Severe Primary Mitral Regurgitation Research Articles

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 > 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 < 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 < 0,0001; 1849 ± 393 vs 2285 ± 499, p < 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 <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 > 50% for AR, and LVEF > 60% for MR, GWI and GCW were significantly lower in MR group, despite higher GLS values (1852 ± 398 vs. 2322 ± 527, p < 0.001; 2194 ± 400 vs. 2615 ± 638, p = 0.005; -22,1 ± 3,3% vs. -18,2 ± 2,9, p < 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 > 60%, LV myocardium develops less work than in moderate to severe AR with a LVEF > 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<.001). LV EDVi (MVP: 77 ± 20 ml/m2; FMR: 107 ± 35, both p<.001 vs N) and LAESVi (MVP: 91 ± 26 ml/m2; FMR: 80 ± 30, both p<.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<.001 vs N) and PDP (MVP: 16 ± 6 ml/m2; MVP: 15 ± 5, both p<.001 vs N). In FMR, LPSS was reduced globally (-12.8 ± 3.3, p<.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.

P4366Application of 3D-dual volume layout imaging for rapid intraprocedural guidance in Mitraclip procedure

Abstract Introduction Intraprocedural guidance and monitoring with transesophageal echocardiography (TEE) and invasive hemodynamic assessment are currently the best available options for evaluating procedural success of percutaneous mitral valve (MV) repair with Mitraclip System (Abbott Vascular, Santa Clara, CA, USA). However, despite its crucial importance, echocardiography has some limitations in immediate evaluation of residual jets after clip implantation, so that, in absence of validated method for double orifice effective regurgitant orifice (ERO) assessment, the most reliable parameter that is currently used is the mean trans-valvular gradient. Purpose This prospective study aimed to assess the role of a new echocardiographic parameter obtained from 3D-Color-Full volume imaging of MR for evaluation of outcomes of mitraclip procedures, comparing it with invasive LAP measurements. Material and methods We prospectively performed the computation of a new parameter in patients with symptomatic moderate-severe to severe primary or secondary mitral regurgitation (MR) underwent MitraClip procedure. This parameter is easy and fast to be obtained out of 3D dataset and represents the 2D area of the proximal isovelocity surface zone visualized from the ventricular view, without any imaging processing (“3D dual volume PISA area”) (figure). It was obtained as following: i) acquisition of 3D-zoomed-color image of MR jet with adequate frame rates; ii)displaying of the volume sampling in “dual volume layout” so one can see the “ventricular aspect” of the jet area corresponding to proximal isovelocity surface “zone”; iii) awareness of correct alignment to the direction of the flow in proximal zone; iiii) freezing and direct measurement of this area (summarize if more than 1 orifice) (1 attached). We compared the variation of this parameter from the beginning to end of procedure with the variation of LAP measurements, that is currently the most important parameter for assessing outcome of procedures. Results The study includes dataset of 11 patients. The baseline value of 3D dual volume PISA area was 1,191±0,40 cm2 and the mean change we obtained was 0,65±0,30 cm2 (mean of 77% of reduction until the end of procedure). Mean values of LAP were slightly decreased in all cases: basal m-LAP was 12±3,3 mmHg and decreased by 15%. Despite the small number of patients, we observed a significant correlation between the changes of LAP and the change of 3D dual volume PISA area (R: 0.6, p: 0,048). Conclusions This is the first demonstration of the usefulness of echocardiographic parameter obtained by 3Ddual volume layout imaging for rapid intraprocedural guidance in Mitraclip procedure. This parameter is related to hemodynamic variations that it currently considerable surrogate of outcomes. These data need to be confirmed by a larger study.

P1779Quantitation of severe degenerative mitral regurgitation by echocardiography and CMR with acetate PET for external reference for left ventricular volumes

Abstract Background Quantitative echocardiographic assessment of severity of primary mitral regurgitation (MR) is challenging. CMR is recommended if MR severity cannot be clearly determined, since quantitation of regurgitation as well as of left ventricular (LV) volumes and function is crucial for the indication for surgery especially in asymptomatic patients. Purpose We aimed to compare volumetric measurements obtained from transthoracic echo (TTE) and cardiovascular magnetic resonance (CMR) using ECG-gated [(11)C]acetate PET as reference for assessment of LV volumes. Methods A total of 51 asymptomatic patients with severe primary mitral regurgitation underwent TTE, CMR and PET on the same day. Mitral regurgitant volumes (RVol) were measured by TTE using proximal convergence (PISA) method and by CMR, subtracting aortic forward flow volume from LV stroke volume. LV volumes were measured by TTE, CMR and PET. Results Despite a fair correlation between regurgitant volumes measured by TTE and CMR (r=0.53, p&lt;0.001), PISA method heavily overestimated regurgitant volumes on TTE as compared to CMR (103±60ml vs. 78±35ml, p&lt;0.001). TTE systematically underestimated LV volumes as compared to CMR (see table) despite a good correlation (r=0.81, 0.67 and 0.76 respective for LV EDV, ESV and SV, p&lt;0.001 for all). There was no difference in LV EF between the methods. LV volumes obtained by CMR and PET showed a strong correlation (r=0.92, 0.79 and 0.89 respective for LV EDV, ESV and SV, p&lt;0.001 for all) and agreement (see table). Comparison of TTE, CMR and PET TTE CMR PET PET TTEvs.CMR PET CMRvs.PET F-test LV EDV, ml 145±34 241±57 234±51 &lt;0.001 0.004 &lt;0.001 LV ESV, ml 47±11 76±22 81±23 &lt;0.001 0.067 &lt;0.001L LV SV, ml 99±26 164±38 152±34 &lt;0.001 &lt;0.001 &lt;0.001 LV EF, % 68±5 69±5 65±6 0.236 &lt;0.001 &lt;0.001 Conclusions As compared to CMR, PISA method used by TTE substantially overestimates regurgitant volumes in patients with asymptomatic primary mitral regurgitation. Conversely, LV volumes in spite of good correlation are heavily underestimated by TTE in comparison with CMR. A strong correlation and agreement between LV volumes measured by CMR and PET confirms the accuracy of the former method which is considered as a golden standard for assessment of ventricular function and volumes. Thus, even so-called quantitative echo measures should be understoas essentially semi-quantitative indicators of severity.

Mitral valve repair based on physical characterization of coaptation forces

Open surgical mitral valve repair (MVr) is the gold standard treatment for severe primary mitral regurgitation (MR). Several approaches have been set forth in prior literature to mimic ventricular systole intraoperatively, such as the saline solution test and the ink test.1 Such methods provide only a morphologic and approximate assessment. The success of an MVr procedure today thus still depends primarily on the expertise of the individual surgeon. Consequently, major heterogeneities are observed globally in MVr repair rates, surgical techniques, and outcomes.

The MITRA-HR study: design and rationale of a randomised study of MitraClip transcatheter mitral valve repair in patients with severe primary mitral regurgitation eligible for high-risk surgery.

Percutaneous mitral valve repair has become an alternative to conventional surgery in patients suffering primary mitral regurgitation (MR) with a contraindication to surgery and could benefit patients at high surgical risk. The aim of the MITRA-HR study is to raise the level of evidence supporting the use of the MitraClip device in primary MR patients with a predefined high risk for surgery. MITRA-HR is a prospective, multicentre, randomised study designed to compare mitral valve repair using the MitraClip with conventional surgery in patients with severe primary mitral regurgitation at high risk for surgery. The surgical risk is defined by age, Society of Thoracic Surgeons (STS) risk estimate score, frailty, major organ system dysfunction, and procedure-specific impediments. The study will enrol 330 patients randomised between conventional surgery and MitraClip with a 1:1 ratio. The composite primary endpoint includes all-cause mortality, unplanned rehospitalisation for cardiovascular reasons, and mitral valve reintervention at 12 months. The main secondary safety endpoint is a major adverse event composite assessment evaluated 30 days after the procedure. The randomised MITRA-HR study is designed to provide additional supportive evidence of non-inferiority in efficacy and superiority in safety for percutaneous mitral valve repair using the MitraClip compared to conventional surgery in high surgical risk patients.

Prognostic Value of Global Longitudinal Strain and Etiology After Surgery for Primary Mitral Regurgitation

ObjectivesThis study sought to investigate whether left ventricular (LV) global longitudinal strain (GLS) is associated with long-term outcome after mitral valve (MV) surgery for primary mitral regurgitation (MR) and assess the differences in outcome according to MR etiology: Barlow’s disease (BD), fibroelastic deficiency (FED), and forme fruste (FF). BackgroundAppropriate timing of MV surgery for primary MR is still challenging and may differ according to the etiology. In these patients, LV-GLS has been proposed as more sensitive measure to detect subtle LV dysfunction as compared with LV ejection fraction. MethodsEchocardiography was performed in 593 patients (64% men, age 65 ± 12 years) with severe primary MR who underwent MV surgery, including assessment of LV-GLS. The etiology (BD, FED, or FF) was defined based on surgical observation. During follow-up, primary endpoint was all-cause mortality and a secondary endpoint included cardiovascular death, heart failure hospitalizations, and cerebrovascular accidents. ResultsDuring a median follow-up of 6.4 (interquartile range: 3.6 to 10.4) years, 146 patients died (16 within 30 days after surgery), 46 patients were hospitalized for heart failure, and 13 patients had a cerebrovascular accident. Age (hazard ratio [HR]: 1.08; 95% confidence interval [CI]: 1.05 to 1.11; p < 0.001) and LV-GLS (HR: 1.13; 95% CI: 1.06 to 1.21; p < 0.001) were independently associated with all-cause mortality. Patients with LV-GLS >–20.6% (more impaired) showed significant worse survival than did patients with LV-GLS ≤–20.6%; of interest, patients with BD showed similar prognosis compared with FED and FF. In addition, previous atrial fibrillation (HR: 1.70; 95% CI: 1.01 to 2.86; p = 0.045) and LV-GLS (HR: 1.01; 95% CI: 1.01 to 1.15; p = 0.019) were independently associated with the secondary endpoint. ConclusionsLV-GLS is independently associated with all-cause mortality and cardiovascular events after MV surgery for primary MR and might be helpful to guide surgical timing. Importantly, patients with BD showed similar prognosis when corrected for age, compared with patients with FED or FF.

2019 AATS/ACC/ASE/SCAI/STS expert consensus systems of care document: A proposal to optimize care for patients with valvular heart disease: A Joint Report of the American Association for Thoracic Surgery, American College of Cardiology, American Society of Echocardiography, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.

This statement was commissioned as a Multisociety Expert Consensus Systems of Care Document by the American Association for Thoracic Surgery (AATS), American College of Cardiology (ACC), American Society of Echocardiography (ASE), Society for Cardiovascular Angiography and Interventions (SCAI), and

FLOATING LEFT ATRIAL MASS IN A PATIENT WITH PROSTHETIC MITRAL VALVE: MANAGEMENT DILEMMA

A giant mobile left atrial mass in a patient with prosthetic mitral valve (MV) with significant co morbidities created a challenging clinical scenario and treatment dilemma. A 53 year old male with history of primary severe mitral regurgitation status post unsuccessful mitral valve repair, redo

75-Year-Old Man With Chest Pain and Dyspnea

75-Year-Old Man With Chest Pain and Dyspnea

Novel mitral valve technologies-transcatheter mitral valve implantation: a systematic review.

Valvular heart disease is an important cause of morbidity and mortality throughout the world; in industrialized nations, mitral regurgitation (MR) is the most common valvular lesion. Untreated, severe MR has a poor prognosis, with a 5-year mortality rate of up to 50%. Surgical repair of symptomatic, severe primary MR has been demonstrated to improve survival. The aim of this review is to assess the early outcomes of newly developed transcatheter mitral valve implantation technologies for the treatment of secondary native valve disease. Furthermore, the outcomes of patients receiving transcatheter treatment of regurgitant failure of surgically repaired or replaced mitral valve has also been addressed. A systematic review of twenty-five studies assessing the outcomes of patients undergoing transcatheter mitral valve implantation for native mitral regurgitation or failed prior surgical repair or bioprosthetic replacement was carried out. The outcomes of 112 patients undergoing transcatheter mitral valve replacement for secondary mitral regurgitation using six different valve systems were assessed. There were 15 early deaths and 24 deaths over the follow-up period. The outcomes of 44 patients undergoing transcatheter valve-in-valve replacement were assessed with an overall mortality of ten patients. There were 20 patients included who had valve-in-ring transcatheter mitral replacement for previous failed repair. The total mortality was five patients during the follow-up period. Transcatheter mitral valve implantation represents a new evolution in management of valvular disease and affords management options to patients who historically may not have been offered treatment. Early results have demonstrated some promise and improvements in technology, imaging modalities and patient selection will surely result in a reliable and durable valve.

RF87 TRANSAPICAL OFF-PUMP MITRAL VALVE REPAIR WITH PTFE CHORD IMPLANTATION

Background: NeoChord DS-1000 system (NeoChord,Inc,Minneapolis, Minnesota)is a novel minimally invasive technique of mitral valve repair (MVR)consisting in off-pump beating heart transapical implantation of artificial neo-chordae under TEE guide. Aim: To evaluate the feasibility,safety and up to 12 months outcome of the NeoChord DS-1000 system in patients with primary mitral regurgitation (MR),due to leaflet(s) prolapse or flail. Methods: From July 2015 to November 2016,34 patients with severe primary MR were selected for transapical Neochordae implantation at 3 centers in Italy. Mitral Valve Academic Research Consortium (MVARC) procedural success criteria were evaluated in all patients at 30 days,6 and 12 months. Results: Mean age was 64.7 ± 11 years,mean STS repair score was 1.06%(IQR 0.46-1.12).25 patients had isolated P2 disease and 9 patients had other or multisegment disease involvement. MR ≤moderate at 30 days was achieved in 91%of patients. In hospital mortality was 2.9% for respiratory failure,and 2 patients had undergone conversion to traditional valve surgery for functional failure and residual significant MR. At discharge 80.6% patients had MR ≤mild and 17% patients had moderate MR.2 patients experienced early device failure with recurrent sever MR and had undergone additional valve surgery (at 61 and 129 days after implantation).22 patients reached 6 month follow up,all had MR ≤moderate and showed significant improvement in NYHA functional class (P &lt; 0.005).10 patients reached 12 month follow up,all had MR ≤moderate and 90% had NYHA class I. Conclusion: Mitral valve repair with the NeoChord DS-1000 system for primary MR due to leaflet(s) prolapse or flail is feasible and safe.Its efficacy is maintained up to 1 year showing significant clinical benefit and functional class improvement.

Traitement percutané de l’insuffisance mitrale par Mitraclip chez le sujet âgé

Mitral regurgitation (MR) is the second most common form of valvular heart disease. It is classified as either primary (degenerative) or secondary (functional). Secondary MR is the consequence of myocardium disease. Primary MR from degenerative valve disease is due to a primary disruption of the mitral valve apparatus from either prolapsed or flail leaflets. It covers all aetiologies in which intrinsic lesions affect one or several components of the mitral valve apparatus. Gold-standard therapeutic management of severe primary MR is surgery usually to repair but sometime to replace the mitral valve. However patients considered to be at high-risk due to their age or the presence of comorbidities – accounting for 50% of all patients – are not eligible for surgery. Catheter-based interventions have been developed to correct MR percutaneously. The only such intervention which has been evaluated in organic MR is the edge-to-edge procedure using the MitraClip® (Abbott Vascular, Menlo Park, CA). MitraClip® offers an alternative to open surgical repair or replacement via a minimally invasive route and it was shown in the EVEREST II study that MitraClip® was safer than surgery even though it was less effective in reducing MR. A substantial number of patients are ineligible for mitral valve surgery because of prohibitive surgical risk. For those patients, MitraClip® may offer an alternative treatment option. Percutaneous edge-to-edge repair is the first percutaneous option accepted in the 2012 ESC guidelines: Percutaneous edge-to-edge procedure may be considered in patients with symptomatic severe primary MR who fulfill the echo criteria of eligibility, are judged inoperable or at high surgical risk by a ‘heart team’, and have a life expectancy greater than 1 year (recommendation class IIb, level of evidence C). Because of its frailty, MitraClip® in the elderly may be a good alternative to mitral surgery when indicated for primary or secondary MD.

Mitral valve repair versus replacement for patients with preserved left ventricular function without heart failure symptoms

ObjectiveThe purposes of this study are to compare outcomes of mitral valve repair (MV-repair) and mitral valve replacement for patients with severe mitral regurgitation with preserved ventricular function and no congestive heart failure (CHF) symptoms and to examine variations in surgeon choice of procedure and outcomes by surgeon volume. MethodsIn total, 2259 consecutive patients in 42 New York State hospitals with the characteristics mentioned previously who underwent mitral valve repair (1801, 79.7%) or replacement between January 1, 2008, and December 31, 2014, were identified from a mandatory statewide clinical registry. Propensity-matching was used to compare mortality and competing risk analyses were used to compare nonfatal outcomes. Median follow-up was 4.0 years. The use of mitral repair and risk-adjusted mortality for surgery were also examined as a function of individual surgeon mitral case volume. ResultsPropensity-matched patients who underwent MV-repair experienced a significantly lower mortality rate at 4 years (3.5% vs 12.1%, P < .001). Greater-volume surgeons were more likely to perform MV-repairs (92% vs 84%, 74%, and 69% in lower volume quartiles, respectively). No significant differences in mortality were observed among volume quartiles. ConclusionsPatients with chronic severe primary mitral valve regurgitation with preserved ventricular function and no CHF symptoms who underwent MV-repair experienced lower mortality and no different reoperation, CHF, or stroke readmission rates than patients who underwent replacement. Greater-volume surgeons were more likely than their lower volume counterparts to choose mitral repair. Repair should be considered as the surgical option for these patients whenever possible.