Significant Functional Mitral Regurgitation Research Articles

Effect of oral tolvaptan for 1 year in patients with functional mitral regurgitation.

The effect of the oral selective vasopressin V2-receptor antagonist tolvaptan for chronic phase therapy on patients with FMR remains unclear. We aimed to determine the efficacy of oral tolvaptan in patients with significant functional mitral regurgitation (FMR) to reduce the mortality and rehospitalization due to worsening heart failure (HF). We enrolled 219 patients (mean age 76 ± 9years, 59.4% men) who were admitted at our hospital due to congestive HF during different two 1-year periods. The patients were divided into 2 groups: those who had significant FMR (MR ≥ grade 2 [n = 76]) and those who did not (MR < grade 2 [n = 143]) at discharge. The patients were further divided into a study group that received tolvaptan during follow-up and a control group that did not receive tolvaptan. We used an inverse probability of treatment weighting method with the primary end point defined as overall all-cause mortality and rehospitalization due to worsening HF within 1year. Of the 76 patients with significant FMR at discharge, 2 of 20 (10%) who were administered tolvaptan died and 8 (40%) were readmitted to a hospital. Of the 56 patients who did not receive tolvaptan, 2 (3.5%) died and 18 (27.5%) required rehospitalization. After multiple adjustments, there were no significant differences for overall survival and rehospitalization between the groups (log-rank p = 0.700 and 0.510, respectively). Our results suggest that oral tolvaptan administration in addition to conventional diuretics had less impact on outcomes in patients with significant FMR.

Prognosis of functional mitral regurgitation after aortic valve replacement for pure severe aortic stenosis.

Whether patients with severe aortic stenosis (AS) and significant functional mitral regurgitation (MR) should undergo isolated aortic (aortic valve replacement [AVR]) or double aortic-mitral valve procedure (DVP) remains controversial. We sought to determine outcomes of such patients undergoing surgical (surgical aortic valve replacement [SAVR]) and transcatheter AVR (TAVR) or DVP, identify echocardiographic parameters predictive of significant residual MR after isolated AVR, and determine its impact on long-term survival. Data prospectively collected from 736 consecutive patients with severe AS and significant MR undergoing AVR or DVP were retrospectively analyzed. Exclusion of organic MR, other valve diseases and concomitant CABG yielded a final population of 74 patients with significant functional MR (32 TAVR, 23 SAVR, 19 DVP). Demographics, postoperative complications and age-adjusted survival were compared. Echocardiographic predictors of significant residual MR and its impact on survival were analyzed for patients undergoing isolated AVR. In the isolated AVR group, MR improvement occurred in 60% of patients and was associated with a significant increase in survival compared to persistence of significant MR (p = .03). Patients with improved MR had significantly greater preoperative left ventricular dilatation (LVEDD: 49 vs. 43 mm, p = .001; LVESD: 35 vs. 29 mm, p = .03; LVEDV: 101 vs. 71 ml, p = .0003; LVESV: 57 vs. 33 ml, p = .002). There was no significant difference in perioperative mortality (5.3 vs. 4.4 vs. 9.4%, p = .85) or age-adjusted long-term survival between isolated AVR and DVP groups (76.3 vs. 84.2% survival at 2-year follow-up, p = .26), or between SAVR, TAVR and DVP groups (78.2 vs. 75.0 vs. 84.2% survival at 2-year follow-up, p = .13). After isolated AVR, MR improvement occurs in 60% of patients. It is predicted by greater ventricular dimensions and associated with significantly better long-term survival. Whether a staged approach with transcatheter correction of MR should be considered in patients with significant residual MR following AVR remains undetermined.

Guide to functional mitral regurgitation: a contemporary review.

Functional mitral regurgitation (FMR) occurs in the absence of organic mitral valve (MV) disease and is a result of LV dysfunction due to ischemic vs. non ischemic etiologies. The prevalence of FMR is increasing, as 2.0-2.5 million people in the USA were diagnosed with FMR in 2000-and this number is expected to double to 4 million by 2030. FMR tends to develop in a significant number of patients after myocardial infarction (MI) and many develop heart failure (HF) subsequently with mortality rates ranging from 15-40% at 1 year. Therefore, there has been much interest and effort to develop optimized methods for quantifying and classifying the severity of FMR, as well as developing effective therapeutic interventions to improve outcomes in patients with significant FMR. Echocardiogram is typically the primary diagnostic method of assessment, however, there have been various technological advances including cardiac CT and cardiac MRI that can better guide quantification and management of this disease. Management of this disease is mostly aimed at optimizing left ventricular (LV) remodeling with surgical and transcatheter management gaining more popularity with recent times. The purpose of this paper is to provide a comprehensive review of the current evaluation methods and interventional strategies for FMR.

Assessing proportionate and disproportionate functional mitral regurgitation with individualized thresholds

The concept of proportionate/disproportionate functional mitral regurgitation (FMR) has been limited by the lack of a simple way to assess it and by the paucity of data showing its prognostic superiority. The aim of this study was to evaluate the prognostic value of an individualized method of assessing FMR proportionality. We retrospectively identified 572 patients with at least mild FMR and reduced left ventricular ejection fraction (<50%) under medical therapy. To determine FMR proportionality status, we used an approach where a simple equation determined the individualized theoretical regurgitant volume (or effective regurgitant orifice area) threshold associated with haemodynamically significant FMR. Then, we compared the measured with the theoretical value to categorize the population into non-severe, proportionate, and disproportionate FMR. The primary endpoint was all-cause mortality. During a median follow-up of 3.8 years (interquartile range: 1.8-6.2), 254 patients died. The unadjusted mortality incidence per 100 persons-year rose as the degree of FMR disproportionality worsened. On multivariable analysis, disproportionate FMR remained independently associated with all-cause mortality [adjusted hazard ratio: 1.785; 95% confidence interval (CI): 1.249-2.550; P = 0.001]. The FMR proportionality concept showed greater discriminative power (C-statistic 0.639; 95% CI: 0.597-0.680) than the American (C-statistic 0.583; 95% CI: 0.546-0.621; P for comparison <0.001) and European guidelines (C-statistic 0.584; 95% CI: 0.547-0.620; P for comparison <0.001). When added to any of the before-mentioned guidelines, FMR proportionality also improved risk stratification by reclassifying patients into lower and higher risk subsets. Disproportionate FMR is independently associated with all-cause mortality and improves the risk stratification of current guidelines.

Computed tomography characteristics of patients with functional MR receiving MitraClip

Abstract Funding Acknowledgements Type of funding sources: None. Background Percutaneous leaflet repair with the MitraClip device (Abbott Vascular, Menlo Park, CA) is safe and effective in patients with severe functional mitral regurgitation (FMR). Residual or recurrent MR may occur in up to 40% of patients and is associated with persistent symptoms and impaired survival. The anatomical characteristics associated with residual or recurrent MR after MitraClip are not well defined by computed tomography angiography (CTA) in FMR population. Methods A retrospective analysis of patients with significant FMR, who underwent retrospective-gated CTA at Minneapolis Heart Institute between July 2015 to January 2020, identified those who underwent percutaneous leaflet repair with MitraClip. Anatomical and functional parameters were assessed by pre-procedure CTA and compared between those with and without residual (≥2) MR. Results A total of 25 patients were included (median[Q1, Q3]; age, 80[75, 85]; 44% men) and classified into ventricular FMR (V-FMR, n = 12) and atrial FMR (A-FMR, n = 13) according to anatomical and functional characteristics by CTA. 50% of V-FMR and 38% of A-FMR had residual/worsening MR. Among V-FMR patients with residual/worsening MR, shorter coaptation length was observed (2.2[2, 2.3] mm vs. 3.5[3, 4], p = 0.006) (Figure). No differences in anatomical or functional characteristics were seen in A-FMR patients. Conclusion Longer coaptation length in V-FMR is predictive of successful MitraClip procedure, whereas mitral annulus size and cardiac volumes are not. &amp;lt;Ventricular FMR&amp;gt; Total (N = 12) No residual/no worsening MR (N = 6) Residual/worsening MR (N = 6) P value Septal-lateral diameter, mm 31.9 (30.5, 37.9) 32.2 (30.1, 39.8) 31.9 (29.5, 35) 0.749 Annulus area, cm&amp;sup2; 11.2 (10.4, 13.6) 11.3 (10.1, 14.6) 11.1 (9.6, 12.6) 0.631 Tenting area, cm&amp;sup2; 1.6 (1.3, 2.1) 1.6 (1.2, 2.2) 1.7 (1.2, 2.3) 0.873 Tenting height, mm 8.5 (6.5, 9.7) 8.5 (6.6, 9.3) 8.3 (6.3, 10.1) 0.749 Coaptation length, mm 2.6 (2.1, 3.5) 3.5 (3.0, 4.0) 2.2 (2.0, 2.3) 0.006 &amp;lt;Atrial FMR&amp;gt; Total (N = 13) No residual/no worsening MR (N = 8) Residual/worsening MR (N = 5) P value Septal-lateral diameter, mm 32.3 (29.5, 39.0) 32.0 (29.2, 39.9) 34.3 (30.8, 39.02) 0.464 Annulus area, cm&amp;sup2; 10.3 (9.2, 14.7) 10.2 (9.0, 14.6) 12.4 (9.4, 14.7) 0.661 Tenting area, cm&amp;sup2; 1.2 (0.8, 1.8) 1.1 (0.7, 2.2) 1.3 (0.7, 1.8) 0.884 Tenting height, mm 5.5 (4.1, 6.9) 6.3 (4.1, 8.7) 4.6 (3.7, 5.8) 0.213 Coaptation length, mm 2.3 (1.5, 2.8) 2.5 (1.4, 3.5) 1.9 (1.5, 2.6) 0.464 Comparison of baseline CT parameters between no residual/ no worsening MR and residual/ worsening MR Abstract Figure.

Disproportionate functional mitral regurgitation: clinical validation of a new conceptual framework

Abstract Background Disproportionate functional mitral regurgitation (FMR) is a novel concept that tries to identify hemodynamically significant FMR by readjusting the effective regurgitant orifice area (EROA) and regurgitant volume (RegVol) cut-offs according to left ventricular end-diastolic volume (LVEDV) and left ventricular ejection fraction (LVEF). However, this theoretical concept lacks clinical validation. The aim of this study was to assess the clinical significance of disproportionate FMR. Methods Patients with at least mild FMR and reduced LVEF (&amp;lt;50%) who underwent transthoracic echocardiography between 2010 and 2014 were retrospectively identified in our laboratory database. Optimal medical therapy (including cardiac resynchronization when indicated) for ≥3 months was a prerequisite for inclusion. Hemodynamically significant FMR was defined as regurgitant fraction &amp;gt;50% and the patient-specific theoretical RegVol cut-off was calculated according to the formula presented in Fig. 1a. The difference between the estimated RegVol by the PISA method and the theoretical RegVol cut-off was considered to represent the haemodynamic burden of MR. The primary endpoint was all-cause death. Patients were censured if mitral intervention or heart transplant was undertaken. Survival analysis was used to assess the effect of disproportionate FMR on mortality in 2 subgroups (LVEF &amp;lt;30% and 30–49%). Results A total of 289 patients (median age 69 years [IQR 60–77], 75% male, 53% of ischemic aetiology) were included. More than 90% were on beta-blockers and renin-angiotensin inhibitors, 44% on aldosterone receptor antagonists, and 73% had implanted devices. The median LVEF and LVEDV were 34% (IQR 27–41) and 170mL (IQR 128–220), respectively. Median EROA was 10mm2 (IQR 3–21) and RegVol was 15 mL (IQR 4–30). RegVol distribution across the cohort was: &amp;lt;10mL: 41%; 10–20mL: 18%; 20–30mL: 15% and &amp;gt;30mL: 26%. Disproportionate FMR was present in 83 patients (29%). These patients had significantly higher SPAP values (41mmHg [IQR 33–50] vs. 33mmHg [IQR 29–40]; p&amp;lt;0.001). During a median follow-up of 44 months (IQR 19–73), 106 patients died. In the LVEF &amp;lt;30% subgroup, age (HR 1.05 per year [1.02–1.08]; p&amp;lt;0.001), LVEF (HR 0.94 per 1% [0.89–0.99]; p=0.042) and TAPSE (HR 0.92 per mm [0.86–0.99]; p=0.030) were independent predictors of mortality. In the LVEF 30–49% subgroup, age (HR 1.05 per year [1.02–1.08]; p=0.003), LVEF (HR 0.94 per 1% [0.89–0.99]; p=0.020) and disproportionate FMR (HR 1.02 per mL [1.01–1.03]; p=0.01) were independently associated with increased mortality. Conclusions Disproportionate FMR proved to be an important independent predictor of mortality in patients with LVEF between 30–49%. These findings were not replicated in those with LVEF&amp;lt;30%, where the degree of biventricular dysfunction seems to outweigh all other echocardiographic parameters, leaving FMR as a bystander. Figure 1 Funding Acknowledgement Type of funding source: None

The Clinical Importance of Functional Mitral Regurgitation and Atrial Fibrillation in Patients with Left Ventricular Assist Device

Functional mitral regurgitation (FMR) and atrial fibrillation (AF) are common in patients undergoing left ventricular assist device (LVAD) implantation. However, the impact of FMR and AF on clinical outcomes is uncertain. The aim of this study is to investigate the prognostic significance of FMR and AF in patients with LVAD. We retrospectively reviewed all patients who underwent LVAD implantation at our center between January 2010 and December 2017. We excluded patients who had previous or concomitant mitral valve procedure and patients who had insufficient quality of echocardiographic images. We defined significant FMR as MR color jet area / left atrial area > 0.2 and AF as persistent AF at LVAD implantation. 427 patient's charts were reviews (125 patients had previous or concomitant mitral valve procedure and 31 patients had insufficient quality of echocardiographic images). 271 were included in this analysis. Mean age of cohort was 57.1 +/-13.0 years, and 84% were male. Of all, 110 (41%) patients had significant FMR and 51 (19%) patients had persistent AF. Patients were divided into 4 groups: no AF and no significant FMR (Group1, n=136), no AF and significant FMR (Group 2, n=84), AF and no significant FMR(Group 3, n=25), and AF and significant FMR (Group 4, n=26). Forty-four (16%) patients died within 2years. Kaplan-Meier curve analysis demonstrated 2-year survival of 77% in Group 1, 87% in Group 2, 92% in Group 3, and 47% in Group 4 (P=0.0006). On the multivariate Cox proportional hazard model Group 4 was significant predictor of mortality [hazard ratio (HR), 2.62; 95% confidence interval (CI),1.27-5.41; P =0.009], independently of other parameters. Coexistence of significant FMR and AF is a poor prognostic marker in patients undergoing LVAD implantation.

Change in Mitral Valve Geometry after Left Ventricular Assist Device Implantation in Patients with Functional Mitral Regurgitation

Previous studies have shown remarkable decrease in severity of functional mitral regurgitation (FMR) after left ventricular assist device (LVAD) implantation with mechanical unloading. This study aimed to identify the change of FMR and mitral geometry in LVAD patients. We retrospectively reviewed all patients who underwent LVAD implantation and had significant FMR without mitral valve procedure between January 2010 and December 2017. All patients underwent echocardiographic examination preoperatively and 1 month after LVAD implantation. We defined significant FMR as MR color jet area / left atrial area &gt; 0.2. We measured mitral annular diameter (MAD) and posterior (Dp) and apical (Da) displacement of the coaptation point of mitral leaflets on echocardiogram. Patients were divided into 2 groups, patients with and without AF. 106 patients were identified, 82 with no AF and 24 with AF. Mitral geometry significantly changed after LVAD insertion in both groups (table). Preoperative MAD was smaller in patients without AF (39.0 +/-4.5 vs. 41.2 +/-3.8mm; P=0.04) and reduced following LVAD in both postoperative (30.3+/-5.4 vs. 36.5 +/-4.1mm; P<0.0001), however, the changes of MAD before and after surgery were larger in patients with no AF (8.8 +/-5.0 vs. 4.7 +/-3.2 mm; P=0.0003). There were no significant differences in Da between groups. Patients with AF had a higher prevalence of significant FMR at 1 month after LVAD implantation than patients with no AF (4% vs. 17%; P =0.03). LVAD implantation significantly changed mitral geometry, however, the changes were less in patients with AF resulting in greater residual FMR.

Functional mitral regurgitation and cardiac resynchronization therapy in the “era” of trans-catheter interventions: Is it time to move from a staged strategy to a tailored therapy?

Cardiac resynchronization therapy (CRT) has been associated to left ventricle (LV) remodelling, reduction of functional mitral regurgitation (FMR) and clinical improvement in patients with heart failure and reduced ejection fraction (HFrEF). The prevalence of significant FMR in patients with LV dyssynchrony that are candidate to CRT is up to 40%. Current approach in patients with FMR undergoing CRT consists of re-evaluation of the amount of FMR following a waiting period of at least 3 months after the implant. In case of persistent significant FMR despite CRT and guideline directed medical therapy, trancatheter Mitral Valve repair (TMVR) is an important option to improve quality of life and prognosis. This stepwise approach does not take into account the probability of the individual response to CRT and the availability of TMVR solutions that are safe and effective in high risk patients. We reviewed the effects of CRT on FMR, the prognostic role of persistence of FMR after CRT treatment and the impact of treatment of FMR in patients CRT non responders. We aimed to point out the limits of current step-wised approach in light on more recent evidence regarding FMR treatment. A new, “tailored” approached is proposed.

Transcatheter mitral valve repair for functional mitral regurgitation: Evaluating the evidence

ObjectivesTwo trials (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation Trial and Percutaneous Repair with the MitraClip Device for Severe Functional/Secondary Mitral Regurgitation Trial) were published in 2018 evaluating the effectiveness and safety of transcatheter repair for patients with heart failure with significant functional mitral regurgitation, which yielded different results. This article reviews the strength of the evidence, differences in trial designs, ethical and implementation implications, and delineates future research needs to help guide the appropriate dissemination of transcatheter repair for functional patients with mitral regurgitation. MethodsThe National Heart, Lung, and Blood Institute convened a workshop of interdisciplinary experts to address these objectives. ResultsTranscatheter repair of functional mitral regurgitation can provide significant benefits in terms of heart failure hospitalizations, survival, and quality of life when appropriate heart failure candidates with moderate to severe or severe mitral regurgitation while on optimal guideline-directed medical therapy can be identified. Key ingredients for success are preoperative evaluation and management and postoperative care by an interdisciplinary heart team. ConclusionsGiven the discordance observed between trials, ongoing innovation in patient management, and potential expansion of indications for use, the evidence base must be expanded to optimize appropriate implementation of this complex therapy. This will require more complete capture of outcome data in real-world settings for all eligible candidates whether or not they receive this therapy. Inevitably, the indications for use of this therapy will expand, as will the devices and therapeutic approaches for this population, necessitating the study of comparative effectiveness through randomized trials or observational studies. Moreover, given the substantial variations in care delivery, conducting implementation research to delineate characteristics of the optimal care model would be of benefit.

P904 Impact of significant functional mitral regurgitation and aortic stenosis on outcome of HFrEF patients

Abstract Background Concomitant aortic stenosis (AS) and functional mitral regurgitation (FMR) are common in patients with left ventricular dysfunction. We evaluated the impact of significant valve diseases on outcome of patients with reduced left ventricular ejection fraction (HFrEF, LVEF &amp;lt; 40%). Methods A total of 1264 consecutive HFrEF patients referred to our department between 2009 and 2017 were screened. Transthoracic echocardiography was performed at baseline visit in all patients. Patients with primary MR or received mitral valve operation before or after baseline visit (n = 64) as well as patients underwent aortic valve replacement (AVR) before baseline visit (n = 66) were excluded. Finally, 1134 HFrEF patients were included for final analysis, and all completed a median clinical follow-up of 26 (12-40) months by medical record review or telephone interview. The primary endpoint was all-cause mortality or heart transplantation (HTx). Results Moderate or severe FMR or AS was detected in 902 (79.5%) and in 119 (10.5%) patients by echocardiography, respectively. Of patients with significant AS, 47 patients underwent AVR shortly after baseline visit. In total, 353 (31.2%, including HTx n = 11) HFrEF patients died or underwent HTx during follow-up. Age, body mass index, diabetes, atrial fibrillation, coronary artery disease, chronic respiratory diseases, and renal dysfunction (all P &amp;lt; 0.05) were defined as clinical covariates associated with all-cause mortality/HTx and served as potential confounders in the multivariable Cox regression models. All-cause mortality/HTx was significantly higher in HFrEF patients with significant FMR than patients without significant FMR (33.8% vs. 20.7%, P &amp;lt; 0.001). Multivariable Cox regression analysis showed significant FMR remained as an independent determinant of all-cause mortality/HTx in patients with HFrEF after adjusted for above mentioned confounders (HR 1.39, 95% CI 1.02-1.90, P = 0.035). Patients with significant AS without AVR faced increased risk of all-cause mortality/HTx as compared to patients without significant AS (HR 2.34, P &amp;lt; 0.001), while risk of all-cause mortality/HTx was significantly lower in patients with significant AS and underwent AVR as compared to patients without significant AS after adjustment for confounders (HR 0.36, P = 0.008). In the subgroup of HFrEF patients with significant FMR, significant AS without AVR was independently associated with increased all-cause mortality/HTx as compared to patients without significant AS (HR 2.30, P &amp;lt; 0.001), while outcome is better in AS and FMR patients underwent AVR as compared to patients with significant FMR and without significant AS (survival: 85.4% vs. 67.5%, P &amp;lt; 0.001; HR 0.34, P = 0.010) after adjustment for potential confounding factors. Conclusion Moderate to severe FMR and/or AS is incrementally related to higher all-cause mortality/HTx in HFrEF patients. AVR could significantly improve the survival of HFrEF patients with concomitant significant AS and FMR.

Predictors of In-Hospital Events for Patients with Nonischemic Acute Heart Failure

Abstract Aim The main purpose of this article is to evaluate the clinical profile and in-hospital outcome among heart failure (HF) patients due to different diseases other than acute coronary syndromes (ACS) admitted in intensive coronary care unit (ICCU) at a tertiary center in South India. Materials and Methods This is an observational study of HF patients who were admitted to ICCU for a period of 6 months from January 2019 to June 2019. ACS patients were excluded. All the demographic data, clinical history, examination details, electrocardiographic (ECG), two-dimensional echocardiography (ECHO), baseline routine, and special investigations were collected. In-hospital progress of the patient was monitored along with events (recurrence of HF, arrhythmias, acute kidney injury, cardiogenic shock, and death). Results The total number of patients included in the study was 130. The male:female ratio was 2.09:1(88/42) with a mean age of 53.61 years. Hypertension and diabetes were present in 52.3% (68 patients). The etiology of HF was either ischemic (51 patients—39.2%) or dilated (24 patients—18.4%) cardiomyopathy in the majority of the patients (75 patients—57.6%). Rest of the diagnosis for HF were hypertrophic cardiomyopathy in 6 (4.6%) patients, chronic rheumatic heart disease in 18 (13.8%) patients, primary pulmonary arterial hypertension in 6 (4.6%) patients, severe valvular pulmonary restenosis in 3 (2.3%) patients, Cor-pulmonale in 6 (4.6%) patients, and others in 16 (12.3%) patients. Events occurred in 17 patients (13.1%). Mortality occurred in 6 patients (4.62%). Patients with events had more severe dyspnea with pedal edema with low systolic blood pressure clinically; all patients had ECG abnormalities with more severe left ventricular (LV) dilatation with right and LV dysfunction with significant functional mitral regurgitation (MR) with more laboratory abnormalities including grossly elevated N-terminal pro B-type natriuretic peptide (NT pro-BNP) levels when compared with patients without events. All the above said parameters were statistically significant (p &lt; 0.05). Conclusion The common cause of HF admissions in ICCU was predominantly due to ischemic cardiomyopathy. Still, valvular heart diseases were accounting for 13.8% of admissions. High incidence of event rate (13.1%) despite the improvement in treatment strategies of ICCU patients in this new era, also the all-cause in-hospital mortality, was 4.62%. There were multiple clinical (degree of dyspnea, pedal edema, low systolic blood pressure), ECHO (LV dilatation with dysfunction, right ventricle dysfunction, significant MR), and laboratory parameters (pre-azotemia, anemia, thrombocytopenia, grossly elevated NT pro-BNP levels) to predict the in-hospital events.

Possible influence of zoonotic parasitic diseases on the immunity system and some forms of cancer

The indications for mitral valve surgery in patients with advanced nonischemic dilated cardiomyopathy and functional mitral regurgitation are still unclear. We reviewed our experience of mitral valve surgery in such patients and explored factors that were predictive of outcomes. Fifty-three consecutive patients with nonischemic dilated cardiomyopathy and an ejection fraction <35% who underwent mitral valve surgery were reviewed. Thirty five patients (66%) suffered all-cause death or underwent admission for heart failure or left ventricular assist device implantation after mitral valve surgery during follow-up (37 ± 27 months); freedom from these events at 3 years was 45%. Mitral valve surgery significantly reduced left ventricular volume (P < 0.01) and pulmonary vascular resistance (P < 0.01) in survivors. New York Heart Association functional class also improved significantly (P < 0.01) at 1 year after surgery. By multivariate analysis, preoperative left ventricular stroke work index (P < 0.04) was the sole significant predictor of composite outcomes including all-cause mortality, admission for heart failure or left ventricular assist device implantation after mitral valve surgery, with a cut-off value of 25.9 g-m/m2/beat. A higher tethering height (≥11 mm, P < 0.01) was a significant predictive factor for mitral regurgitation recurrence (P = 0.02). Mitral valve surgery for significant functional mitral regurgitation associated with nonischemic cardiomyopathy is still challenging. However, thorough hemodynamic investigations prior to surgery could provide useful indications regarding mitral valve surgery in these patients, contributing to an improvement in their clinical outcomes.

Left Ventricular Stroke Work Index Associated With Outcome After Mitral Valve Surgery for Functional Regurgitation in Nonischemic Dilated Cardiomyopathy

The indications for mitral valve surgery in patients with advanced nonischemic dilated cardiomyopathy and functional mitral regurgitation are still unclear. We reviewed our experience of mitral valve surgery in such patients and explored factors that were predictive of outcomes. Fifty-three consecutive patients with nonischemic dilated cardiomyopathy and an ejection fraction <35% who underwent mitral valve surgery were reviewed. Thirty five patients (66%) suffered all-cause death or underwent admission for heart failure or left ventricular assist device implantation after mitral valve surgery during follow-up (37 ± 27 months); freedom from these events at 3 years was 45%. Mitral valve surgery significantly reduced left ventricular volume (P < 0.01) and pulmonary vascular resistance (P < 0.01) in survivors. New York Heart Association functional class also improved significantly (P < 0.01) at 1 year after surgery. By multivariate analysis, preoperative left ventricular stroke work index (P < 0.04) was the sole significant predictor of composite outcomes including all-cause mortality, admission for heart failure or left ventricular assist device implantation after mitral valve surgery, with a cut-off value of 25.9 g-m/m2/beat. A higher tethering height (≥11 mm, P < 0.01) was a significant predictive factor for mitral regurgitation recurrence (P = 0.02). Mitral valve surgery for significant functional mitral regurgitation associated with nonischemic cardiomyopathy is still challenging. However, thorough hemodynamic investigations prior to surgery could provide useful indications regarding mitral valve surgery in these patients, contributing to an improvement in their clinical outcomes.

LONG-TERM SURVIVAL IMPACT OF CONCOMITANT MITRAL VALVE INTERVENTION IN PATIENTS WITH SEVERE AORTIC STENOSIS AND FUNCTIONAL MITRAL REGURGITATION UNDERGOING AORTIC VALVE REPLACEMENT

Whether patients with severe aortic stenosis (AS) and significant (≥moderate) functional mitral regurgitation (FMR) should undergo isolated aortic valve replacement (AVR) or double aortic and mitral valve replacement (DVR) remains controversial. Accordingly, we sought to compare their perioperative and long-term outcomes following AVR or DVR. Among patients undergoing isolated AVR, we also sought to determine the impact of significant residual MR on long-term survival. Data prospectively collected from 736 consecutive patients with severe AS and FMR were retrospectively analyzed, and their echocardiograms reviewed by a single blinded cardiologist. Patients with organic or ischemic MR (previous or concomitant CABG/PCI), previous AVR or more-than-mild aortic regurgitation were excluded, resulting in 74 patients constituting our study population. Of these, 19 patients had a DVR, and 55 patients an isolated AVR. Among patients undergoing DVR, 14 (74%) underwent mitral valve replacement and 5 (26%) underwent mitral valve repair. Their pre-operative characteristics, post-operative complications and age-adjusted survival over time were compared. Patients from the isolated AVR group were older and had milder FMR (87% moderate and 13% severe MR vs 12% moderate and 88% severe MR in the DVR group, p < 0.0001). Patients undergoing DVR required more post-operative blood transfusions (84% vs 38%, p=0.0005) and had a longer hospital stay (9.9 vs 7.0 days, p=0.01), but there were no differences in perioperative mortality (5.3% vs 6.7%, p=0.83) or other complications compared with patients undergoing isolated AVR. After adjustment for age, there was no significant difference in survival over time between the two groups (p=0.26, see figure). However, patients in the isolated AVR group whose MR improved following surgery (60%) had significantly increased long-term survival compared with patients in the group with significant residual MR (40%) (p=0.03). In patients with severe AS and significant FMR, DVR is not associated with significant differences in perioperative mortality, perioperative complications and long-term age-adjusted survival. In patients undergoing isolated AVR, nearly a third remain with significant residual MR at long-term follow up, and persistence of significant residual MR after surgery is associated with significantly lower long-term survival. This suggests that in patients with significant FMR and severe AS, a concomitant mitral intervention should be strongly considered, or a staged approach contemplated in the absence of MR improvement after the initial surgery.

WHAT PREOPERATIVE ECHOCARDIOGRAPHIC PARAMETERS CAN HELP PREDICT IMPROVEMENT OF SIGNIFICANT MITRAL REGURGITATION IN PATIENTS WITH CONCOMITANT SEVERE AORTIC STENOSIS UNDERGOING ISOLATED AORTIC VALVE REPLACEMENT?

There is no scientific consensus regarding whether patients with concomitant severe aortic stenosis (AS) and significant (≥moderate) functional mitral regurgitation (MR) should undergo isolated aortic (AVR) or double valve replacement (DVR). Since post-operative improvement of MR is associated with better long-term survival, we sought to identify preoperative echocardiographic parameters predictive of MR improvement following isolated AVR.

Effect of Successful Edge-to-Edge Mitral Valve Repair on Ventricular Arrhythmic Burden in Patients With Functional Mitral Regurgitation and Implantable Cardiac Devices

Significant mitral regurgitation (MR) may be present in up to half of patients with heart failure (HF) and it is associated with adverse cardiac remodeling and myocardial stretch. These are potential triggers for ventricular arrhythmias (VA) in patients with HF, and therefore MR may enhance electrical ventricular vulnerability. Our aim was to evaluate VA burden before and after percutaneous mitral valve repair (PMVR) in patients with implantable cardiac devices. We conducted a prospective registry of all consecutive patients (n = 34, age 69.0 ± 12.2 years, 77% male) with significant functional mitral regurgitation (FMR) who underwent MitraClip implantation in 2 centers between June 2014 and July 2018. VA burden was defined as the total number of events during device follow-up before and after PMVR. Among patients presenting VA during follow-up before or after PMVR, device success at hospital discharge was related to a significant reduction in the incidence of Nonsustained ventricular tachycardia (VT, p = 0.002) and any sustained VT or rapid VT/ventricular fibrillation (p = 0.034). Regarding implantable cardiac defibrillator (ICD) therapies, successful PMVR was related to a reduction in incidence of either antitachycardia pacing or appropriate shocks (p = 0.045) and in the occurrence of any defibrillation shocks (p = 0.045). Overall, effective repair lead to a significant reduction in the VA burden, with a significant decrease in the occurrence of any VA (p = 0.004) and any ICD therapies (p = 0.045). In conclusion, device success after PMVR was related to a reduction in overall arrhythmic burden and ICD therapies in our cohort.

The healthcare burden of disease progression in medicare patients with functional mitral regurgitation

Objective: This retrospective database analysis estimated the incremental effect that disease progression from non-clinically significant functional mitral regurgitation (nsFMR) to clinically significant FMR (sFMR) has on clinical outcomes and costs.Methods: Medicare Fee for Service beneficiaries with nsFMR were examined, defined as those with a heart failure diagnosis prior to MR. Patients were classified as ischemic if there was a history of: CAD, AMI, PCI, or CABG. The primary outcome was time to sFMR, defined as pulmonary hypertension, atrial fibrillation, mitral valve surgery, serial echocardiography, or death, using a Cox hazard regression model. Annualized hospitalizations, inpatient hospital days, and healthcare expenditures were also modeled.Results: Patients with IHD had higher risk (Hazard Ratio = 1.22 [1.14–1.30]) for disease progression compared to patients without. The progression cohort had significantly more annual inpatient hospitalizations (non-IHD = 1.32; IHD = 1.40) than the non-progression cohort (non-IHD = 0.36; IHD = 0.34), and significantly more annual inpatient hospital days (non-IHD = 13.07; IHD = 13.52) than the non-progression cohort (non-IHD = 2.29; with IHD = 2.08). The progression cohort had over 3.5-times higher costs vs the non-progression cohort, independent of IHD (non-IHD = $12,798 vs $46,784; IHD = $12,582 vs $49,348).Conclusion: Treating FMR patients earlier in their clinical trajectory may prevent disease progression and reduce high rates of healthcare utilization and expenditures.

Prognostic impact of MitraClip in patients with left ventricular dysfunction and functional mitral valve regurgitation: A comprehensive meta-analysis of RCTs and adjusted observational studies

The real prognostic impact of MitraClip in patients with significant functional mitral regurgitation (FMR) and left ventricular (LV) dysfunction remains to be elucidated. Two randomized controlled trials (RCTs) with conflicting results have been recently published.We conducted a comprehensive meta-analysis of all RCTs and adjusted observational studies to evaluate the clinical impact of percutaneous mitral valve repair when compared with optimal medical therapy (OMT) alone, in patients with symptomatic FMR and LV dysfunction. Death from any cause and heart failure rehospitalizations at the longest available follow-up were the primary endpoints. Cardiac death, one year and short-term death were the secondary ones. 2255 patients (1207 for MitraClip and 1048 for OMT-only) from 8 studies (2 RCTs and 6 observational studies) were included. At a median (mid-term) follow-up of 438 days (IQR 360–625) MitraClip was associated with a significant reduction of all-cause death (odds Ratio [OR] 0.55, 95%CI 0.41–0.73, p < 0.001; [ORadj] 0.66, 95%CI 0.49–0.90, p = 0.009) and rehospitalization (OR 0.49, 95%CI 0.24–1.00, p = 0.05 and ORadj 0.63, 95%CI 0.43–0.94, p = 0.02). At one year, adjusted analysis demonstrated a trend favoring the experimental cohort (ORadj 0.73, 95%CI 0.53–1.02, p = 0.07). Meta-regression suggested that benefit of MitraClip on mid-term survival persists even after accounting for the prevalence of implanted CRT, burden of comorbidities, NYHA class, cardiomyopathy etiology and LV function and dimensions. In conclusion, MitraClip for FMR in patients with LV dysfunction is associated with a considerable reduction of death and HF hospitalization at mid-term follow-up. Further ongoing RCTs are needed to strengthen present results.

CHANGE IN FUNCTIONAL MITRAL REGURGITATION POST TAVR IN PATIENTS WITH REDUCED EJECTION FRACTION

Significant functional mitral regurgitation (MR) is common in patients with reduced ejection fraction and is associated with increased mortality. Previous studies have demonstrated improvement in the degree of MR in TAVR recipients regardless of its etiology and baseline ejection fraction (EF). This