Severe Secondary Mitral Regurgitation Research Articles

Repeat Mitral Valve Interventions After Transcatheter Edge-to-Edge Repair: The COAPT Trial

The frequency and effectiveness of repeat mitral valve interventions (RMVI) after transcatheter edge-to-edge repair (TEER) for secondary mitral regurgitation (MR) are unknown. We aimed to examine the rate of and outcomes following RMVI after TEER in the COAPT trial.The COAPT tria randomized heart failure (HF) patients with severe secondary MR to TEER with the MitraClipTM device plus guideline-directed medical therapy (GDMT) versus GDMT alone. We evaluated the characteristics and outcomes of patients who had a RMVI during 4-year follow-up. A MitraClip implant was attempted in 293 patients randomized to TEER+GDMT, 10 of whom (underwent a RMVI procedure (9 repeat TEER and 1 surgical mitral valve replacement) after 4-years of follow-up (cumulative incidence 3.90%,95% CI 2.08-7.08; median 182 days after the initial procedure). Patients with RMVI had larger mitral annular diameters, fewer clips implanted and were more likely to have ≥3+ MR at discharge compared with those without RMVI. Reasons for RMVI included failed index procedure due to difficult transseptal puncture (n=2) or tamponade (n=1); residual or recurrent severe MR after an initially successful procedure (n=5); partial clip detachment (n=1); and site-assessed mitral stenosis (n=1). RMVI was successful in 8/10 (80%) patients. Patients who underwent RMVI had higher 4-year rates of HFH but similar mortality compared with those without RMVI. The annualized incidence rates of all HFH in patients who underwent RMVI were 234 events per 100 person years (95% CI 139-395) pre-RMVI and 46 per 100 person years (95% CI 25-86) post-RMVI as compared with 32 events per 100 patient years (95% CI 28-36) among patients not undergoing RMVI. The rate ratio of HFH was reduced after RMVI in patients undergoing RMVI (0.20, 95% CI 0.09-0.45).

Changes in Left Ventricular Function and Outcomes After Trancatheter Edge-to-Edge Repair for Secondary Mitral Regurgitation

BackgroundTranscatheter edge-to-edge repair (TEER) improved outcomes in patients with heart failure (HF) and severe secondary mitral regurgitation (SMR) compared with guideline-directed medical therapy (GDMT) alone regardless of the severity of baseline left ventricular ejection fraction (LVEF). The study aimed to evaluate the effect of early changes in LVEF after TEER and GDMT alone in patients with HF and severe SMR. MethodsWithin the COAPT trial, we evaluated outcomes according to changes in LVEF from baseline to 30 days. The primary outcome was all-cause death or HF hospitalization (HFH) between 30 days and 2 years. ResultsAmong 432 patients with paired echocardiographic data, 182 (42.1%) had increased LVEF (LVEF change 6.0% ± 4.9%) and 250 (57.9%) had a decrease or no change in LVEF (LVEF change –6.6% ± 5.6%) from baseline to 30 days. LVEF at 30 days increased more frequently with GDMT alone compared with TEER plus GDMT (51.4% vs 33.0%; P = .0001). Between 30 days and 2 years, there were no significant differences in death or HFH in the increase LVEF and the decrease LVEF groups (58.8% vs 51.4%; multivariable-adjusted HR, 0.97; 95% CI, 0.87-1.08; P = .59). TEER plus GDMT reduced the 30-day to 2-year rate of death or HFH compared with GDMT alone consistently in patients with increase LVEF and decrease LVEF (Pint = 0.75). ConclusionsAmong patients with HF and severe SMR, early improvements in LVEF were more frequent with GDMT alone compared with TEER plus GDMT but were not associated with subsequent outcomes at 2 years. TEER reduced death or HFH during 2-year follow-up irrespective of early LVEF changes.

Artificial intelligence-derived risk score for mortality in secondary mitral regurgitation treated by transcatheter edge-to-edge repair: the EuroSMR risk score.

Risk stratification for mitral valve transcatheter edge-to-edge repair (M-TEER) is paramount in the decision-making process to appropriately select patients with severe secondary mitral regurgitation (SMR). This study sought to develop and validate an artificial intelligence-derived risk score (EuroSMR score) to predict 1-year outcomes (survival or survival + clinical improvement) in patients with SMR undergoing M-TEER. An artificial intelligence-derived risk score was developed from the EuroSMR cohort (4172 and 428 patients treated with M-TEER in the derivation and validation cohorts, respectively). The EuroSMR score was validated and compared with established risk models. The EuroSMR risk score, which is based on 18 clinical, echocardiographic, laboratory, and medication parameters, allowed for an improved discrimination of surviving and non-surviving patients (hazard ratio 4.3, 95% confidence interval 3.7-5.0; P < .001), and outperformed established risk scores in the validation cohort. Prediction for 1-year mortality (area under the curve: 0.789, 95% confidence interval 0.737-0.842) ranged from <5% to >70%, including the identification of an extreme-risk population (2.6% of the entire cohort), which had a very high probability for not surviving beyond 1 year (hazard ratio 6.5, 95% confidence interval 3.0-14; P < .001). The top 5% of patients with the highest EuroSMR risk scores showed event rates of 72.7% for mortality and 83.2% for mortality or lack of clinical improvement at 1-year follow-up. The EuroSMR risk score may allow for improved prognostication in heart failure patients with severe SMR, who are considered for a M-TEER procedure. The score is expected to facilitate the shared decision-making process with heart team members and patients.

Percutaneous Mitral Valve Repair in Pediatric Patients.

Rigorous clinical trials have demonstrated the safety and efficacy of Transcatheter Edge-to-Edge Repair to treat severe secondary mitral regurgitation (MR) in adults with primary cardiomyopathy who have failed guideline-directed medical therapy, as well as those with primary MR at high surgical risk. To date, there are only three case reports describing this procedure in the pediatric population. We report a case series of four pediatric patients, including the youngest and smallest reported, who underwent this procedure.

Mortality Associated With Proportionality of Secondary Mitral Regurgitation After Transcatheter Mitral Valve Repair: North American Mitraclip for Functional Mitral Regurgitation Registry

The association, if any, between the effective regurgitant orifice area (EROA) to left ventricular end-diastolic volume (LVEDV) ratio and 1-year mortality is controversial in patients who undergo mitral transcatheter edge-to-edge repair (m-TEER) with the MitraClip system (Abbott Vascular, Santa Clara, CA). This study's objective was to determine the association between EROA/LVEDV and 1-year mortality in patients who undergo m-TEER with MitraClip. In patients with severe secondary (functional) mitral regurgitation (MR), we analyzed registry data from 11 centers using generalized linear models with the generalized estimating equations approach. We studied 525 patients with secondary MR who underwent m-TEER. Most patients were male (63%) and were New York Heart Association class III (61%) or IV (21%). Mitral regurgitation was caused by ischemic cardiomyopathy in 51% of patients. EROA/LVEDV values varied widely, with median=0.19 mm2/ml, interquartile range [0.12,0.28] mm2/ml, and 187 patients (36%) had values <0.15 mm2/ml. Postprocedural mitral regurgitation severity was substantially alleviated, being 1+ or less in 74%, 2+ in 20%, 3+ in 4%, and 4+ in 2%; 1-year mortality was 22%. After adjustment for confounders, the logarithmic transformation (Ln) of EROA/LVEDV was associated with 1-year mortality (odds ratio 0.600, 95% confidence interval 0.386 to 0.933, p=0.023). A higher Society of Thoracic Surgeons risk score was also associated with increased mortality. In conclusion, lower values of Ln(EROA/LVEDV) were associated with increased 1-year mortality in this multicenter registry. The slope of the association is steep at low values but gradually flattens as Ln(EROA/LVEDV) increases.

Regurgitant volume to LA volume ratio in patients with secondary MR: the COAPT trial.

The conceptual framework of proportionate vs. disproportionate mitral regurgitation (MR) translates poorly to individual patients with heart failure (HF) and secondary MR. A novel index, the ratio of MR severity to left atrial volume (LAV), may identify patients with 'disproportionate' MR and a higher risk of events. The objectives, therefore, were to investigate the prognostic impact of MR severity to LAV ratio on outcomes among HF patients with severe secondary MR randomized to transcatheter edge-to-edge repair (TEER) with the MitraClip™ device plus guideline-directed medical therapy (GDMT) vs. GDMT alone in the COAPT trial. The ratio of pre-procedural regurgitant volume (RVol) to LAV was calculated from baseline transthoracic echocardiograms. The primary endpoint was 2-year covariate-adjusted rate of HF hospitalization (HFH). Among 567 patients, the median RVol/LAV was 0.67 (interquartile range 0.48-0.91). In patients randomized to GDMT alone, lower RVol/LAV was independently associated with an increased 2-year risk of HFH (adjHR: 1.77; 95% CI: 1.20-2.63). RVol/LAV was a stronger predictor of adverse outcomes than RVol or LAV alone. Treatment with TEER plus GDMT compared with GDMT alone was associated with lower 2-year rates of HFH both in patients with low and high RVol/LAV (Pinteraction = 0.28). Baseline RVol/LAV ratio was unrelated to 2-year mortality, health status, or functional capacity in either treatment group. Low RVol/LAV ratio was an independent predictor of 2-year HFH in HF patients with severe MR treated with GDMT alone in the COAPT trial. TEER improved outcomes regardless of baseline RVol/LAV ratio. Trial Name: Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation (The COAPT Trial) (COAPT) ClinicalTrial.gov Identifier NCT01626079URL https://clinicaltrials.gov/ct2/show/NCT01626079.

Mitral valve transcatheter edge-to-edge repair with PASCAL vs MitraClip: A systematic review and meta-analysis.

Transcatheter edge-to-edge repair (TEER) using the MitraClip (Abbott Vascular) system has emerged as a standard treatment for patients with symptomatic severe secondary or inoperable primary mitral regurgitation (MR). The relatively recent approval of the PASCAL Transcatheter Valve Repair System (Edwards Lifesciences) has expanded the options of TEER devices. However, evidence comparing PASCAL with MitraClip systems is still limited. We conducted a systematic literature research and meta-analysis in PubMed, Medline, and EMBASE databases for studies comparing PASCAL and MitraClip systems. Four observational studies and 1 randomized controlled trial, involving 1315 patients total, were eligible for inclusion. All patients exhibited symptomatic (NYHA II-IV) MR grades 3+ or 4+. Baseline characteristics were comparable across all included studies. The clinical outcomes were assessed according to the Mitral Valve Academic Research Consortium consensus. The procedural success rates for the 2 devices were comparable in terms of achieving post-procedural MR grades of less than or equal to 2+ and less than or equal to 1+. Furthermore, most patients improved their clinical status, with no significant differences between patients treated with PASCAL and those treated with MitraClip. In terms of safety, both procedures exhibited low overall mortality rates and occurrence of major adverse events (MAE), without significant difference between the 2 devices. These findings remained consistent in both short- and long-term follow-up assessments. Our study revealed similar effectiveness and safety profiles between the PASCAL and MitraClip devices in patients experiencing significant symptomatic MR.

The power of optimal medical therapy in heart failure with secondary mitral regurgitation

Abstract Background Guideline-directed medical therapy (GDMT) for the management of heart failure (HF) may impact on the frequency of severe secondary mitral regurgitation (SMR). Objective To evaluate the impact of optimization of GDMT on the grade of SMR in a cohort of HF patients managed in a multidisciplinary HF clinic and to assess predictors and prognosis of deterioration of SMR. Methods In a prospective, consecutive, observational registry of HF patients, a 2-dimensional transthoracic echocardiography was performed at baseline and at 1 year of follow-up. Patients treated with surgical or interventional mitral valve repair were excluded. The primary endpoint was all-cause death. Results Of a total of 2.980 HF patients, 1814 patients had 2 echocardiograms performed 1 year apart. At baseline, 99 patients had a severe SMR (5.5%), 389 (21.4%) moderate and the remainder had mild, trace or none SMR. After 1-year, 80.8% of those with baseline severe SMR presented a regression to non-severe SMR, 66.6% of those with moderate SMR regressed to mild SMR and 1.1% of those with non-severe SMR at baseline worsened to severe SMR. Older age (OR 1.42 per every decade; 95% CI 1.19-1.69, p&amp;lt;0.001), ischaemic aetiology of HF (OR 1.64; 95% CI 1.11-2.42, p&amp;lt;0.001) and baseline NTproBNP (OR 1.19; 95% CI 1.08-1.32, p&amp;lt;0.001) were independently associated with worsening of SMR at 1 year of follow-up. Patients with baseline severe SMR that improved at 1 year had a similar risk of the primary endpoint to those with non-severe SMR at both time points (HR 0.93; 95% CI 0.62-1.42; p=0.75), even after adjusting for age, sex and LVEF (HR 0.99; 95% CI 0.65-1.52; p= 0.98). On the contrary, patients with non-severe SMR that worsen showed the worst prognosis (Figure 1). Conclusions Most of the patients with HF and severe SMR show a regression of SMR within 1 year of GDMT. Patients with baseline severe SMR that improved at 1 year have a similar prognosis than those with non-severe SMR at both time points. Older age, ischaemic aetiology and higher levels of NTproBNP were associated with deterioration of SMR.Table 1.Population characteristicsFigure 1.Survival curves

Heart failure medical therapy and outcomes in patients undergoing transcatheter mitral valve repair for secondary mitral regurgitation: a TVT Registry analysis across 449 US centers

Abstract Background Guidelines recommend medical therapy optimization prior to transcatheter mitral valve repair (TMVr) in patients with heart failure (HF), left ventricular ejection fraction (LVEF) &amp;lt;50%, and severe secondary mitral regurgitation (SMR). Whether TMVr is being performed on the background of optimal guideline directed medical therapy (GDMT) in clinical practice is unknown. Purpose To assess pre-procedure GDMT (B-blockers, ACEI [angiotensin converting enzyme inhibitor]/ARB [angiotensin receptor blocker], ARNI [angiotensin receptor neprilysin inhibitor], MRA [mineralocorticoid receptor antagonist]) use and association with outcomes in patients with HF and LVEF &amp;lt;50% undergoing TMVr. Methods Patients with LVEF &amp;lt;50% who underwent TMVr for SMR from July 2019 – March 2022 in the Transcatheter Valve Therapy Registry were identified. Patients on inotropes or in shock pre-TMVr were excluded. Cox proportional hazards models were constructed to evaluate adjusted associations between pre-TMVr medical therapy (no, single, double, or triple therapy) and risk of the one-year composite outcome of mortality or HF hospitalization. Sensitivity analyses excluded patients with HF with mildly reduced ejection fraction (HFmrEF) (LVEF &amp;gt;40%) or New York Heart Association (NYHA) class I (asymptomatic) prior to TMVr. Results A total of 4,199 patients across 449 sites were identified. Prior to TMVr, B-blockers (85.1%) were prescribed most frequently, followed by ACEI/ARB (44.4%), MRA (28.6%), and ARNI (19.9%). Triple therapy was prescribed for 19.2% of patients, while 38.2% were on double therapy, 36.0% were on single therapy, and 6.5% were on no medical therapy. Triple therapy use varied from 0 - 61% across sites with an adjusted median odds ratio of 1.48 (95% confidence interval [CI] 1.25-3.88, P&amp;lt;0.001), suggesting a 1.5-fold variation in the likelihood that similar risk patients at 2 random US sites received triple therapy pre-TMVr (Figure 1). In patients with one-year follow-up available (n=2,014, 341 sites), the composite rate of one-year mortality or HF hospitalization was lowest in patients on triple therapy (23.1%) compared with double (24.8%), single (35.7%), and no (41.1%) therapy (P≤0.01). Associations persisted after accounting for clinically relevant covariates, with lower risk in patients on triple therapy (adjusted hazard ratio [aHR] 0.73, 95% CI 0.55-0.97) and double therapy (aHR 0.60, 95% CI 0.50-0.74) prior to TMVr compared with no/single therapy. Results were similar when only patients with symptomatic HFrEF were considered (i.e., those with HFmrEF or NYHA class I pre-TMVr were excluded) (Figure 2). Conclusions Under one-fifth of patients who underwent TMVr for SMR were prescribed comprehensive GDMT, with substantial variation across clinical sites. Compared with no or single therapy, triple and double therapy use prior to TMVr was independently associated with reduced risk of mortality or HF hospitalization one-year after intervention.Figure 1Figure 2

Acute changes of right ventricular longitudinal strain after transcatheter edge-to-edge repair in patients with functional mitral regurgitation

Abstract Background Transcatheter edge-to-edge repair (TEER) is a valid therapeutic option in symptomatic patients with severe secondary mitral valve regurgitation (SMR) at high surgical risk. While right ventricular (RV) dysfunction is a predictor of poor outcomes in this context, TEER may lead to an improvement of RV function which portends a better outcome. Purpose The aim of this study was to investigate acute change in RV function and its prognostic implication after successful TEER in patients with severe SMR. Methods Patients with severe SMR who underwent TEER from 2013 to 2021 at our center were retrospectively screened. Only patients with successful procedure (MR ≤ grade 2) and adequate echocardiographic images for longitudinal strain assessment were enrolled. RV function was estimated at baseline and pre-discharge by echocardiographic evaluation; RV global longitudinal strain (RVGLS) and RV free wall longitudinal strain (RVFWLS) were assessed before and after TEER. Longitudinal strain improvement was defined as an increase of post procedural strain greater than median value variation. Population was then divided in two groups based on RVGLS significant improvement. The primary outcome was a composite of all-cause death, heart transplantation (HT) and left ventricular assist device (LVAD) implantation during follow-up, assessed with Kaplan-Maier curves and compared by log-rank test. Results A total of 61 patients were included. Mean age was 70±10 years, 89% patients were symptomatic with NYHA class 3-4, mean furosemide daily dose was 200±146 mg. Pre-TEER median left ventricle ejection fraction (LVEF) was 29% [IQR, 26; 35%], RV fractional area change (FAC) was 32% [IQR 26; 37%] and tricuspid anulus plan systolic excursion (TAPSE) was 17 mm [IQR 14; 20 mm]. Median RVGLS and RVFWLS at baseline were respectively -11% [IQR -13; -9%] and -14% [IQR -17; -11%]. After TEER a significant variation of RVGLS and RVFWLS was observed (RVGLS: -13% [IQR -15; -10%] p 0.012; RVFWLS: -16% [-19; - 13%] p 0.001). Moreover, a significant reduction in estimated systolic pulmonary artery pressure (sPAP) between baseline (45 mmHg [IQR 35; 55mmHg]) and post TEER (40 mmHg [IQR 30;45 mmHg] p &amp;lt;0.001) was observed. Median improvement of RVGLS was 1.3%. After mean follow up time of 55±7 months event rate for the combined primary endpoint was numerically lower in the improved RVGLS group, although the difference was not statistically significant (p 0.243). Interestingly, rate of HT was significantly lower in RVGLS-improved group (p 0.032). Conclusions This study showed significant pre-discharge improvement of RV longitudinal strain in patient with severe SMR after successful TEER. At follow-up this improvement did not affect the outcome in terms of freedom from composite endpoint of all-cause death, HT or LVAD implantation but events were numerically lower in patients with strain improvement. Further data on larger population are needed to confirm our observations.Table 1,2Figure 1,2

Abstract 18572: Mimickers of Chiari Network in the Left Atrium

Case: 84-year-old female with ischemic cardiomyopathy and severe secondary mitral regurgitation with restricted leaflet mobility due to chordae tethering and a large central regurgitant jet. She underwent trans-catheter edge to edge repair with Mitra Clip NTW. The clip was aligned in the 12 to 6 o'clock position in the middle of A2/P2 scallop and appropriate graft was obtained with good tissue bridging. The trans mitral gradient at the end of the procedure was 3 mmHg and final V-waves at 10 mmHg. After the guiding catheter was moved back to the right atrium, the transesophageal echocardiogram (TEE) showed the presence of an echo dense flickering, bubble-like mobile structure around the right upper pulmonary vein. The heart team agreed that it looked like an endothelial disruption induced by the guiding catheter. After careful consideration and using shared decision making, the patient was maintained on Eliquis for 6 months without evidence of thromboembolic phenomena. Repeat TEE showed a healed dissection flap and no echo dense structure seen previously. Discussion: Unlikely to be thrombus or air bubbles, this structure looked like what we would see in a Chiari network. Complications after Mitra Clip procedure have been well described and can be broadly divided into procedure related and device related. Endothelial disruption with the imaging characteristics shown in this case has not been described. There are no evidence-based guidelines on how to proceed with this type of complication. It is well known that endothelial damage increases the risk for thrombosis and embolic phenomena. Due to concerns of a stroke, the decision was made to start anticoagulation with the plan of redo TEE. This case demonstrates the importance of performing TEE after Mitra Clip procedure to look for lesions that would increase the risk of stroke. It also demonstrates that patients with endothelial disruption after Mitra clip may benefit from short term anticoagulation for stroke prevention.

Secondary Mitral Regurgitation and Transcatheter Mitral Valve Therapies: Do They Have a Role in Advanced Heart Failure with Reduced Ejection Fraction?

Transcatheter mitral valve repair should be considered for patients with severe secondary mitral regurgitation with symptomatic heart failure with reduced ejection fraction for symptom improvement and survival benefit. Patients with a higher severity of secondary mitral regurgitation relative to the degree of left ventricular dilation are more likely to benefit from transcatheter mitral valve repair. A multidisciplinary Heart Team should participate in patient selection for transcatheter mitral valve therapy.

Mitral valve transcatheter edge-to-edge repair with PASCAL Vs MitraClip: A aystematic teview and meta-analysis.

Transcatheter edge-to-edge repair (TEER) using the MitraClip (Abbott Vascular) system has emerged as a standard treatment for patients with symptomatic severe secondary or inoperable primary mitral regurgitation (MR). The relatively recent approval of the PASCAL Transcatheter Valve Repair System (Edwards Lifesciences) has expanded the options of TEER devices. However, evidence comparing PASCAL with MitraClip systems is still limited. We conducted a systematic literature research and meta-analysis in PubMed, Medline, and EMBASE databases for studies comparing PASCAL and MitraClip systems. Four observational studies and 1 randomized controlled trial, involving 1315 patients total, were eligible for inclusion. All patients exhibited symptomatic (NYHA II-IV) MR grades 3+ or 4+. Baseline characteristics were comparable across all included studies. The clinical outcomes were assessed according to the Mitral Valve Academic Research Consortium consensus. The procedural success rates for the 2 devices were comparable in terms of achieving post-procedural MR grades of less than or equal to 2+ and less than or equal to 1+. Furthermore, most patients improved their clinical status, with no significant differences between patients treated with PASCAL and those treated with MitraClip. In terms of safety, both procedures exhibited low overall mortality rates and occurrence of major adverse events (MAE), without significant difference between the 2 devices. These findings remained consistent in both short- and long-term follow-up assessments. Our study revealed similar effectiveness and safety profiles between the PASCAL and MitraClip devices in patients experiencing significant symptomatic MR.

Effect of concurrent mitral valve surgery for secondary mitral regurgitation upon mortality after aortic valve replacement or coronary artery bypass surgery.

It is uncertain whether concurrent mitral valve repair or replacement for moderate or greater secondary mitral regurgitation at the time of coronary artery bypass graft or aortic valve replacement surgery improves long-term survival. Patients undergoing coronary artery bypass graft and/or aortic valve replacement surgery with moderate or greater secondary mitral regurgitation were reviewed. The effect of concurrent mitral valve repair or replacement upon long-term mortality was assessed while accounting for patient and operative characteristics and mitral regurgitation severity. Of 1,515 patients, 938 underwent coronary artery bypass graft or aortic valve replacement surgery alone and 577 underwent concurrent mitral valve repair or replacement. Concurrent mitral valve repair or replacement did not alter the risk of postoperative mortality for patients with moderate mitral regurgitation (hazard ratio = 0.93; 0.75-1.17) or more-than-moderate mitral regurgitation (hazard ratio = 1.09; 0.74-1.60) in multivariable regression. Patients with more-than-moderate mitral regurgitation undergoing coronary artery bypass graft-only surgery had a survival advantage from concurrent mitral valve repair or replacement in the first two postoperative years (P = 0.028) that did not persist beyond that time. Patients who underwent concurrent mitral valve repair or replacement had a higher rate of later mitral valve operation or reoperation over the five subsequent years (1.9% vs. 0.2%; P = 0.0014) than those who did not. These observations suggest that mitral valve repair or replacement for more-than-moderate mitral regurgitation at the time of coronary artery bypass grafting may be reasonable in a suitably selected coronary artery bypass graft population but not for aortic valve replacement, with or without coronary artery bypass grafting. Our findings are supportive of 2021 European guidelines that severe secondary mitral regurgitation "should" or be "reasonabl[y]" intervened upon at the time of coronary artery bypass grafting but do not support 2020 American guidelines for performing mitral valve repair or replacement concurrent with aortic valve replacement, with or without coronary artery bypass grafting.

Wall Motion Score Index Predicts Persistent Moderate or Severe Secondary Mitral Regurgitation and its Prognostic Role in Patients Undergoing Percutaneous Coronary Intervention

Wall Motion Score Index Predicts Persistent Moderate or Severe Secondary Mitral Regurgitation and its Prognostic Role in Patients Undergoing Percutaneous Coronary Intervention

Right ventricle to pulmonary artery coupling as a predictor of perioperative outcome in patients with secondary mitral valve insufficiency.

The aim of the study was to assess some parameters of right ventricle (RV) function as predictors of short-term mortality in patients with severe secondary mitral regurgitation (SMR) after mitral valve surgery. We conducted a retrospective analysis of 112 consecutive patients with severe SMR who had undergone mitral valve repair or replacement with or without concomitant coronary artery bypass surgery. We assessed RV to pulmonary artery coupling by calculating the ratio of tricuspid annular plane systolic excursion (TAPSE) to non-invasively estimated RV systolic pressure (RVSP). The study endpoint was 30 days post-procedural mortality. Overall, the 30-day mortality was 6%. TAPSE/RVSP ratio < 0.42 mm/mmHg was a significant predictor of mortality and remained so after adjusting for age and sex. The Kaplan-Meier survival analysis showed that patients with RVSP > 55 mmHg and those with TAPSE/RVSP ratio < 0.42 mm/mmHg had a lower survival probability. TAPSE/RVSP < 0.42 mm/mmHg is a strong predictor of short-term mortality in patients with SMR when considered for valve surgery.

Perspectives on Secondary Mitral Regurgitation in Heart Failure.

This review focuses on broader perspectives of mitral regurgitation (MR) in patients with heart failure. The ratio of regurgitant volume to end-diastolic volume appears to help identify patients who may benefit from valve interventions. Secondary MR is not only attributed to geometric changes of the LV but also related to the structural changes in the mitral valve that include fibrosis of the mitral leaflets and changes in the extracellular matrix. The transition from mild to severe secondary MR can occur at different rates, from a slow LV remodeling process to a more abrupt process precipitated by an inciting event such as atrial fibrillation. Septal flash and apical rocking, two new visual markers of LV mechanical dyssynchrony, appear to be predictive of MR reduction following cardiac resynchronization therapy. Optimal guideline-directed medical therapy has been shown to decrease the severity of secondary MR effectively. A theoretical framework to characterize secondary MR as it relates to the onset of MR is proposed. Type A: Early onset of MR contemporaneous with myocardial injury. The maladaptive LV remodeling occurs in parallel with MR. Type B: LV remodeling proceeds without significant MR until the LV is moderately dilated, which coincides with or without inciting factors such as atrial fibrillation. Type C: LV remodeling proceeds after myocardial injury without significant MR until the LV is severely dilated. MR is a late manifestation of LV remodeling.

Transcatheter Edge-to-Edge Repair in 5,000 Patients With Secondary Mitral Regurgitation: COAPT Post-Approval Study

BackgroundReal-world applicability of the COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation) randomized controlled trial (RCT) has been debated because of careful patient selection and the contrasting results of the MITRA-FR (Multicentre Study of Percutaneous Mitral Valve Repair MitraClip Device in Patients with Severe Secondary Mitral Regurgitation) RCT. ObjectivesThe COAPT-PAS (COAPT Post-Approval Study) was initiated to assess the safety and effectiveness of the MitraClip in patients with secondary mitral regurgitation (SMR). MethodsCOAPT-PAS is a prospective, single-arm, observational study of 5,000 consecutive patients with SMR treated with the MitraClip at 406 U.S. centers participating in the TVT (Transcatheter Valve Therapy) registry from 2019 to 2020. The 1-year outcomes from the COAPT-PAS full cohort and the COAPT-like and MITRA-FR–like subgroups who met RCT inclusion/exclusion criteria are reported. ResultsPatients in the COAPT-PAS had more comorbidities, more severe HF and functional limitations, and less guideline-directed medical therapy than those in the COAPT or MITRA-FR RCTs. Patients in the COAPT-PAS full cohort and the COAPT-like (n = 991) and MITRA-FR–like (n = 917) subgroups achieved a 97.7% MitraClip implant rate, a similar and durable reduction of mitral regurgitation to ≤2+ at 1 year (90.7%, 89.7%, and 86.6%, respectively), a large improvement in quality of life at 1 year (Kansas City Cardiomyopathy Questionnaire +29 COAPT-PAS, +27 COAPT-like, and +33 MITRA-FR–like), faster procedure times, similar or lower clinical event rates compared with the RCTs’ MitraClip arms, and lower clinical event rates than the RCTs’ guideline-directed medical therapy only arms. One-year heart failure hospitalizations was 18.9% in COAPT-PAS, 19.7% in COAPT-like compared with 24.9% in COAPT-RCT, and 28.7% in COAPT-PAS-MITRA-FR–like compared with 47.4% in MITRA-FR-RCT. ConclusionsThis large, contemporary, real-world study reinforces the safety and effectiveness of the MitraClip System in patients with SMR, including those who met the COAPT or MITRA-FR RCT inclusion/exclusion criteria and patients excluded from the RCTs.

One-year real-world outcomes for patients undergoing transcatheter mitral valve repair: the Gulf MTEER registry (GULF Mitral Transcatheter Edge to Edge Repair)

BackgroundSevere mitral regurgitation (MR) with left ventricular dysfunction portends worse outcomes. Over the course of the last two decades, transcatheter repair of the mitral valve offered an alternative therapeutic modality...

Usefulness of Vena Contracta for Identifying Severe Secondary Mitral Regurgitation: A Three-Dimensional Transesophageal Echocardiography Study

Usefulness of Vena Contracta for Identifying Severe Secondary Mitral Regurgitation: A Three-Dimensional Transesophageal Echocardiography Study