Severe Primary Mitral Regurgitation Research Articles

ECHOCARDIOGRAPHIC OUTCOMES FOLLOWING EDWARDS TRANSCATHETER MITRAL VALVE REPLACEMENT SYSTEM FOR SIGNIFICANT MITRAL REGURGITATION: A SINGLE CENTRE EXPERIENCE

Transcatheter mitral valve repair (TMVr), particularly edge-to-edge repair, is now a well-established alternative for patients with severe primary mitral regurgitation (MR) considered to be high or prohibitive surgical risk. More recently, transcatheter mitral valve replacement (TMVR) has emerged as a potential therapeutic option for the treatment of clinically significant MR. Several devices are under preclinical and clinical assessment, and the early experience has demonstrated the feasibility of TMVR. Specifically, the Edwards EVOQUE TMVR system has shown promise in early clinical experiences for mitral regurgitation. This analysis sought to evaluate 30-day echocardiographic outcomes with the EVOQUE TMVR System (Edwards Lifesciences) for the treatment of MR.

Early Experience With a Novel Transfemoral Mitral Valve Implantation System in Complex Degenerative Mitral Regurgitation

The aim of this study was to evaluate the feasibility, procedural results, and 6-month outcomes of a novel transfemoral transcatheter mitral valve implantation (TMVI) system (Cephea) in patients with complex primary mitral regurgitation (MR). TMVI is emerging as an alternative to surgery in patients with severe MR. To date, the great majority of TMVI systems use the transapical surgical approach. This study included consecutive patients undergoing transfemoral TMVI with the Cephea valve system. All patients were suboptimal candidates for catheter-based repair for anatomic reasons. Patients underwent clinical, echocardiographic, and computed tomographic angiographic follow-up at 6months. Main outcomes were procedural success, peri-procedural complications, and valve hemodynamic status early and at 6-month follow-up. Three patients with severe primary MR (2 women, mean age 79 ± 3 years) at prohibitive surgical risk (mean European System for Cardiac Operative Risk Evaluation II score 13.8 ± 2.4%) were included. The valves were successfully implanted in all patients, with no procedural complications. Post-procedural echocardiography showed normal valve function in all patients (mean transvalvular gradient 3mmHg; range: 2 to 4mmHg), no moderate to severe valvular or paravalvular leak, and no clinically significant left ventricular outflow tract obstruction. At 6months, all patients had improved quality of life (mean improvement vs. baseline 16.4 ± 12 points). All valve hemodynamic parameters were maintained. Computed tomographic angiography confirmed annular stability, proper valve geometry and no structural failure. The transfemoral delivery of a purposely designed mitral prosthesis (Cephea valve) was safe and feasible in prohibitive risk patients. Valve performance was sustained, and clinical outcomes improved at 6months.Larger clinical studies are required.

VALUE OF 3D SPECKLE TRACKING ECHOCARDIOGRAPHY IN ASSESSMENT OF LEFT VENTRICULAR SYSTOLIC MECHANICS BEFORE AND AFTER MITRAL VALVE REPLACEMENTIN PATIENTS WITH SEVERE PRIMARY MITRAL REGURGITATION

Background: The mitral valve repair or replacement is indicated for patients with symptomatic mitral incompetence. When operative treatment is being considered, the chronic and often slowly but relentlessly progressive nature of MR must be weighed against the immediate risks and long-term uncertainties attendant onsurgery, especially if mitral valve replacement (MVR) is required. Objectives: Tostudy and assess the left ventricular function in patients with mitral valve incompetence before and after mitral replacement. By real-time 3-dimensional (3D) speckle tracking echocardiography (RT3D-STE). Patients and methods: The ethical approval was obtained from the hospital ethical research committee and each patient entering the study signed an informed consent. The study involved 40 patient with severe primary mitral regurgitation collected from the Cardiology clinic of Al-Azhar University Hospitals. The patients were screened for the study enrolment prospectively. The study was performed at Islamic cardiac center of cardiology, Al-Azhar University at the period from June 2019 to April 2020.Detailed history, physical examination, resting ECG, conventional 2D echocardiography assessment, strain imaging with measurement of LV-GLS 2D speckle tracking and RT3D-STE (Left ventricular ejection fraction (LVEF), and global longitudinal, area, radial, and circumferential strain (GLS, GAS, GRS, and GCS). Results: Real time 3D speckle tracking echocardiography was an echocardiographic modality that could detect early and subtle LV dysfunction in patients with mitral regurgitation. Conclusion: Real time 3D speckle tracking echocardiography could detect early and subtle LV dysfunction in patients with mitral regurgitation and could predict prognosis of the patient and determine the time of surgery in which the patient could get the most value. Abbreviation: MVR: mitral valve replacement, LV: left ventricle, GLS: global longitudinal strain, GAS: global area strain, GCS: global circumferential strain, GRS: global radial strain

Left atrial strain as a pre-operative prognostic marker for patients with severe mitral regurgitation

BackgroundIn patients with severe mitral regurgitation (MR), additional echocardiographic indices could be helpful to optimize surgical timing before irreversible left heart myocardial dysfunction has occurred. We investigated the correlation of left atrial (LA) strain by speckle tracking echocardiography with prognosis after mitral surgery for severe MR, and its association with LA fibrosis. Method71 patients with primary severe MR undergoing pre-operative echocardiographic assessment were initially enrolled. Exclusion criteria were: other valvular disease>moderate, history of coronary artery disease, heart failure (HF), hypertrophic cardiomyopathy, left bundle branch block, previous pacemaker implantation, heart transplantation, poor acoustic window.The primary endpoint was the occurrence of composite events (HF and mortality); the secondary endpoint was post-operative functional capacity (NYHA and Borg CR10 class). LA fibrosis was assessed by atrial biopsy specimens in a subset of patients. ResultsOf 65 eligible patients, the primary endpoint occurred in 30 patients (medium follow-up: 3.7 ± 1 years for event-group, 6.8 ± 1 years for non-event group). After Kaplan-Meier analysis, peak atrial longitudinal strain (PALS) provided good risk stratification (5-year event-free survival:90 ± 5% for PALS≥21% vs 30 ± 9% for PALS<21%, p < 0.0001); it was an independent and incremental predictor of outcome in four multivariate Cox adjusted models. There was also an association between PALS and the secondary endpoint (NYHA: r2 = 0.11, p = 0.04; Borg CR10: r2 = 0.10, p = 0.02) and an inverse correlation between PALS<21% and LA fibrosis (r2 0.80, fibrosis: 76.6 ± 20.7% vs 31.9 ± 20.8%;p < 0.0001). ConclusionsGlobal PALS emerged as a reliable predictor of outcome and functional capacity for severe primary MR, and as a marker of LA fibrosis.

Flexible or rigid ring in mitral annuloplasty-do the results differ?

Mitral valve annuloplasty has evolved over the decades since its introduction and Carpentier played a major role in developing the technique. Mitral valve repair is preferred over replacement for severe primary mitral regurgitation, as it restores normal life expectancy when successful and does not require lifelong anticoagulation. There is an ongoing debate regarding the choice of ring for mitral valve annuloplasty-rigid or flexible. At present, the choice of ring is based on the availability of the ring and left to the surgeon's discretion. This is a retrospective study conducted at a tertiary referral centre. To compare the outcomes of mitral valve repair annuloplasty with flexible and rigid rings. The hospital records of 112 patients who underwent mitral valve annuloplasty between January 2010 and December 2014 at our hospital were studied. All patients were followed up for 5years. The rigid and flexible groups were compared for left ventricular (LV) size regression and the presence of mitral regurgitation (MR). One hundred and eight patients had no progression of mitral regurgitation at 5-year follow-up, compared with the immediate postoperative period. The choice of the ring (rigid and flexible) did not affect the recurrence of mitral regurgitation. At 5-year follow-up, three patients (2 patients in the rigid group and 1 patient in the flexible group) had 3+ MR. One of the two patients in the rigid group had poor functional status and underwent mitral valve replacement (MVR). The other two patients (one in the rigid group and one in the flexible group) with 3+ MR had class II NYHA symptoms and were on medical follow-up. The left ventricular internal diameter diastolic (LVIDD) measured 59.1mm in the flexible ring group and 56.76mm in the rigid group preoperatively and these values reduced to 48.4mm and 47.3mm, at 5-year follow-up respectively. The mean left ventricular internal diameter systolic (LVIDS) size regression at 5years was 4.5 ± 6.09mm in the flexible ring group and 3.2 ± 7.17mm in the rigid ring group and the difference is not statistically significant (p value 0.314). The mean LVIDD size regression at 5years was 10.62 ± 6.57mm in the flexible ring group and 9.38 ± 9.29mm in the rigid ring group and the difference is not statistically significant (p value 0.408). The choice of rigid or flexible ring did not have a marked difference on the outcome of mitral valve annuloplasty at midterm follow-up.

Prevalence and Predictors of Atherosclerotic Peripheral Arterial Obstructive Disease in Severe Heart Valve Diseases.

Despite witnessing an upsurge in heart valve diseases (HVDs), the correlation between HVDs and atherosclerotic peripheral arterial obstructive disease (PAOD) remains unclear. This study aims to investigate the prevalence and predictors of PAOD in HVDs.In this study, a total of 245 consecutive patients were examined: 153 with severe aortic valve stenosis (AS), 66 with severe primary mitral valve regurgitation (MR), and 26 with severe pure native aortic valve regurgitation (AR). All patients underwent ultrasound scan of the carotid artery to ascertain the presence of internal carotid artery stenosis (ICAS). ICAS was defined as a peak systolic velocity ≥ 125 cm/second and/or ≥ 50% reduction in diameter. In addition, we measured the ankle-brachial index in each leg using a volume plethysmograph. A result of ≤ 0.9 was considered lower extremity artery disease (LEAD).The presence of ICAS was statistically more frequent in patients with severe AS than in patients with severe MR and AR (11.1% versus 1.5% versus 3.8%; P = 0.038). LEAD was present in patients with severe AS (17.6%) and MR (10.6%) but not in patients with severe AR (P = 0.037). The multivariate analysis revealed that the presence of severe AS (OR, 5.6 [1.3-24.9]; P = 0.023) was an independent predictor for ICAS, while history of coronary artery disease (OR, 4.8 [2.2-10.5]; P < 0.001) was an independent predictor for LEAD.The prevalence of PAOD varies depending on each valvular disease. Individual screening should be considered on the basis of atherosclerotic risk factors, especially for patients with severe AS.

Volume-Outcome Association of Mitral Valve Surgery in the United States

Early surgery for severe primary degenerative mitral regurgitation is recommended, provided optimal outcomes are achievable. Contemporary national data defining mitral valve surgery volume and outcomes are lacking. To assess national 30-day and 1-year outcomes of mitral valve surgery and define the hospital- and surgeon-level volume-outcome association with mitral valve repair or replacement (MVRR) in patients with primary mitral regurgitation. This multicenter cross-sectional observational study used the Society of Thoracic Surgeons Adult Cardiac Surgery Database to identify patients undergoing isolated MVRR for primary mitral regurgitation in the United States. Operative data were collected from July 1, 2011, to December 31, 2016, and analyzed from March 1 to July 1, 2019, with data linked to the Centers for Medicare and Medicaid Services. The primary outcome was 30-day in-hospital operative mortality after isolated MVRR for primary mitral regurgitation. Secondary outcomes were 30-day composite mortality plus morbidity (any occurrence of bleeding, stroke, prolonged ventilation, renal failure, or deep wound infection), rate of successful mitral valve repair of primary mitral regurgitation (residual mitral regurgitation of mild [1+] or better), and 1-year mortality, reoperation, and rehospitalization for heart failure. A total of 55 311 patients, 1094 hospitals, and 2410 surgeons were identified. Increasing hospital and surgeon volumes were associated with lower risk-adjusted 30-day mortality, lower 30-day composite mortality plus morbidity, and higher rate of successful repair. The lowest vs highest hospital volume quartile had higher 1-year risk-adjusted mortality (hazard ratio [HR], 1.61, 95% CI, 1.31-1.98), but not mitral reoperation (odds ratio [OR], 1.51; 95% CI, 0.81-2.78) or hospitalization for heart failure (HR, 1.25; 95% CI, 0.96-1.64). The surgeon-level 1-year volume-outcome associations were similar for mortality (HR, 1.60; 95% CI, 1.32-1.94) but not significant for mitral reoperation (HR, 1.14; 95% CI, 0.60-2.18) or hospitalization for heart failure (HR, 1.17; 95% CI, 0.91-1.50). National hospital- and surgeon-level inverse volume-outcome associations were observed for 30-day and 1-year mortality after mitral valve surgery for primary mitral regurgitation. These findings may help to define access to experienced centers and surgeons for the management of primary mitral regurgitation.

Outcomes of urgent/emergent transcatheter mitral valve repair (MitraClip): A single center experience.

To describe the outcomes of urgent/emergent transcatheter edge-to-edge mitral valve repair (TMVr) and compare the clinical, echocardiographic, and procedural characteristics of survivors and nonsurvivors. TMVr is a treatment strategy for select patients with severe primary or secondary mitral regurgitation. However, knowledge regarding outcomes for urgent/emergent TMVr is limited. All urgent or emergent TMVr procedures using MitraClip performed at the University of Washington Medical Center between January 2018 and March 2019 were identified and clinical, echocardiographic, hemodynamic, procedural, and outcomes data were obtained by chart review. Outcomes included all-cause mortality, hospital mortality, procedural success, periprocedural complications, and hospital readmission. Of the 20 patients who underwent urgent/emergent TMVr, eight were treated for cardiogenic shock (CS), four for acute decompensated heart failure (ADHF) with hypoxemic respiratory failure requiring mechanical ventilation, and eight for ADHF with failure of inpatient medical therapy. Mechanical circulatory support (MCS) was used in six patients; preceding TMVr in three patients and immediately post-TMVr in three patients. Overall, 30-day mortality and hospital readmission rates were 21 and 13%, respectively. Over a median 153 days (IQR 20-491) of follow-up, 10 patients (50%) died. Preprocedure CS, new or ongoing MCS post-TMVr, refractory respiratory failure post-TMVr, and acute kidney injury post-TMVr were associated with mortality. In a single-center retrospective analysis, urgent/emergent TMVr in high-risk patients with ADHF or CS was associated with high short-term mortality and periprocedural complications. Prospective studies are warranted to inform patient selection and periprocedural management for urgent/emergent TMVr.

Early failure of mitral valve repair with anterior leaflet pericardial patch augmentation in rheumatic and radiation-induced valvulitis.

Rheumatic mitral valve disease remains an important cause of mitral regurgitation (MR), accounting for 7% to 15% of organic MR cases in large epidemiologic studies (1,2). Similarly, a history of radiation to the mediastinum, as is common in the treatment of several malignancies, is associated with future valve dysfunction in up to one-third of patients. Mitral valve repair (MVr) is favored over replacement for severe primary MR; this is due to a significant 30-day and mid to long-term mortality benefit, as well as a reduction in peri-operative complications (3,4). However, due to ongoing inflammation and leaflet infiltration, MVr in rheumatic or radiation-induced valvulitis may be associated with decreased durability and an increased risk of reoperation (5). In order to improve outcomes of MVr in these populations, adjunctive reparative procedures have been introduced. One such technique involves the use of autologous or bovine pericardium to reconstruct or enlarge the anterior mitral leaflet (AML) and normalize its coaptation with the posterior leaflet, with further reinforcement from a supporting annuloplasty ring (Figure 1) (6). While small studies suggest excellent mid-term survival with this approach, moderate or greater recurrent MR and reoperation occurs in 11.2% and 4.6% of patients, respectively, with rheumatic MR. Poor outcome data exists in the literature regarding MVr techniques for radiation-induced valvulitis (6,7). Herein, we provide an in-depth clinical and imaging appraisal of two such cases, with a focused review on pathophysiology and management. Open in a separate window Figure 1 MVr utilizing an annuloplasty ring and AML pericardial patch augmentation. (A) Schematic of AML pericardial patch augmentation MVr. There is a reconstructed and enlarged AML, normalized anterior and posterior leaflet coaptation, and reinforcement from a supporting annuloplasty ring; (B,C) systolic and diastolic transesophageal echocardiography mid-esophageal four-chamber views. Displayed is the augmented anterior mitral leaflet and pericardial patch (red arrow). MVr, mitral valve repair; AML, anterior mitral leaflet; PML, posterior mitral leaflet.

Mechanism of Eccentric Cardiomyocyte Hypertrophy Secondary to Severe Mitral Regurgitation.

Primary valvular heart disease is a prevalent cause of morbidity and mortality in both industrialized and developing countries. Although the primary consequence of valvular heart disease is myocardial dysfunction, treatment of valvular heart diseases centers around valve repair or replacement rather than prevention or reversal of myocardial dysfunction. This is particularly evident in primary mitral regurgitation (MR), which invariably results in eccentric hypertrophy and left ventricular (LV) failure in the absence of timely valve repair or replacement. The mechanism of LV dysfunction in primary severe MR is entirely unknown. Here, we developed the first mouse model of severe MR. Valvular damage was achieved by severing the mitral valve leaflets and chords with iridectomy scissors, and MR was confirmed by echocardiography. Serial echocardiography was performed to follow up LV morphology and systolic function. Analysis of cardiac tissues was subsequently performed to evaluate valve deformation, cardiomyocyte morphology, LV fibrosis, and cell death. Finally, dysregulated pathways were assessed by RNA-sequencing analysis and immunofluorescence. In the ensuing 15 weeks after the induction of MR, gradual LV dilatation and dysfunction occurred, resulting in severe systolic dysfunction. Further analysis revealed that severe MR resulted in a marked increase in cardiac mass and increased cardiomyocyte length but not width, with electron microscopic evidence of sarcomere disarray and the development of sarcomere disruption. From a mechanistic standpoint, severe MR resulted in activation of multiple components of both the mammalian target of rapamycin and calcineurin pathways. Inhibition of mammalian target of rapamycin signaling preserved sarcomeric structure and prevented LV remodeling and systolic dysfunction. Immunohistochemical analysis uncovered a differential pattern of expression of the cell polarity regulator Crb2 (crumbs homolog 2) along the longitudinal axis of cardiomyocytes and close to the intercalated disks in the MR hearts. Electron microscopy images demonstrated a significant increase in polysome localization in close proximity to the intercalated disks and some areas along the longitudinal axis in the MR hearts. These results indicate that LV dysfunction in response to severe MR is a form of maladaptive eccentric cardiomyocyte hypertrophy and outline the link between cell polarity regulation and spatial localization protein synthesis as a pathway for directional cardiomyocyte growth.

Long-term echocardiographic evaluation of asymptomatic patients undergoing minimally invasive valve repair for severe primary mitral regurgitation

Asymptomatic patients with newly diagnosed severe primary mitral regurgitation (MR) may not be candidates for surgery according to clinical guidelines. We aimed to determine whether asymptomatic patients with severe primary MR benefit from minimally invasive mitral valve repair. This prospective registry study assessed consecutive asymptomatic patients who underwent mitral valve repair using right minithoracotomy. Left ventricular ejection fraction, end‑diastolic and end‑‑systolic volumes, end‑diastolic and end‑systolic diameters, as well as left atrial (LA) area and volume were measured. Major adverse cardiovascular and cerebrovascular events (MACCEs) were assessed at 6, 12, and 24 months after surgery. The study included 114 patients, of whom 16 (14%) were lost to follow‑up (except the endpoint of death). No deaths were reported during follow‑up. A comparison of median echocardiographic parameters at baseline and 24 months revealed significant reverse remodeling: left ventricular ejection fraction, 68% vs 60% (P <0.001); end‑diastolic volume, 165 cm3 vs 107.5 cm3 (P <0.001); end‑systolic volume, 51 cm3 vs 43.5 cm3 (P = 0.02), end‑diastolic diameter, 58 mm vs 49 mm (P <0.001); end‑systolic diameter, 35 mm vs 30 mm (P <0.001); LA area, 26 cm2 vs 18 cm2 (P <0.001); and LA volume, 96 cm3 vs 49.5 cm3(P <0.001). There were 9 MACCEs (9.2%): 2 reoperations (2%), 1 hospitalization for heart failure (1%), and 6 cases of new‑onset atrial fibrillation (6.1%). Minimally invasive mitral valve repair is safe and effective in asymptomatic patients with severe primary MR. It should be recommended regardless of ventricular and atrial dimensions.

Transcatheter Mitral Valve Replacement: State of the Art.

The emergence of transcatheter aortic valve replacement (TAVR) has segued the development of transcatheter mitral valve (MV) repair devices. Transcatheter mitral valve repair has become a well-established alternative for patients with severe primary and secondary mitral regurgitation (MR) and with a perceived surgical risk. Transcatheter mitral valve replacement (TMVR) could become a more complete form of reduction of severe MR compared to MV repair devices, albeit with significant engineering challenges and all the risks associated with a bioprosthetic heart valve. The development of TMVR devices has become prominent while companies race to become the first commercially available system. Careful consideration of design challenges should be conducted by the developmental companies to ensure successful devices. Preclinical and clinical trials have shown promising results, showcasing the feasibility of total valve replacement utilizing transcatheter procedure techniques. Further development, testing, and trials need to be conducted before TMVR can become a sensible MR treatment. This review describes design challenges and considerations along with the state of the art, involving designs in both clinical and preclinical stages.

STAGING CARDIAC DAMAGE IN PRIMARY MITRAL VALVE REGURGITATION

In patients with severe primary mitral regurgitation (MR), the indication for surgery is currently based on symptoms, left ventricular (LV) function, occurrence of atrial fibrillation and pulmonary hypertension. The aim of this study was to evaluate the prognostic impact of a new staging

Transcriptional Alterations to the Left Ventricle after Chronic Exposure to Severe Primary Mitral Regurgitation Initiate Early and Persistent Remodeling Towards Failure

Objective: Mitral regurgitation (MR) initiates left ventricular (LV) dilation, with increased chamber compliance to normalize increased diastolic filling pressures. Cardiac function remains preserv...

P903 Myocardial work in moderate to severe aortic versus primary mitral regurgitation

Abstract Funding Acknowledgements None OnBehalf None BACKGROUND Myocardial work is an emerging non-invasive technic based on echocardiographic pressure-strain loops that assess left ventricular (LV) function. The method was studied in a large variety of pathologies, but its role in the assessment of valvular regurgitations is still unknown. PURPOSE To compare myocardial work indices in moderate and severe aortic and primary mitral regurgitation. METHODS Seventy-eight patients with moderate and severe aortic regurgitation (AR) or primary mitral regurgitation (MR) and preserved LV ejection fraction (LVEF &amp;gt; 50%) were retrospectively analyzed.. Patients with significant valvular stenosis were excluded. Demographic, clinical and echocardiographic data, including LV global longitudinal strain (GLS) and myocardial work indices, were assessed. RESULTS The mean age was 58 ± 14 years, and 46 patients (59%) were men. Thirty seven patients had moderate or severe AR and 41 patients had moderate or severe MR. The two groups were homogeneous in terms of demographic and clinical data, except for age. As expected, diastolic blood pressure was lower in patients with AR compared to MR group (67 ± 8 mmHg vs. 73 ± 10 mmHg, p = 0,003), patients with MR had a higher LVEF compared to AR group (63 ± 6% vs 59 ± 6%, p = 0,03), and a higher left atrial indexed volume (53 ± 16ml/m² vs 34 ± 12ml/m², p &amp;lt; 0.0001). Overall, GLS, myocardial work index (GWI) and myocardial constructive work (GCW) were significantly lower in patients with moderate or severe AR compared to MR ( -18,1 ±3% vs -21,3 ±3,3%, p &amp;lt; 0,0001; 1849 ± 393 vs 2285 ± 499, p &amp;lt; 0,0001; and 2194 ± 395 vs 2576 ± 594, p = 0,003, respectively). Global wasted work (GWW) and global work efficiency (GWE) were similar. When comparing only asymptomatic patients, results were similar, with higher GLS, GWI and GCW in moderate to severe MR vs. AR (-22,9 ± 3,4 vs.-18,4 ± 3,4%, p &amp;lt;0,001; 2446 ± 570 vs. 1927 ± 338, p = 0.001 and 2767 ± 688 vs. 2236 ± 377, p = 0.005). Interestingly, when comparing asymptomatic patients with a LVEF &amp;gt; 50% for AR, and LVEF &amp;gt; 60% for MR, GWI and GCW were significantly lower in MR group, despite higher GLS values (1852 ± 398 vs. 2322 ± 527, p &amp;lt; 0.001; 2194 ± 400 vs. 2615 ± 638, p = 0.005; -22,1 ± 3,3% vs. -18,2 ± 2,9, p &amp;lt; 0.001). CONCLUSION Patients with moderate to severe MR have higher values of GLS, global work index and global constructive myocardial work. This could translate into the fact that in moderate or severe MR, the myocardium develops a higher amount of work than in AR, maybe to account for the loss of stroke volume into the left atrium. In asymptomatic moderate to severe MR with LVEF &amp;gt; 60%, LV myocardium develops less work than in moderate to severe AR with a LVEF &amp;gt; 50%, suggesting maybe a compensated state.

1115 Ultra-slow low-dose thrombolytic therapy as an option of treatment in intracardiac thrombus: a case report

Abstract We present a case of a 57-year-old male with previously known primary severe mitral regurgitation, who was admitted to the ICU due to massive venous thromboembolism with associated right ventricle dysfunction and with two large mobile right atrial thrombi (2.4 x 1.5 cm and 3.6 x 3.7 cm). Despite of five days with a therapeutic aPTT achieved with unfractionated heparin (UFH), a TTE showed deterioration of the right ventricle systolic function, persistence of the right atrial masses with similar dimensions together with new mobile thrombi on the coronary sinus and on the right pulmonary artery. Due to deterioration of his clinical condition and given the refractoriness to the classical treatment with UFH, it was decided to administer an ultra-slow low-dose thrombolysis protocol, which consisted in a 24-hour infusion of 24 mg of alteplase at a rate of 1 mg per hour, without bolus. The treatment was continued by 48 consecutive hours, with clinical improvement and important reduction of the right atrial masses with resolution of the coronary sinus and right pulmonary artery thrombi. The patient started hypocoagulation with warfarin bridging with low molecular weight heparin (LMWH). Seven days after alteplase discontinuation there was complete resolution of the intracardiac thrombi. One month after ICU admission a successful mitral valve replacement surgery was conducted. Three months after discharge, the patient is in functional New York Heart Association (NYHA) class I with no cardiovascular events or hospitalizations. This case demonstrates that ultra-slow low-dose thrombolysis is a valid bailout treatment option in patients with large intracardiac thrombi refractory to anticoagulation. Abstract 1115 Figure. TTE showing right atrial masses

P1754 Regional left ventricular longitudinal myocardial dysfunction in mitral valve prolapse could be primary

Abstract Background Regional left ventricular dysfunction in patients with mitral valve prolapse (MVP) and normal ejection fraction has been described by different Authors, and recent data point to a dysfunction (prevalently longitudinal strain) of the myocardium of the LV base secondary to dilatation of the mitral annulus. Purpose To investigate degree and extent of regional LV dysfunction and its mechanisms in patients with MVP, severe regurgitation and normal global systolic function, compared to patients with equivalent degree of regurgitation but functional etiology (FMR). Methods Speckle-tracking echocardiography was performed in 30 controls (N), and in severe primary (MVP, n= 50) or functional (FMR, n= 20) mitral regurgitation, to measure global, regional and segmental longitudinal peak systolic strain (LPSS, %), and time delay of peak maximum strain (TTPd, ms, calculated as time to peak maximum strain - time of aortic valve closure). Maximum and minimum mitral annulus diameters and area were measured with 3D echo. We also evaluated as recommended: LV end-diastolic volume index (EDVi, ml/m2), ejection fraction (EF, %), and left atrial end-systolic volume index (LAESVi, ml/m2) with 2D echo; LV stroke volume index, and non-invasive pulmonary systolic (PSP, mmHg) and diastolic pressures (PDP), mmHg) with Doppler echo. Results Age, heart rate, BSA and systolic blood pressure were similar between groups. Atrial fibrillation was present in 34% of MVP and 71% of FMR patients. LV EF was normal in MVP and reduced in FMR (43 ± 14 % vs N, p&amp;lt;.001). LV EDVi (MVP: 77 ± 20 ml/m2; FMR: 107 ± 35, both p&amp;lt;.001 vs N) and LAESVi (MVP: 91 ± 26 ml/m2; FMR: 80 ± 30, both p&amp;lt;.001 vs N) were similarly increased (volume overload) in MVP and FMR, as were PSP (MVP: 42 ± 23 ml/m2; FMR: 52 ± 25, both p&amp;lt;.001 vs N) and PDP (MVP: 16 ± 6 ml/m2; MVP: 15 ± 5, both p&amp;lt;.001 vs N). In FMR, LPSS was reduced globally (-12.8 ± 3.3, p&amp;lt;.001 vs N and MVP) and similarly at LV base, papillary and apical levels. In contrast, in MVP global (-19.4 ± 3.7%) and apical (-23.4 ± 4.5%) LPSS were normal, whereas LV base (-12.3 ± 5.8%, p=.003 vs N) and papillary (-17.1 ± 4%, p=.024 vs N) LPSS were reduced; further, LPSS reduction was localized to the anterior (-16 ± 4, p=.028 vs N), lateral (-17 ± 5, p=.006 vs N) and posterior (-16 ± 6, p=.007 vs N) segments, and was associated with an increased TTPd in the same segments in MVP but not in FMR patients. At multivariate analysis, degree and localisation of regional myocardial dysfunction in patients with MVP was not related to the prolapsing scallop, dimension of the mitral annulus, degree of volume overload or pulmonary pressures, or stroke volume index. Conclusions In patients with MVP, severe regurgitation and normal EF, there is a specific dysfunction pattern of regional LV longitudinal function which appears to be primary and not dependent on the degree of preload increase, mitral annulus dilatation, or localization of the prolapsing scallop.

P201 Cost-effectiveness analysis of 3D versus 2D transesophageal echocardiography for the evaluation of patients with primary mitral regurgitation with indication of surgical treatment

Abstract Funding Acknowledgements Department of Cardiovascular Imaging / Brazilian Society of Cardiology OBJECTIVES To perform the cost-effectiveness analysis of three-dimensional transesophageal echocardiography (3DTEE) in comparison to two-dimensional transesophageal echocardiography (2DTEE) for the anatomic-functional evaluation and surgical planning of severe primary mitral regurgitation. METHODS: a complete economic study was based on a systematic review of 3DTEE and 2DTEE accuracy and private health system costs of two different surgical interventions: mitral valve plasty and mitral valve replacement. The prevalence of common postoperative complications was also predicted for elective procedures: atrial fibrillation (8.6%); acute myocardial infarction (1.4%); thrombosis (3.5%); bleeding (1.5%); endocarditis (6.3%). The decision tree method was adopted as a data analysis model. The Bayes" theorem was used based on sensitivity and specificity measurements. The costs, considering literature and professional tables, were: 3DTEE = US$ 349; 2DTEE = US$ 204; diagnostic evaluation = US$ 597; surgical procedure = US$ 3,643; surgical treatment = US$ 374. RESULTS: The deterministic analysis of the diagnostic test shows that 3DTEE (non-dominated) is superior to 2DTEE (absolutely dominated). The 3DTEE presents a cost reduction of US$ 1,147 and incremental effectiveness (true identification) of 22% when compared to 2DTEE. The multivariate probabilistic sensitivity analysis showed that after 100,000 iterations, the diagnosis based on the 3DTEE becomes the first choice regardless of the willingness to pay threshold. CONCLUSIONS: 3DTEE was cost-effective compared to 2DTEE. Thus, 3DTEE is a potential device to promote health compared to 2DTEE for surgical planning of severe primary mitral regurgitation Abstract P201 Figure. Sensitivity Analysis

Myocardial fibrosis in asymptomatic and symptomatic chronic severe\xa0primary mitral regurgitation and relationship to tissue characterisation and left ventricular\xa0function on cardiovascular magnetic resonance

BackgroundMyocardial fibrosis occurs in end-stage heart failure secondary to mitral regurgitation (MR), but it is not known whether this is present before onset of symptoms or myocardial dysfunction. This study aimed to characterise myocardial fibrosis in chronic severe primary MR on histology, compare this to tissue characterisation on cardiovascular magnetic resonance (CMR) imaging, and investigate associations with symptoms, left ventricular (LV) function, and exercise capacity.MethodsPatients with class I or IIa indications for surgery underwent CMR and cardiopulmonary exercise testing. LV biopsies were taken at surgery and the extent of fibrosis was quantified on histology using collagen volume fraction (CVFmean) compared to autopsy controls without cardiac pathology.Results120 consecutive patients (64 ± 13 years; 71% male) were recruited; 105 patients underwent MV repair while 15 chose conservative management. LV biopsies were obtained in 86 patients (234 biopsy samples in total). MR patients had more fibrosis compared to 8 autopsy controls (median: 14.6% [interquartile range 7.4–20.3] vs. 3.3% [2.6–6.1], P < 0.001); this difference persisted in the asymptomatic patients (CVFmean 13.6% [6.3–18.8], P < 0.001), but severity of fibrosis was not significantly higher in NYHA II-III symptomatic MR (CVFmean 15.7% [9.9–23.1] (P = 0.083). Fibrosis was patchy across biopsy sites (intraclass correlation 0.23, 95% CI 0.08–0.39, P = 0.001). No significant relationships were identified between CVFmean and CMR tissue characterisation [native T1, extracellular volume (ECV) or late gadolinium enhancement] or measures of LV function [LV ejection fraction (LVEF), global longitudinal strain (GLS)]. Although the range of ECV was small (27.3 ± 3.2%), ECV correlated with multiple measures of LV function (LVEF: Rho = − 0.22, P = 0.029, GLS: Rho = 0.29, P = 0.003), as well as NTproBNP (Rho = 0.54, P < 0.001) and exercise capacity (%PredVO2max: R = − 0.22, P = 0.030).ConclusionsPatients with chronic primary MR have increased fibrosis before the onset of symptoms. Due to the patchy nature of fibrosis, CMR derived ECV may be a better marker of global myocardial status.Clinical trial registration Mitral FINDER study; Clinical Trials NCT02355418, Registered 4 February 2015, https://clinicaltrials.gov/ct2/show/NCT02355418

Robotic Mitral Valve Repair: Indication for Surgery Does Not Influence Early Outcomes

ObjectiveTo evaluate the outcomes of robotic mitral valve repair (MVr) by primary indication per American Heart Association guidelines for surgery: class I vs class IIa. Patients and MethodsFrom January 1, 2008, through September 30, 2016, 603 patients underwent robotic MVr for severe primary mitral regurgitation. Medical records of 576 consenting patients were retrospectively reviewed to determine the primary indication for surgery. Patients were stratified into class I or class IIa, and preoperative, intraoperative, and postoperative variables were compared. ResultsOf 516 patients, 428 (83%) had class I indication and 88 (17%) had class IIa indication for surgery. Preoperatively, no significant differences were observed between both cohorts. Importantly, a significantly higher number of patients with class I indication underwent MVr for bileaflet prolapse (172 of 428 [40%] vs 21 of 88 [25%]; P=.03). Early MVr outcomes indicated recurrent mitral regurgitation (moderate or greater) in only 12 of 576 (2%), and no significant differences were observed between classes (P=.23). Apart from parameters for ventricular size, all other intraoperative and postoperative variables were comparable between both cohorts. ConclusionComparable outcomes were indicated across all classes of indications for MVr surgery. These results continue to support the use of this surgical technique, even in less sick patients. Early referral along with more extensive robotic MVr experience will likely result in further improvements in long-term outcomes.