitral Regurgitation

ObjectiveTo investigate the clinical presentation, pathophysiology, and treatment for "paroxysmal severe mitral regurgitation" (MR), which is an underappreciated cause of heart failure with preserved left ventricular ejection fraction. MethodsWe retrospectively reviewed cases of transient severe MR that were evaluated at Mayo Clinic in Rochester, Minnesota, between January 1, 2006, and December 31, 2019. Paroxysmal severe MR was defined as the appearance of transient severe MR in patients with mild MR at rest, normal left ventricle (LV) size, left ventricular ejection fraction greater than 40%, and absence of obstructive coronary artery disease. ResultsWe identified 6 patients (5 women) with a median age of 68 years. There were 3 distinct mechanisms of paroxysmal severe MR, which we labeled types 1, 2, and 3. Type 1 MR was caused by LV dyssynchrony from a rate-dependent left bundle branch block, which led to apical leaflet tenting and incomplete coaptation. Type 2 MR occurred from mitral annular dilatation during maneuvers that increased left-sided volume. Type 3 MR was caused by coronary artery vasospasm with apical leaflet tenting. Treatments varied depending on the underlying cause and included cardiac resynchronization therapy for type 1, surgical valve replacement for type 2, and medical therapy for type 3. ConclusionParoxysmal severe MR is a rare cause of heart failure in patients with preserved LV function. We have identified 3 distinct mechanisms that can lead to this dynamic process, with treatments varying based on the underlying cause.

Abstract 14327: Tricuspid Valve Annular Area Correlations and Determinants in Healthy Controls and Patients With Severe Mitral Regurgitation

Introduction: Concomitant tricuspid valve (TV) repair during mitral valve (MV) surgery based on annular dilation rather than the degree of regurgitation (TR) has been shown to be beneficial and is supported by the guidelines. Hypothesis: Assess the correlations between tricuspid and mitral annular areas (TVA and MVA, respectively) indexed to body surface area (BSA) measured by cardiac computed tomography (CT), and identify the determinants of the TVA in normal and diseased states. Methods: We included 50 consecutive controls (no valvular heart disease undergoing coronary CTA), 50 primary mitral regurgitation (PMR) patients referred for robotic repair, and 25 functional MR (FMR) patients referred for percutaneous therapy, without significant associated TR (≤2+ TR). We used dedicated CT software (Aquarius, TeraRecon) to perform the annular measurements. A mid-diastolic phase acquisition (~70%) was used Results: Patients with FMR were older (median age [25th, 75th] = 70 years [63,77.5] vs. 55 [48,59] in PMR and 48 [38,55] in controls), had more clinical comorbidities, and lower ejection fraction (32% [23,40] vs. &gt;60% in both other groups). TVA was significantly correlated to MVA in controls (r≥0.5; p&lt;0.001), as well as in patients with PMR and FMR. (Figure 1). Table 1 shows the univariate correlations and multivariate determinants of the TVA. In the multivariate analysis, the MVA, RA area, and LVEDV were the independent predictors of TVA. Interestingly, the MVA was the most important predictor (β= 0.420, p&lt;0.001). Conclusion: In individuals without valvular heart disease and in patients with severe MR (PMR and FMR) with ≤ 2+ TR, the TVA was largely determined by the MVA.

Abstract 16215: Ventricular Dyssynchrony is Associated With Arrhythmic Mitral Prolapse Prior to Chamber Remodeling

Introduction: Asymptomatic patients on active surveillance for degenerative mitral regurgitation are at risk of ventricular arrhythmia and sudden death. Hypothesis: Abnormal myocardial mechanics may precede ventricular remodeling and may help identify at-risk patients. Methods: Multi-directional myocardial mechanics and LV dyssynchrony were assessed in 204 consecutive patients awaiting surgical mitral repair for severe degenerative MR in a quaternary mitral reference center. Results: The mean age was 58 ±12.5 years and 40% were females. The mean EF was 63% ± 6% and 92% had compensated LV function (EF&gt;60% and LVESD&lt;4cm) and only 24% had elevated LV filling pressures (E/e'≥13). Indexed LV wall stress-to-LVEDD, relative wall thickness and indexed LV mass-to-BSA were similar amongst males-females, although males had higher mean blood pressure (94 Vs. 90, P=0.02) . The peak global longitudinal strain (GLS) was -25.2% ± 3.3% and the mid-ventricular circumferential and radial strains were -33.5%±6.7% and 56%±25% respectively. Ventricular ectopy was present in 24.5% of patients and only 17% had atrial fibrillation (Afib) despite the significantly dilated left atria (mean LAVi 70±26.6 ml/m 2 ). The median LV mechanical dispersion was 40msec (IQR 30.7-56.5) but increased significantly with ventricular ectopy (65msec, P&lt;0.01) and further influenced by concomitant Afib (p=0.001 for 2-factor interaction). Diastolic LV function did not correlate with dispersion (r=0.02 and 0.01 for E/A and E/e', P=NS) but was associated with the duration of LV diastolic filling (mean 502±140msec; r=0.2, P=0.004). Interpapillary radial strain delay was noted in the study cohort (mean delay 52.8msec, range 0-335msec) while intepapillary activation delay was manifested with concomitant ventricular ectopy (mean time-to-peak LS delay 57.5±48msec). Conclusions: Left ventricular dyssynchrony manifested by increased mechanical dispersion and imbalanced interpapillary mechanics are observed prior to overt chamber remodeling in significant degenerative MR and is associated with ventricular ectopy. Further studies are needed to assess the related clinical implications and potential impact on risk stratification in this patient group.

Abstract 16327: Clinical Profiles, Care Patterns, Outcomes and Sex Differences of Patients With STEMI in India: Insights From the North Indian ST-segment Elevation Myocardial Infarction (NORIN STEMI) Registry

Background: Although major strides have been made in the care of patients (pts) with STEMI in high-income countries, little is known about the characteristics, practice patterns, outcomes &amp; sex differences of pts with STEMI in India. Methods: The NORIN STEMI registry is an ongoing investigator-initiated prospective cohort study of pts presenting with STEMI at tertiary medical centers in North India. This registry started enrolling pts in January 2019. Results: Of 3,635 participants enrolled to date, 16% were women &amp; the median age was 55 (IQR 45-62) years with 33% aged &lt;50 years. Prior to STEMI, 63% were smokers, 29% had hypertension, 24% diabetes, &amp; 54% were obese or overweight (Figure). Overall, 11% were previously treated with aspirin or statins. Only 2% of these patients had health insurance, &amp; 65% had lower socioeconomic status. Most (93%) initially presented to a non-PCI capable facility. Almost all received aspirin, statin, P2Y12i &amp; heparin on presentation; 66% were treated with PCI (98% femoral access), 15% fibrinolysis alone, 3% both fibrinolysis &amp; PCI, &amp;21% were medically managed; symptom onset to balloon time was 2.9 (0.6-9) days. LVEF was &lt;40% in 46% &amp; mechanical complications occurred in 1.3% (n=35 VSD, n=12 severe MR). 30-day mortality was 9%. Women were less likely to receive PCI (58% vs 67%) &amp; had a 2-fold higher mortality vs men (OR adj 2.1; 1.6-3.0; Figure). Conclusion: In this contemporary registry of pts with STEMI in North India, over a third were younger than 50 years &amp; tobacco smoking was a dominant risk factor. There were significant delays in timely reperfusion therapy with resultant severe LV dysfunction present in over half &amp; high mortality particularly in women. It is critical to identify barriers, increase awareness, and develop strategies to improve STEMI care in India.

Outcomes of transcatheter mitral valve repair from the latest nationwide inpatient sample database 2016–2017

Abstract Background Transcatheter mitral valve repair (TMVR) is an alternative treatment option for severe mitral regurgitation (severe MR) in patients with high surgical risk. Previous studies have demonstrated safety and efficacy of TMVR. The aim of our study was to assess comorbid and patient outcome data in a nationwide sample. Methods From the Nationwide Inpatient Sample (NIS) 2016–2017, all adult patients with mitral valve regurgitation were identified. Patients were divided into two group- TMVR and SMVR (surgical mitral valve repair). Patients requiring surgical valve replacement were excluded. Primary outcomes were inpatient mortality and length of stay. Multivariate analysis was performed to adjust for comorbidities. Results A total of 6211 TMVR were performed, while 3789 SMVR were performed. TMVR patients were older (78.34 vs 62.26 years) and had more females (48.86 vs 36.18%). Comorbidities were higher in the TMVR group [heart failure (81.02 vs 46.02%, p&amp;lt;0.001), diabetes mellitus (27.13 vs 15.81%, p&amp;lt;0.001), chronic kidney disease (39.3 vs 13.7%, p&amp;lt;0.001), chronic lung disease (27.13 vs 16.65%, p&amp;lt;0.001). Complications were higher in the SMVR [Cardiogenic shock (3.8 vs 6%, p=0.007), blood transfusion requirement (19.44 vs 4.85%, p=0.001), respiratory failure (10.99 vs 7.37, p=0.012)]. Mean length of stay was higher with SMVR [8.60±0.22 (4.139–5.17) days] compared to TMVR [4.65±0.26 (8.167–9.03) days]. In-patient mortality was lower in TMVR (2.01 vs 2.45%, p-0.02). After adjusting for comorbidities on multivariate analysis, there was no difference in mortality between the groups (adjusted OR=1.081±0.419 (0.506–2.311). Conclusion From nationwide data, we report TMVR as a relatively safe treatment modality for severe MR, with comparable inpatient mortality and fewer complications than SMVR, despite having a significantly higher burden of comorbidities. Funding Acknowledgement Type of funding source: None

Prognostic differences between atrial functional mitral regurgitation and ventricular functional mitral regurgitation

Abstract Introduction Atrial functional mitral regurgitation (A-FMR) has been under-recognized until recently as a cause of FMR, and the prognostic difference between A-FMR and ventricular FMR (V-FMR) has not been fully elucidated. As there has been different mechanisms of FMR suggested in A-FMR and V-FMR, we hypothesized that prognosis and prognostic predictors of A-FMR may differ from those of V-FMR. Purpose To investigate the prognosis and prognostic predictors of A-FMR in comparison with V-FMR. Methods Among 1312 consecutive patients with grade 3+ (moderate to severe) or 4+ (severe) MR, 378 consecutive FMR patients were identified by excluding patients with degenerative MR, previous cardiac surgery, or concomitant aortic valve disease and/or mitral stenosis. FMR with ejection fraction (EF) &amp;lt;40% or FMR due to regional wall motion abnormalities with leaflet tethering were classified as V-FMR (N=288), and FMR due to left atrial (LA) and/or annular dilatation with preserved or mid-range EF (≥40%) were classified as A-FMR (N=90). All-cause death and heart failure hospitalization were analyzed as cardiovascular (CV) events in this study. Surgical or percutaneous mitral valve intervention without CV events was handled as not reaching an endpoint and these cases were censored. Results A-FMR were significantly older (76 [69–82] vs. 70 [58–77] years), higher rates of female (64 vs. 35%) and atrial fibrillation (88 vs. 42%), and lower B-type natriuretic peptide (BNP) values (169 [101–318] vs. 447 [213–952] pg/ml) compared to V-FMR (all P&amp;lt;0.05). On echocardiography, LV end-diastolic and end-systolic dimensions (52 [48–57] vs. 64 [58–72] mm, 34 [31–37] vs. 55 [48–64] mm), respectively) were smaller, and EF (55 [50–60] vs. 28 [19–35] %) and LA volume (99 [73–137] vs. 73 [57–91] ml/m2) were larger in A-FMR (all P&amp;lt;0.05). Effective regurgitant orifice area (32 [26–40] vs. 31 [24–45] mm2) and regurgitant volume (50±15 vs. 52±16 ml) were similar (both n.s.). During a median follow up of 1407 days, 206 (54%) patients developed CV events. Kaplan-Meier analysis revealed that V-FMR had a significantly higher rates of CV events compared to A-FMR (Figure) with adjusted hazard ratio (HR) of 1.762 [1.168–2.660], P=0.007 after adjusted for variables including age, sex, New York Heart Association functional class, previous heart failure hospitalization, estimated glomerular filtration rate (eGFR) and BNP. Further, stepwise multivariate analysis showed that independent prognostic predictors of A-FMR were LA volume and eGFR, while those for V-FMR were LA volume, age, and LV end-systolic dimension. Conclusions A-FMR had relatively better prognosis compared to V-FMR, and there were different prognostic predictors between A-FMR and V-FMR. Our results suggest that different treatment strategies need to be considered between A-FMR and V-FMR. The Kaplan-Meier life table Funding Acknowledgement Type of funding source: None

Meta-analysis confirms improvement of hospitalizations and all-cause mortality of transcatheter mitral valve repair in functional mitral regurgitation

Abstract Background Moderate-to-severe or severe functional mitral regurgitation (FMR) is associated with higher rates of hospitalizations and with increased mortality in heart failure (HF). Transcatheter mitral valve repair by MitraClip® implantation (TMVrMC) may effectively reduce severe MR, and is associated with symptomatic improvement. However, the long-term clinical effects of this procedure are not well defined. Aims We analyzed outcomes for rehospitalization and survival in HF patients with moderate-to-severe or severe FMR treated by either medical treatment (MT) only versus TMVrMC+MT by meta-analysis. Methods and results By systematic search of bibliographic databases, we evaluated publications comparing HF patients with FMR treated by MT only versus treatment by MT combined with TMVrMC. Studies with a minimum of 25 enrolled patients and a follow/up period of at least 12 months were deemed eligible for this meta-analysis. We identified n=7 studies enrolling 2,884 HFrEF patients, divided into two study arms: TMVrMC+MT (n=1,618), versus FMR patients receiving MT only (n=1,266). At 12 months, there was a significant reduction in all-cause mortality favoring TMVrMC+MT (OR: 0.65; CI 95% 0.53–0.79), compared with the MT only patients. At 24 months, a significant reduction of all-cause mortality in the TMVrMC+MT patient group (OR: 0.54; CI: 95%: 0.43–0.67; p&amp;lt;0.001) was calculated. TMVrMC+MT was associated with significantly lower rates of unplanned re-admissions for heart failure compared with MT only at 12 months (OR: 0.69; 95%; CI 0.53–0.89; p&amp;lt;0.001) and at 24 months (OR: 0.53; 95% CI: 0.39–0.71; p&amp;lt;0.001). In one publication, a survival benefit of TMVrMC+MT over MT alone was shown at 5 years post intervention (HR: 0.75; 95% CI: 0.69–0.94; p=0.012) after weighting for propensity score and controlling for age. Conclusions This meta-analysis on n=2,884 patients with moderate-to-severe or severe FMR reveals that TMVrMC+MT, as compared with MT alone, is associated with a significant reduction of rehospitalizations and improvement of survival up to 24 months after MitraClip implantation. However, the discordant results of 2 randomized controlled trials (MITRA-FR and COAPT) warrant further clarification, i.e. of the eligible FMR patient profiles who might benefit from TMVrMC+MT in terms of improvement of prognosis. These data imply additional evidence for TMVrMC in eligible HF patients with relevant FMR, which might be important for an update of the corresponding guidelines. Funding Acknowledgement Type of funding source: None

Predictors of outcomes in patients with mitral regurgitation undergoing percutaneous valve repair

Abstract Background Percutaneous mitral valve repairs has been increasingly performed worldwide. The MITRA-UMG registry provides a snapshot of a real-world clinical data and outcomes. Purpose We sought to investigate predictors of clinical outcomes in patients with mitral regurgitation undergoing percutaneous valve repair. Methods The MITRA-UMG registry retrospectively collected data from consecutive patients with symptomatic moderate-to-severe or severe MR underwent MitraClip implantation. The primary endpoint of interest was the composite of cardiovascular death or rehospitalization for HF. Results Between March 2012 and July 2018, a total of 133 consecutive patients admitted to our institution were included. Acute procedural success was obtained in 95.4% of patients, with no intraprocedural death. The composite primary endpoint of cardiovascular death or rehospitalization for heart failure was met in 50 patients (38%) with cumulative incidences of 7%, 25%, at 30 days and 1 year, respectively. In the Cox multivariate model, NYHA functional class IV, left ventricular end-diastolic volume index (LVEDVi), Euroscore II, independently increased the risk of the primary endpoint at long-term follow-up. At Kaplan-Meier analysis, a LVEDVi &amp;gt;92 ml/m2 was associated with an increased incidence of the primary endpoint. Conclusions In searching the ideal phenotype of patients who benefit most of percutaneous mitral valve repair, those presenting with severely dilated ventricles (LVEDVi &amp;gt;92 ml/m2), high operative risk (EUROSCORE II &amp;gt;7%) or advanced heart failure symptoms (NYHA IV) at baseline carried the worst prognosis at long-term. Funding Acknowledgement Type of funding source: None

Workup and Management of Primary Mitral Regurgitation

We summarize the current concepts and methods for diagnosis and management of primary mitral regurgitation due to leaflet prolapse or flail. Current practice guidelines emphasize accurate diagnosis of chronic primary severe MR, differentiating between symptomatic and asymptomatic states, and assessing both hemodynamic and functional impact, thereby ensuring timely surgical or transcatheter intervention for those who stand to benefit from it. No effective medical therapy for chronic severe mitral regurgitation has been found to date. Surgical repair has significant advantages over valve replacement in primary MR patients with favorable anatomy. Transcatheter interventions may be an option in selected patients who are at prohibitive surgical risk. Successful management of chronic severe primary MR relies on accurate diagnosis and careful timing of intervention. Care should be individualized and rely on input from a heart valve team that includes expert imagers, surgeons, and interventional cardiologists.

MitraClip implantation followed by insertion of a left ventricular assist device in patients with advanced heart failure.

AimsMitral valve regurgitation (MR) is common in patients with advanced heart failure (HF). Percutaneous mitral valve repair (PMVR) via MitraClip (MC) has emerged as a feasible treatment strategy for these high‐risk patients. However, as HF often further progresses, there is a frequent need for left ventricular assist device (LVAD) implantation in these patients. We aimed to investigate whether prior MC implantation affects the subsequent LVAD implantation and outcome.Methods and resultsThirty‐seven patients with advanced HF and significant MR who underwent LVAD implantation were retrospectively analysed. Follow‐up data were collected at 1 year after LVAD implantation. Primary endpoint was all‐cause mortality. Secondary endpoint included peri‐operative parameters and clinical development depicted as New York Heart Association (NYHA) class and Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) level. Seventeen patients initially received a MC device (MC group), resulting in a significant reduction in MR grade. After MC, NYHA class and INTERMACS level further worsened, leading to subsequent LVAD implantation after a median time of 475 days in the MC group. At LVAD implantation, overall characteristics were comparable with those of the patients undergoing LVAD implantation without prior MC placement (no‐MC group). Procedural data revealed a higher incidence of right ventricular (RV) failure needing mechanical RV assistance and a longer need for nitric oxide ventilation in the MC group after LVAD implantation. One‐year survival was slightly better in the no‐MC group compared with the MC group [41% (n = 7/17) vs. 65% (n = 13/20); P = 0.15], albeit event‐free survival was comparable between both groups, MC and no‐MC.ConclusionsLVAD implantation after MC is feasible and safe. However, in patients with advanced HF and severe MR, PMVR may only delay a needed LVAD implantation and thereby lead to poorer peri‐operative RV function and impaired outcome. Arguably, these patients might benefit from the timely management of advanced HF by the means of early LVAD implantation or heart transplantation.

Predictors of outcomes in patients with mitral regurgitation undergoing percutaneous valve repair

Percutaneous mitral valve repair has been increasingly performed worldwide after approval. We sought to investigate predictors of clinical outcome in patients with mitral regurgitation undergoing percutaneous valve repair. The MITRA-UMG study, a single-centre registry, retrospectively collected consecutive patients with symptomatic moderate-to-severe or severe MR undergoing MitraClip therapy. The primary endpoint was the composite of cardiovascular death or rehospitalization for heart failure. Between March 2012 and July 2018, a total of 150 consecutive patients admitted to our institution were included. Procedural success was obtained in 95.3% of patients. The composite primary endpoint of cardiovascular death or rehospitalization for HF was met in 55 patients (37.9%) with cumulative incidences of 7.6%, 26.2%, at 30 days and 1-year, respectively. In the Cox multivariate model, NYHA functional class and left ventricular end-diastolic volume index (LVEDVi), independently increased the risk of the primary endpoint at long-term follow-up. At Kaplan–Meier analysis, a LVEDVi > 92 ml/m2 was associated with an increased incidence of the primary endpoint. In this study, patients presenting with dilated ventricles (LVEDVi > 92 ml/m2) and advanced heart failure symptoms (NYHA IV) at baseline carried the worst prognosis after percutaneous mitral valve repair.