Severe Organic Mitral Regurgitation Research Articles

Left atrial function assessed by speckle tracking echocardiography as a marker of atrial reverse remodeling in patients with mitral regurgitation treated with transcatheter edge-to-edge repair

Abstract Funding Acknowledgements Type of funding sources: None. Background Left atrial reverse remodeling has been defined relying on changes in left atrial volume following specific procedures. Little is known about functional assessment of the left atrium by left atrial strain and left atrial emptying fraction (LAEF) following edge-to-edge mitral repair. Purpose The aim of this study is to assess left atrial function by speckle tracking echocardiography and changes in LAEF, as markers of atrial reverse remodeling, in patient with mitral regurgitation treated with edge-to-edge repair technique. Methods A total of 35 patients diagnosed with severe functional or organic mitral regurgitation who underwent trans-catheter edge-to-edge mitral valve repair were selected. Demographic, clinical and echocardiographic data were collected at the time of enrollment and after a minimum follow-up of six months. The primary endpoint was to assess if left atrial speckle tracking echocardiographic parameters (LASr, LAScd, LASct) and changes in LAEF were reliable indicators of left atrial reverse remodeling, defined as a reduction in indexed left atrial volume ≥ 15% with respect to basal assessment. Collaterally, we tried to identify clinical and standard echocardiographic parameters significantly related to atrial reverse remodeling. Changes between baseline and follow-up parameters were assessed using paired t-test. Results LASr, LASct and LAEF improved significantly in patients with left atrial remodeling during follow-up (LASr: 15,8%±8,43 vs 19,7%±12,22 - P 0,047; LASct: −6,4%±6,21 vs − 9,9%±8,52 - P 0,036; LAEF: 35,5%±14,17 vs 44,1%±15,17 - P 0,003). Collaterally, among all demographics, clinical and echocardiographic data, the absence of coronary artery disease, a systolic dominant pulmonary vein flow, as assessed with pulse-wave-Doppler after the repair, therapy with ACEi/ARB, lower increases in mitral valve pressure gradient after the procedure and lower pulmonary artery systolic pressure at discharge significantly correlated with reverse atrial remodeling. Conclusions In patients with mitral regurgitation treated with edge-to-edge repair, the assessment of left atrial function by speckle tracking echocardiography and left atrial emptying fraction correlates with atrial reverse remodeling, after a minimum follow-up of six months from the procedure. Further studies are needed to better clarify the impact of left atrial remodeling on strong clinical outcomes in patient with mitral regurgitation treated with edge-to-edge repair technique and the role of functional parameters in the definition of the optimal candidate and timing for the repair.

963 PRELIMINARY OBSERVANIONAL STUDY ON CARDIAC REMODELING IN PATIENTS UNDERGOING EDGE-TO-EDGE TRANS-CATHETER MITRAL VALVE REPAIR WITH MITRA CLIP DEVICE

Abstract Preliminary Observational Study on Cardiac Remodeling in Patients Undergoing Edge-to-Edge Trans-catheter Mitral Valve Repair with MitraClip Device Considering the current interest to the new trans-catheter mitral valve repair, it has been our aim to investigate the remodeling of left ventricular (LV), left atrium (LA) and right ventricular (RV) in a cohort of 24 patients with severe organic (13 cases) or functional (11 cases) mitral regurgitation (MR), on a 6 months follow-up. Their mean age was 78,54 ± 7,64 years, and STS score 4,69 ± 2,39 and EuroSCORE II of 5,10 ± 3,28%, and a corresponding ASA score of 3, due to age, co-morbidity and impaired cardiac function (NHIA III/IV). In our study we used advanced techniques of 3D- echocardiography, for the advantage of images independent from the cutting sections, probe angles, and operators skills: this method accuracy is comparable to that of cardiac magnetic resonance imaging. In detail, all enrolled patients underwent transthoracic 3D, spackle tracking imaging, to assess valve anatomy, and suitability for MitraClip treatment according to the EVEREST anatomic eligibility criteria. They were on optimized medications and, when necessary, previously treated with percutaneous angioplasty and stent implantation. Our results, in both functional and organic cases of MV regurgitation, can be summarized in a statically significant improvement of the NHYA class, reduction in the degree of MV and tricuspid valve insufficiency, decrease in LV end-diastolic diameter and diastolic volume, and mainly in a corrected direction of LV outflow towards the high pressure aortic system: so we explain the unchanged left ventricular ejection fraction. The LA remodeling was present with a significant reduction in LA volume only in patients without atrial fibrillation, while in its function there was a reduced peak strain. Regard the indicative parameters of afterload on the right heart chambers, the derived systolic pulmonary arterial pressure decreased, and in case of tricuspid regurgitation, a significant decrease in the maximal velocity of the blood flow was observed. There was also a statistically significant reduction in the right atrial area, and in RV size, both correlated with a reduced back flow in the RA. About the RV volumetric remodeling there was no statistically significant improvement in the end-diastolic RV volume, most probably of its better compliance towards a low pressure inflow. An improvement in RV systolic function parameters was obtained in terms of increased ejection fraction, decreased free wall strain, and decreased velocity at the tricuspid annular. In Conclusion, the clinical improvement observed after Mitral Clip repair consist in decreased overload to the left chambers, facilitating their reverse remodeling, and in the LV function. In perspective, we are planning to perform pre-operative models of MV repair, where we can calculate the reduced volume of regurgitated blood and the increase in the LVEF physiological outflow, in order to better tailor the indications to this procedure.

665 Longitudinal strain impairment in organic mitral regurgitation: look beyond the valve

Abstract Aims Global longitudinal strain (GLS) is a hallmark of cardiac damage in mitral regurgitation (MR). GLS > −18% in patients with severe organic MR (OMR) and normal LV ejection fraction (LVEF) is an independent predictor of postoperative LV dysfunction. While it is known that GLS is impaired in less than severe functional ischaemic MR (FMR), the value of GLS in less than severe OMR is not known. We aimed to determine prevalence and determinants of any GLS impairment in OMR, in comparison to FMR. Methods We retrospectively evaluated 51 consecutive patients (33 OMR and 18 FMR) with mild-to-moderate, moderate and moderate-to-severe MR (Table*). Overall, GLS was higher in OMR than FMR (17.9±4.5 vs. 10.3±5.3, P<0.001), with rate of impairment of 45% in OMR and 89% in FMR (P= 0.0024). Results However, no significant difference was found in GLS between mild-to-moderate, moderate and moderate-to-severe MR patients within OMR (17.7±4.7 vs. 16.9±3.9 vs. 22.4±3, respectively, P>0.05), as well as FMR (9.8±6.6 vs. 10.7±5.3 vs. 10.4±5.3, respectively, P>0.05) groups. GLS correlated directly with left ventricular (LV) ejection fraction (EF) in both OMR (r=0.69, P<0.001) and FMR (r=0.90, P<0.001), and inversely with LV mass indexed for body surface area (LVMi) in both OMR (r = −0.50, P=0.005) and FMR (r = −0.48, P=0.042). While correlation with LVEF was better for FMR than OMR (Z − 1.95, P=0.026), correlation with LVMi was similar for OMR and FMR groups (Z − 0.082, P>0.05). Conclusions In patients with OMR, GLS may be reduced, despite normal LVEF, in less than severe MR. Prevalence and degree of GLS impairment in OMR is less than in FMR. In OMR, as well as in FMR, GLS impairment is independent of entity of MR, but rather correlates with LVMi, maybe reflecting impact of myocardial fibrosis derived by increased LVMi on GLS.

Recurrence of Functional Versus Organic Mitral Regurgitation After Transcatheter Mitral Valve Repair: Implications from Three-Dimensional Echocardiographic Analysis of Mitral Valve Geometry and Left Ventricular Dilation for a Point of No Return

MitraClip implantation has become the standard transcatheter mitral valve repair (TMVR) technique for severe mitral regurgitation (MR). However, approximately one third of patients have poor outcomes, with MR recurrence at follow-up. The aim of this study was to investigate whether quantitative analysis of mitral valve (MV) geometry on three-dimensional (3D) echocardiography can identify geometric parameters associated with the recurrence of severe functional MR (FMR) versus organic MR (OMR) at 6-month follow-up after TMVR using the MitraClip. Sixty-one patients with severe FMR (n=45) or OMR (n=16) who underwent transesophageal 3D echocardiography before and 6months after TMVR were retrospectively analyzed. MV geometry was quantified using 3D echocardiography software. Vena contracta area (VCA) at 6-month follow-up was used to define two outcome groups: patients with good results with VCA<0.6cm2(MR<0.6) and those with MR recurrence with VCA≥0.6cm2(MR≥0.6). MR recurrence was found in 34% of all study patients (21 of 61). In patients with FMR, significant differences between MR<0.6 and MR≥0.6 were found at baseline for tenting index (1.13 vs 1.23, P=.004), tenting volume (2.8 vs 4.0ml, P=.04), indexed left ventricular (LV) end-diastolic volume (68.0 vs 99.9ml/m2, P=.001), and VCA (0.71 vs 1.00cm2, P=.003); no significant parameters of MR recurrence were found in patients with OMR. Multivariate analysis identified indexed LV end-diastolic volume as the strongest independent determinant of MR recurrence. Receiver operating characteristic analysis identified a tenting index of 1.185 (area under the curve 0.79) and indexed LV end-diastolic volume of 88ml/m2 (area under the curve 0.76) to best discriminate between MR<0.6 and MR≥0.6. MR recurrence after TMVR in patients with FMR is associated with advanced LV dilation and MV tenting before TMVR, which provides clinical implications for a point of no return beyond which progressive LV dilation with MV geometry dilation and tethering cannot be effectively prevented by TMVR. In contrast, no significant determinants of MR recurrence and progressive MV annular dilation could be identified in patients with OMR.

P1470 Rare cause of papillary muscle rupture post cardiac surgery

Abstract Introduction Papillary muscle rupture (PMR) secondary to mitral valve repair surgery is a rare complication in the postoperative period of cardiac surgery Purpose We present a case of PMR with fatal outcome after mitral valve repair with a rigid ring secondary to accidental ligature of the circumflex artery (CA). Methods An 83-year-old male referred for valvular surgery for symptomatic mitral regurgitation (MR). In the last echocardiography LVEF was mildly depressed (45-50%), severe organic MR (A2 chord rupture), functional TR, and moderate degenerative AR. With these findings and together with a normal coronary angiography, he was presenting at the Heart Team for triple valvular surgery. The procedure consisted of implanting aortic biological prosthesis, mitral and tricuspid annuloplasty. During the pump output, he presented ventricular arrhythmias, but in the intraoperative transesophageal echocardiography (TEE) a good result was demonstrated. At 24h postoperatively the patient enters arrhythmic storm, ischemia data appear on ECG (ST-segment depression of V1-V3 and DI-aVL) and elevation of markers of myocardial damage (TnIc 450 ng/mL), which point to complication postsurgical cardiology is contacted for urgent echocardiography. Results The echocardiography showed a massive MI due to postero-medial PMR, inferior and inferolateral akinesia and severe biventricular dysfunction. With these findings and with the suspicion of accidental ligation of CA during the implantation of the mitral annulus, urgent catheterization is considered. Given the evolution of the ischemic event and the delicate hemodynamic situation, this option is discarded, so that angiographic confirmation is not achieved. Finally, the patient undergoes cardiac revision surgery as a last option. After performing sternotomy, cardiac rupture at a lower level is evidenced, patch closure is attempted but due to tissue friability it is not achieved and the patient dies in the surgical act. Conclusion RMP after mitral valve surgery is a very rare complication. The majority of published cases are related to increased tension forces after mitral replacement with preservation of the subvalvular apparatus. Our case would be the first described of MPR secondary to accidental ligation of AC after mitral annuloplasty.

P763 Asymptomatic severe organic mitral regurgitation: Does the anatomic substrate affect the functional response to supine ergometry?

Abstract Asymptomatic severe mitral regurgitation (MR) remains a grey zone in decision making for intervention. The predictive role of left ventricular (LV) functional reserve remains uncertain and the potential role of the anatomical substrate has not been elucidated. Aim of the study was to compare the LV function and hemodynamic changes during supine ergometry (Ex) in asymptomatic severe MR between myxomatous (Myx) and degenerative (Deg) substrate. Methods 32 patients with Deg (male M/female F = 15/17) and 19 with MyxS (M/F = 7/12) were studied at rest (R) and Ex. We estimated heart rate (HR), rate-pressure product (HRxBP), LV endsystolic (LVESV)- enddiastolic volume (LVEDV), ejection fraction (EF), LV longitudinal strain (GLS), transmitral E wave (E), ratio E/e, peak tricuspid gradient (TrPG). To adjust for a potential volume effect on GLS, GLS was normalized to volumes and respective ratios were considered (GLS/LVESV, GLS/LVEDV). Parameters were measured at R and Ex and % changes were calculated : %d (Ex-R). Results Myx and Deg had similar chronotropic reserve and HR-BP. Myx were younger, and during Ex they had a greater LVEDV, a greater EF. a smaller E/e, and a smaller TrPG compared with Deg. Myx group, despite having a better GLS both at R and Ex, revealed a smaller % GLS improvement from R to Ex (15% vs 32%). The normalized GLS/LVESV and GLS/LVEDV were similar at R between Myx and Deg, but they showed a smaller improvement during Ex in Myx. (table-results) Conclusion Despite similar severity of MR, asymptomatic patients with MyxS revealed a different dynamic profile during Ex compared with Deg. The underlying MV substrate in organic MR might be related with a different LV adaptation to volume loading combined with subsequent uneven stress induced hemodynamic response. The disparities found might have implications both in the nature history of MR as well as in the decision making for intervention. RESULTS Parameter DegS MyxS p Age(years) 65 ± 11 44 ± 12 &amp;lt;0. 001 LVEDV Ex (ml) 85 + 32 117 ± 41 =0. 007 EF Ex(%) 65 + 7 69 ± 8 =0. 05 GLS R(%) -17.6 ± 6.8 -22.2 ± 4.3 =0. 04 GLS Ex(%) -22 ± 4 -25.0 ± 5.7 =0. 05 % d (Ex-R) LV strain/endsystolic volume 0.84 ± 0.4 -0.54 ± 0.5 =0. 05 E/e" Ex 16.7 ± 8.8 9.7 ± 2.2 =0. 004 TrPG Ex(mmHg) 59 ± 11 44 ± 11 =0. 0001

MISSION: IMPOSSIBLE; The First Randomized Trial in Asymptomatic Patients with Severe Organic Mitral Valve Regurgitation

One of the biggest controversies in valvular heart diseases is the best treatment strategy in asymptomatic patients with severe, organic mitral valve regurgitation (MR) and preserved left ventricul...

Left Ventricular Global Longitudinal Strain as a Marker of Left Ventricular Dysfunction after Mitral Valve Surgery in Organic Mitral Regurgitation

Introduction Due to lack of reliable echocardiographic parameters to predict recovery after the surgery, the optimal timing of mitral valve surgery in asymptomatic patients with mitral regurgitation (MR) remains controversial. Therefore this study sought to evaluate left ventricular (LV) global longitudinal strain (GLS), assessed with 2 dimension speckle-tracking echocardiographic analysis (2D- STE) as a predictor of LV dysfunction after mitral valve repair (MVR). Method We conducted a meta-analysis and searched MEDLINE, EMBASE, and Cochrane. Selected studies reported GLS and ejection fraction (EF) amongst asymptomatic patients with moderate to severe organic MR and preoperative preserve LVEF. In all studies echocardiography was performed at baseline and long-term follow-up (>6 months) after MVR. The two primary outcomes were the pooled standardized mean difference (SMD) of EF and GLS between patients with LV dysfunction at follow up which was defined as LVEF Result Four studies met the inclusion criteria. A total of 799 patients (65.9% men, mean age 61.3) with moderate to severe organic MR who underwent successful MVR were included. LV dysfunction at follow up was present in 57 (16.2%) patients. The mean preoperative LVEF and LVGLS were 63.8% (SD 6.4) and −20.7 (SD 3.2), respectively. Many relevant outcomes were inconsistently recorded across studies and thus only a select few were eligible for further analysis. Notably, patients with postoperative LVEF ≥ 50% had a more negative GLS at baseline (i.e. closer to normal) when compared to the group with post-operative LV dysfunction (GLS pooled SMD = 2.94; 95% CI: 1.87-4.02; I-squared 17%, tau-squared heterogeneity p = 0.15). Furthermore, using baseline GLS as a predictor of post-op LV dysfunction was associated with a sensitivity of 79% (95% CI: 0.75-0.83) and a specificity of 75% (95% CI: 46-96%). Conclusion In asymptomatic patients with moderate to severe organic MR and preoperative normal LVEF who underwent MVR, LVGLS demonstrated to be a predictor of postoperative LV dysfunction.

A Simplified Technique for Correcting Mitral Valve Regurgitation via Minimally Invasive Approach

Mitral valve regurgitation may require complex repair techniques that are challenging in minimally invasive and may expose patients to prolonged cardiopulmonary bypass and cross-clamp times. Here, we present a stepwise operative approach that may facilitate the repair of the mitral valve in a minimally invasive fashion and may be carried out even when multiple posterior segments are involved. This how-to-do article presents a method that was performed in 148 patients that were referred to our institution for severe organic mitral regurgitation between 2008 and 2016. At mean ± SD follow-up of 45.5 ± 27 months, freedom from recurrent of mitral regurgitation 2+ or greater and reoperation was 95.2%.

Assessment of right ventricular function by free wall longitudinal strain in organic mitral regurgitation

Organic mitral regurgitation (MR) is a frequent heart valve disease which influences ventricular functions and impacts cardiovascular outcome. Right Ventricular Free Wall Longitudinal Strain (RVLS) is a good prognosticator in heart failure. Hence, we aimed to study its determinants in organic MR. One hundred ninety-two patients (60 ± 15 years, 125 males) with mild to severe chronic organic MR were prospectively enrolled and underwent a comprehensive echocardiography with RVLS assessment. RV ejection fraction (EF) was also measured by cardiac magnetic resonance (CMR) imaging ( n = 128) or radionuclide angiography ( n = 6) in 134 patients (70%) Patients were stratified into 2 groups according to RVLS ≤ −26% (normal function) or > −26% (RV dysfunction). Patients with RV dysfunction exhibited a more severe condition with greater MR (SOR MR: 0.46 ± 0.25 cm 2 versus 0.38 ± 0.22 cm 2 , P = 0.023), were more symptomatic (NYHA 2.0 ± 0.9 versus 1.5 ± 0.6, P < 0.0001), had a lower left ventricular global longitudinal strain (LVGLS) (−19.6 ± 3.9% versus −21.5 ± 2.8%, P = 0.0001) and a lower RV EF by CMR/radionuclide Imaging (45.8 ± 10% versus 50.2 ± 7%, P = 0.0037). RVLS correlated with TAPSE ( r = −0.40, P < 0.0001), RV Fractional shortening ( r = −0.38, P < 0.0001), TEI index ( r = 0.3, P < 0.0001) and tricuspid annular systolic velocity ( r = −0.27, P < 0.0001). In addition, RVLS correlated only weakly ( r = −0.40, P < 0.0001) with RV EF. In multivariate analysis, pathophysiological determinants of RVLS were rhythm ( β = −0.26, P < 0.0001), pulmonary vascular resistance (Abbas formula, β = 0.26, P < 0.0001), LVGLS ( β = 0.19, P = 0.01) and LV end-systolic volume ( β = 0.15, P = 0.028). RVLS correlates with classical echocardiographic parameters of RV function. RVLS is influenced by pulmonary vasculature resistance (ventriculo-arterial coupling) and LV function (RV to LV interdependence), in agreement with previous findings. As a simple parameter, RVLS could be added to the routine assessment of RV function in organic MR.

Prognostic of the right ventricular strain in organic mitral regurgitation

Organic mitral regurgitation (MR) is a frequent heart valve disease which influences ventricular functions and impacts cardiovascular outcome. Right Ventricular Free Wall Longitudinal Strain (RVLS) is a good prognosticator in heart failure. Hence, we aimed to study its predictive value in organic MR. Two hundred fifty-eight patients (59 ± 15 years, 154 males) with mild to severe organic MR were prospectively enrolled with a complete echocardiography including RV free wall and LV global longitudinal strain assessment. Out of 181 patients with moderate to severe MR, 101 had normal LV and RV function (NoDysf), 40 patients (22%) had an isolated LV dysfunction (≤ −20%, LVdysf), 17 (9%) had an isolated RV dysfunction (≤ −21%, RVdysf), 23 (13%) had a biventricular dysfunction (BiVdysf). Biventricular dysfunction was strongly associated with worse structural (tricuspid annulus diameter: 22.2 ± 3.5 mm/m 2 vs. 19.2 ± 3.5 mm/m 2 , P = 0.0003) and functional RV remodeling (RV fractional shortening: 27.6 ± 9.6% vs. 38.3 ± 11.4%, P < 0.0001, TAPSE: 19.4 ± 5.3 mm vs. 25 ± 4.6 mm, P < 0.0001, tricuspid annular S wave velocity: 12.6 ± 2.9 cm/s vs. 15.5 ± 3.1 cm/s, P = 0.0001) compared with NoDysf. Pulmonary pressure (51.4 ± 20.4 mmHg vs. 39.11 ± 4 mmHg, P = 0.0002) and resistances (Abbas formula: 0.36 ± 0.15 vs. 0.22 ± 0.08, P < 0.0001) were increased in BiVdysf. Forty-nine patients (19%) experienced a cardiovascular events during the follow up period (21.6 ± 14.4 months). At 40 months follow-up, survival free of event was impaired in patients with BiVdysf compared with other groups (Nodysf: 73.2 ± 6%, RVDysf: 70.2 ± 13%, LVDysf: 66 ± 10% and BiVDysf: 41 ± 19%, P = 0.011). In organic MR, we identified by echocardiographic strain modality a sub-group of patients (BiVDysf), which portends a higher cardiovascular risk. The adjunction of RV longitudinal strain assessment in the clinical work-up of these patients could improve the evaluation of cardiovascular risk and may be helpful in the clinical-decision making process.

Identification of the Asymptomatic Patient With Severe Mitral Regurgitation: Discrepancy Between Research and Clinical Practice.

Organic mitral regurgitation (MR) is a common disorder, and because of the increase in population and its aging, the occurrence of MR is steadily increasing. Current guideline recommendations on the management of asymptomatic severe MR are conflicting and based solely on registries or nonrandomized trials in expert heart valve clinics, resulting in a lack of evidence for the best treatment strategy. In this review, we will evaluate the latest evidence on diagnostic approaches and treatment strategies for asymptomatic patients without a clear indication for surgical intervention. Implications for management in daily practice are discussed, including an update on the diagnostic approaches that are currently available for the evaluation of MR. For optimal care, it is important that every severe MR patient, including the unidentified patient, is referred to a specialized heart team and is assessed on an individual basis according to the guideline recommendations, experience of the surgical center, and the patient's characteristics and preferences. Screening and diagnostic approaches need to be performed on the basis of standardized protocols and strict criteria. In addition, specialized valve centers must meet the surgical criteria to guarantee high reparability rates in asymptomatic patients. Awareness among cardiologists and cardiothoracic surgeons, improved guidelines adherence, and a systematic approach, including strict criteria in the management of asymptomatic patients with severe organic MR, will ensure reliable and applicable results in research and daily clinical practice.

PROGNOSTIC VALUE OF INCREASE IN SYSTOLIC PULMONARY ARTERIAL PRESSURE AT LOW LEVEL OF EXERCISE IN ASYMPTOMATIC PATIENTS WITH ORGANIC MITRAL REGURGITATION -RESULTS FROM THE PROGRAM STUDY

The optimal timing of mitral valve surgery in asymptomatic patients with chronic severe organic mitral regurgitation (MR) is controversial. Exercise-induced pulmonary arterial hypertension (systolic pulmonary arterial pressure [SPAP] > 60 mmHg) has been shown to predict cardiac events. The objective of this study was to examine the prognostic value of the increase in the SPAP during the early phase of the exercise test in asymptomatic organic MR.

Relationship between mitral annulus function and mitral regurgitation severity and left atrial remodelling in patients with primary mitral regurgitation.

To explore the relationship between the mitral annular (MA) remodelling and dysfunction, mitral regurgitation (MR) severity, left ventricular (LV) and atrial (LA) size and function in patients with organic MR (OMR). A total of 52 patients (57 ± 15 years, 31 men) with mild to severe OMR and 52 controls underwent 3D transthoracic echocardiography acquisitions of the mitral valve (MV), LA, and LV. MA geometry and dynamics, LV and LA volumes, LV ejection fraction (LVEF) and emptying fractions (LAEF) were assessed using dedicated software packages. LA and LV myocardial deformations were assessed using 2D speckle-tracking echocardiography. OMR patients presented larger and more spherical MA than controls during the entire systole (P < 0.001). Although the MA non-planarity at early-systole was similar between OMR and controls (157 ± 13° vs. 153 ± 12°, P = NS), the MA became flatter from mid- to end-systole (153 ± 12 vs. 146 ± 10° and 157 ± 12 vs. 147 ± 8°, P < 0.01) in OMR. MA area fractional change was lower in patients with OMR (22 ± 5% vs. 28 ± 5%, P < 0.001), and correlated with the MR orifice and volume (r = -0.52 and r = -0.55). MA fractional area change correlated with LA minimum and maximum volumes (r = 0.77 and r = 0.70), total and active LAEF (r = 0.72 and r = 0.76), and LA negative strain and strain rate (r = 0.52 and r = 0.57), but not with the LVEF or LV global longitudinal strain. In a multivariate regression model using LAEF and LVEF, solely active LAEF correlated with the MA fractional area change (β = 0.51, P = 0.005). In patients with OMR, MA reduced function correlates with the MR severity and the LA size and function, but not with the LV function.

Patient-Specific Quantitation of Mitral Valve Strain by Computer Analysis of Three-Dimensional Echocardiography: A Pilot Study.

A paucity of data exists on mitral valve (MV) deformation during the cardiac cycle in man. Real-time 3-dimensional (3D) echocardiography now allows dynamic volumetric imaging of the MV, thus enabling computerized modeling of MV function directly in health and disease. MV imaging using 3D transesophageal echocardiography was performed in 10 normal subjects and 10 patients with moderate-to-severe or severe organic mitral regurgitation. Using proprietary 3D software, patient-specific models of the mitral annulus and leaflets were computed at mid- and end-systole. Strain analysis of leaflet deformation was derived from these models. In normals, mean strain intensity averaged 0.11±0.02 and was higher in the posterior leaflet than in the anterior leaflet (0.13±0.03 versus 0.10±0.02; P<0.05). Mean strain intensity was higher in patients with mitral regurgitation (0.15±0.03) than in normals (0.11±0.02; P=0.05). Higher mean strain intensity was noted for the posterior leaflet in both normal and organic valves. Regional valve analysis revealed that both anterior and posterior leaflets have the highest strain concentration in the commissural zone, and the boundary zone near the annulus and at the coaptation line, with reduced strain concentration in the central leaflet zone. In normals, MV strain is higher in the posterior leaflet, with the highest strain at the commissures, annulus, and coaptation zones. Patients with organic mitral regurgitation have higher strain than normals. Three-dimensional echocardiography allows noninvasive and patient-specific quantitation of strain intensities because of MV deformations and has the potential to improve noninvasive characterization and follow-up of MV disease.

THE PRONOSTIC VALUE OF RIGHT VENTRICULAR SYSTOLIC FUNCTION IN ASYMPTOMATIC PATIENTS WITH ORGANIC MITRAL REGURGITATION

In patients with asymptomatic severe organic mitral regurgitation (MR), there is a dilemma with regard to the type of treatment that should be used: i.e. watchful waiting versus early prophylactic surgery. It is thus important to develop novel biomarkers to assist the clinician in this difficult therapeutic decision making. The triggers for performing mitral valve surgery are essentially based on MR severity, symptoms, and LV function. We hypothesized that the assessment of right ventricular (RV) function could be useful to enhance risk stratification and therapeutic decision process. The objective of the study is to assess the impact of right ventricular function on prognosis in patients with asymptomatic mitral regurgitation. As part of the prospective study PROGRAM, 120 asymptomatic patients with at least a moderate MR were recruited. The RV function was assessed in a CoreLab and included the following measurements: tricuspid annular plane systolic excursion (TAPSE), tricuspid annular plane velocity (TAPSV), right ventricular fractional shortening (RVFS) and right ventricular free wall longitudinal strain (RVLS). The primary study end-point was the composite of occurrence of atrial fibrillation, symptoms, hospitalization for heart failure, or death. RVLS correlated with the MR effective regurgitant orifice area (EROA; r=0.45, p<0.0001), the RVFS (r = 0.6, p <0.001), and the TAPSE (r = 0.46, p<0.001). Ten percent (10%) of patients had RV dysfunction according to RVLS (i.e. < 20%) versus 2% according to TAPSE (i.e. <17). During a mean follow-up of 17±15 months, the rate of composite events was 57% for patients with RV dysfunction based on RVLS versus 27% in those with no RV dysfunction (P=0.08).In multivariable analysis, independent predictors of events was the EROA (P= 0.006), RV strain (p=0.05). The results of this study suggest that the assessment of RV function with the use of RV free wall longitudinal strain provides incremental prognostic valve beyond the other echocardiographic parameters of MR severity and LV function. This information could be helpful to identify the patients with asymptomatic severe MR who may benefit from early surgery.

Psychoemotional and Quality of Life Response to Mitral Operations in Patients With Mitral Regurgitation: A Prospective Study

Severe mitral regurgitation (MR) is associated with frequent alteration of psychoemotional status (PES), with anxiety and stress symptoms related to health-related quality of life (HR-QOL). Yet, it is unknown whether surgical correction of MR leads to improvement or deterioration in PES and HR-QOL. We prospectively performed comprehensive MR assessment and administered questionnaires assessing PES and HR-QOL in 131 patients (aged 60 years; 75% men) before and 6 months after operation for organic MR and compared them to 62 patients who did not undergo operation for mitral disease and 36 normal controls of similar age assessed with the same methods. Baseline PES was poorer preoperatively in patients undergoing mitral operation compared with patients who did not undergo mitral operation and normal controls (anxiety and posttraumatic stress [PTS]; both p < 0.01) with poorer physical HR-QOL (p < 0.01). Six months later, all these psychoemotional variables improved (all p ≤ 0.02) in the patients who underwent mitral operation, whereas no change was observed in the other 2 groups (all p > 0.1). Improvement after mitral repair resulted in postoperative normalization of emotional and physical well-being, with similar scores among all groups (all p ≥ 0.4). At 6-month follow-up, no difference in improvement in PES and HR-QOL was noted according to the surgical approach (robotic versus sternotomy, all p ≥ 0.2). Patients with severe organic MR present with frequent psychoemotional alterations and HR-QOL deterioration, in contrast to patients who do not undergo mitral operation and normal controls. After mitral operation, notable improvement results in normalization of emotional and physical well-being. Quantification ofemotional and physical well-being provides important outcome measures in patients with organic MR and uncovers important benefits provided by surgical correction of MR.

TCTAP A-091 Effects of Left Atrial Strain on Functional Capacity in Severe Organic Mitral Regurgitation

TCTAP A-091 Effects of Left Atrial Strain on Functional Capacity in Severe Organic Mitral Regurgitation

Aortic valve sclerosis as a marker of coronary artery atherosclerosis; a multicenter study of a large population with a low prevalence of coronary artery disease

There are no studies analyzing the association between aortic valve sclerosis (AVS) and coronary artery disease (CAD) in a large and multicenter patient population with an overall low prevalence of CAD. We hypothesized that AVS could predict the presence and degree of CAD in patients with severe organic mitral regurgitation. MethodsWe retrospectively analyzed consecutive patients with flail mitral leaflet who had coronary angiography for pre-surgical screening and not because suspect of CAD. End-points were considered: 1) any degree of CAD (stenosis>20%) and 2) obstructive CAD (stenosis>75% of at least one coronary artery). AVS was defined as focal areas of increased echogenicity and thickening of the leaflets. Traditional clinical risk factors were considered: age, male gender, hypertension (>140/90mmHg or medical therapy), hypercholesterolemia (total cholesterol>200mg/dl or statin), diabetes, family history of CAD and smoking habit. Results675 patients (mean age: 64±12; 27% female) formed the study population. Among patients with AVS, 60% and 39% had any-CAD and ob-CAD respectively, on the opposite among patients without AVS 12% and 7% had any-CAD and ob-cad. After adjustment for clinical risk factors, AVS was associated with a 22.7 fold increased risk of any degree of CAD (95% CI 8.1 63.6 p<0.0001) and with a 21.8 fold increased risk of obstructive-CAD (95% CI 6.6 71.9; p<0.0001). ConclusionIn a large and multicenter sample of patient with flail mitral leaflet, AVS was strongly associated with the presence and degree of CAD independently of clinical risk factors.

Tissue Doppler Imaging Predicts Left Ventricular Reverse Remodeling After Surgery for Mitral Regurgitation

Tissue Doppler imaging of systolic mitral annular velocity (Sm) has been shown to be able to detect early left ventricular (LV) dysfunction in the presence of chronic severe mitral regurgitation with normal left ventricular ejection fraction. We investigated the association of preoperative Sm with LV reverse remodeling after mitral valve surgery. Patients with chronic severe organic mitral regurgitation exhibiting LV ejection fraction greater than 60% were enrolled. The LV reverse remodeling was defined as changes of LV mass index of 20% or greater postoperatively. The primary endpoints were to compare the changes of LV mass index in relation to the tertile distribution of the Sm and evaluate predictive value of the Sm for LV reverse remodeling. In all, 169 patients were analyzed. The changes of LV mass index in the first tertile was 25% (11%to 37) compared with 34% (19% to 43%) in the second tertile and 34% (26% to 47%) in the third tertile (p= 0.003). On multivariate analysis, Sm was the only independent predictor of LV reverse remodeling (odds ratio 1.77, 95% confidence interval: 1.30 to 2.40, p < 0.001). The optimal cutoff value measured by receiver-operating characteristic curve analysis was 7 cm/s of Sm (area under the curve 0.721, 95% confidence interval: 0.64 to 0.80, p< 0.001). In patients with severe mitral regurgitation exhibiting LV ejection fraction greater than 60%,surgery may be considered before the Sm is decreased below 7 cm/s to achieve favorable LV reverse remodeling.