Transcatheter Mitral Valve Interventions Research Articles

Transcatheter Mitral Valve Intervention: Current and Future Role of Multimodality Imaging for Device Selection and Periprocedural Guidance.

Mitral regurgitation (MR) is a broadly diffuse valvular heart disease (VHD) with a significant impact on the healthcare system and patient prognosis. Transcatheter mitral valve interventions (TMVI) are now well-established techniques included in the therapeutic armamentarium for managing patients with mitral regurgitation, either primary or functional MR. Even if the guidelines give indications regarding the correct management of this VHD, the wide heterogeneity of patients' clinical backgrounds and valvular and heart anatomies make each patient a unique case, in which the appropriate device's selection requires a multimodal imaging evaluation and a multidisciplinary discussion. Proper pre-procedural evaluation plays a pivotal role in judging the feasibility of TMVI, while a cooperative work between imagers and interventionalist is also crucial for procedural success. This manuscript aims to provide an exhaustive overview of the main parameters that need to be evaluated for appropriate device selection, pre-procedural planning, intra-procedural guidance and post-operative assessment in the setting of TMVI. In addition, it tries to give some insights about future perspectives for structural cardiovascular imaging.

Computed Simulation of Transcatheter Edge-to-Edge Mitral Valve Repair - A Proof of Concept Study.

As transcatheter mitral valve (MV) interventions are expanding and more device types and sizes become available, a tool supporting operators in preprocedural planning and the clinical decision-making process is highly desirable. We sought to develop a finite element (FE) computational simulation model to predict results of transcatheter edge-to-edge (TEER) interventions. We prospectively enrolled patients with secondary mitral regurgitation (MR) referred for a clinically indicated TEER. Three-dimensional (3D) transesophageal echocardiograms performed at the beginning of the procedure were used to perform the simulation. On the 3D dynamic model of the MV that was first obtained, we simulated the clip implantation using the same clip(s) type, size, number, and implantation location that was used during the intervention. The 3D model of the MV obtained after simulation of the clip implantation was compared to the clinical results obtained at the end of the intervention. We analyzed the degree and location of residual MR and the shape and area of the diastolic mitral valve area. We performed computational simulation on 5 patients. Overall, the simulated models predicted well the degree and location of the residual regurgitant orifice(s) but tended to underestimate the diastolic mitral orifice area. In this proof-of-concept study, we present preliminary results on our algorithm simulating clip implantation in 5 patients with functional MR. We show promising results regarding the feasibility and accuracy in terms of predicting residual MR and the need to improve the estimation of the diastolic mitral valve area.

Etiologies and Impact of Exclusion Rates for Transcatheter Mitral and Tricuspid Valve Structural Heart Clinical Trials at a High-Volume Quaternary Care Hospital

There are various devices under clinical investigation for transcatheter mitral valve intervention (TMVI) and tricuspid valve intervention (TTVI), but exclusion rates remain high. We aim to investigate exclusion rates for transcatheter mitral valve repair (TMVr), transcatheter mitral valve replacement (TMVR), transcatheter tricuspid valve repair (TTVr) and transcatheter tricuspid valve replacement (TTVR). There were a total of 129 patients who were referred to St. Francis Hospital & Heart Center valve clinic and completed screening between January 2021 and July 2022. Causes for exclusion were classified into 4 categories: patient withdrawal, anatomic unsuitability, clinical criteria and medical futility. Among 129 patients, the exclusion rates for TMVr, TMVR, TTVr and TTVR were 81%, 85%, 91% and 87%, respectively. Patient withdrawal and medical futility were leading etiologies for exclusion, followed by anatomical unsuitability. TMVr had the highest rate of patient withdrawal (64%), the lowest anatomic unsuitability (5%) due to short posterior leaflet length. Replacement interventions have higher anatomic unsuitability (33%) compared to repair interventions (17%) (p=0.04). Most exclusions of anatomic unsuitability was due to mitral stenosis or small annulus size for TMVR and large annulus size for TTVR. Fifty percent of exclusions from TTVr were due to presence of pacemaker/defibrillator leads. Among patients excluded from their respective trials, patients being referred for TMVr had the highest recurrent hospitalization and repair group had a higher mortality (p<0.01 and p=0.01, respectively). In conclusion, exclusion rates for TMVI and TTVI trials remain high due to various reasons, limiting patients’ enrollment and treatment. This supports the need for further device improvement or exploring alternative means of therapy.

An ex-vivo and in-vitro dynamic simulator for surgical and transcatheter mitral valve interventions

PurposeMinimally invasive mitral valve surgery (MIMVS) and transcatheter edge-to-edge repair (TEER) are complex procedures used to treat mitral valve (MV) pathologies, but with limited training opportunities available. To enable training, a realistic hemodynamic environment is needed. In this work we aimed to develop and validate a simulator that enables investigation of MV pathologies and their repair by MIMVS and TEER in a hemodynamic setting.MethodsDifferent MVs were installed in the simulator, and pressure, flow, and transesophageal echocardiographic measurements were obtained. To confirm the simulator’s physiological range, we first installed a biological prosthetic, a mechanical prosthetic, and a competent excised porcine MV. Subsequently, we inserted two porcine MVs—one with induced chordae tendineae rupture and the other with a dilated annulus, along with a patient-specific silicone valve extracted from echocardiography with bi-leaflet prolapse. Finally, TEER and MIMVS procedures were conducted by experts to repair the MVs.ResultsSystolic pressures, cardiac outputs, and regurgitations volumes (RVol) with competent MVs were 119 ± 1 mmHg, 4.78 ± 0.16 l min−1, and 5 ± 3 ml respectively, and thus within the physiological range. In contrast, the pathological MVs displayed increased RVols. MIMVS and TEER resulted in a decrease in RVols and mitigated the severity of mitral regurgitation.ConclusionEx-vivo modelling of MV pathologies and repair procedures using the described simulator realistically replicated physiological in-vivo conditions. Furthermore, we showed the feasibility of performing MIMVS and TEER at the simulator, also at patient-specific level, thus providing new clinical perspectives in terms of training modalities and personalized planning.

Rationale and design of a randomized clinical trial evaluating the efficacy of mechanical neuroprotection in reducing the risk of silent brain infarcts associated with percutaneous left atrial appendage closure: study protocol for a LAAC-SBI trial

BackgroundLeft atrial appendage closure (LAAC) procedures prevent cardioembolic stroke in patients with atrial fibrillation who have contraindications to oral anticoagulant medications. However, these procedures carry certain risks of peri-procedural complications. One such complication is silent brain infarcts (SBI), which can lead to cognitive impairment and mood disturbances. The implementation of mechanical neuroprotection systems during LAAC procedures may reduce the risk of SBI and associated cognitive and mood disorders.MethodsThe LAAC-SBI trial is a prospective, multicenter, randomized, and double-blind interventional study. The study aims to enroll a total of 240 patients, with 120 patients allocated to each group. The study group will evaluate the use of the Sentinel CPS during LAAC, while the control group will undergo LAAC procedures without the Sentinel CPS. The primary endpoint of the study is the number of new SBIs or stroke foci detected by diffusion-weighted magnetic resonance imaging (DW MRI). Secondary endpoints include deterioration of cognitive function, development of dementia syndrome, and occurrence of depressive disorders. These endpoints will be assessed using questionnaire tools such as the Montreal Cognitive Assessment (MoCA), Trail Making Test (TMT), Controlled Oral Word Association Test (COWAT), and Hospital Anxiety and Depression Scale (HADS). The observational period for patients in the study is 2 years.DiscussionIf the study demonstrates a favorable outcome with reduced incidence of SBI and improved cognitive and mood outcomes in patients receiving cerebral protection devices during LAAC, it will have significant implications for clinical management standards. This would support the use of neuroprotection devices not only for LAAC but also in procedures such as atrial fibrillation ablation or transcatheter mitral valve interventions, where the risk of embolic events and subsequent brain injury may also be present.Trial registrationClinicalTrials.gov NCT05369195. Registration on 11.05.2022.

Surgical outcomes of patients at prohibitive risk who are reconsidered for surgery

ObjectivesTranscatheter treatment of advanced mitral and tricuspid valve disease is largely limited to patients at prohibitive surgical risk, although many are not candidates for transcatheter treatment. Here, we describe surgical outcomes of patients at prohibitive risk who were ineligible for transcatheter therapies to guide surgeons in management of this unique population. MethodsPatients at prohibitive risk, defined per surgeon or cardiologist discretion, who were initially referred for a transcatheter mitral or tricuspid intervention in a multidisciplinary atrioventricular valve clinic, were identified from 2019 to 2022. Preoperative risk, operative outcomes, and long-term mortality were evaluated. ResultsA total of 337 patients at prohibitive risk were referred for evaluation in a multidisciplinary atrioventricular valve clinic. Of those, 161 underwent transcatheter therapy, 130 patients underwent continued medical management, and 45 were reevaluated and had high-risk surgery. Among surgical patients, 51% were women with a median age of 76 years (quartile 1-quartile 3, 65-81 years). Most patients presented in heart failure (83%; n = 37 out of 45), and 73% were in New York Heart Association functional class III or IV. Most patients (94%; n = 43) had a mitral valve intervention, of whom 56% (24 out of 43) had a mitral valve replacement. The 30-day mortality rate was 4% (2 out of 45) and major morbidity occurred in 33% (15 out of 45). By Kaplan-Meier analysis, 1-year survival was 86% ± 9%. ConclusionsSelect patients at prohibitive risk who were ineligible for transcatheter mitral or tricuspid valve intervention underwent surgery with overall low operative mortality and excellent 1-year survival. Patients a prohibitive risk whose anatomy is not amenable to transcatheter devices should be reconsidered for surgery.

Multimodality imaging for patient selection, procedural guidance, and follow-up of transcatheter interventions for structural heart disease: a consensus document of the EACVI Task Force on Interventional Cardiovascular Imaging: part 1: access routes, transcatheter aortic valve implantation, and transcatheter mitral valve interventions.

Transcatheter therapies for the treatment of structural heart diseases (SHD) have expanded dramatically over the last years, thanks to the developments and improvements of devices and imaging techniques, along with the increasing expertise of operators. Imaging, in particular echocardiography, is pivotal during patient selection, procedural monitoring, and follow-up. The imaging assessment of patients undergoing transcatheter interventions places demands on imagers that differ from those of the routine evaluation of patients with SHD, and there is a need for specific expertise for those working in the cath lab. In the context of the current rapid developments and growing use of SHD therapies, this document intends to update the previous consensus document and address new advancements in interventional imaging for access routes and treatment of patients with aortic stenosis and regurgitation, and mitral stenosis and regurgitation.

P81: Development Of A Pre-Operative Planning Tool For Patients With Mitral Regurgitation

Mitral regurgitation is the most frequent valve disease in patients over the age of 65 years. In patients with high surgical risk, transcatheter mitral valve intervention (TMVI) is the preferred therapy. However, patient selection for this therapy remains a challenge. This study aims at developing a simulation tool to assist surgeons pre-operatively to choose the treatment based on the patient’s characteristics. In this study, a clinical data (echocardiography and CT scans) of a TMV recipient with a history of severe mitral calcification was considered. Left ventricular (LV) and mitral valve (MV) models were obtained from pre-TMVI CT scans. Pre- and post-TMVI hemodynamics were generated by a lumped-parameter model which were then applied as boundary conditions for two fluid–structure interaction (FSI) simulations with contractile LV and dynamic MV; first, a pre-TMVI simulation with the anatomical MV model and second, a post-TMVI simulation with a Tendyne transcatheter mitral valve model. Mitral pressure gradients (MPG) and effective orifice area (EOA) were calculated. The predictions of the pre-TMVI simulations closely resembled Echo data. Calcified mitral leaflets led to a narrowing of the diastolic opening area resulting in an increased pressure gradient over the MV; EOA (FSI: 2.1 cm2, ECHO: 1.9 cm2), MPG (FSI: 3.8 mmHg, ECHO: 3.4mmHg). These values improved significantly for the post-TMVI simulation (EOA: 4.5 cm2, MPG: 1.1 mmHg), Figure 1. By combining medical imaging and computer modeling, we established a validated tool that can be used pre-TMVI to assist clinicians to select the optimal therapy based on patients’ characteristics.Figure 1. Pre-, and post-TMVI simulation of a patient with severely calcified mitral valve; TMVI: transcatheter mitral valve intervention

Clinical Outcomes of Patients Who Underwent Mitral Valve Intervention and Predictive Selection of Patients for Possible Trans-Catheter Mitral Valve Intervention

Mitral regurgitation (MR) is a common valvular disease, with mitral valve surgery being the only available therapy in public hospitals. This study investigated real-world outcomes of patients who underwent mitral surgery for MR in a tertiary centre. Three registrars performed a retrospective analysis of patients who underwent mitral valve surgery from 2010 to 2021, and data were input into Microsoft Excel. Data were analysed with JASP. A total of 906 patients were identified. Of the 906 patients, 398 had mitral valve repair and 508 had mitral valve replacement. The mortality rate for mitral valve repair was 2% (eight patients). Complications included stroke (0.8%), dialysis (2.5%), pacemaker implantation (2.8%), return to theatre (6.3%), and death at 1 year (1.5%). The mortality rate for mitral valve replacement was 9.3% (47 patients). Complications included stroke (1.7%), dialysis (6.9%), pacemaker (4.5%), return to theatre (12.2%), and death at 1 year (3%). A total of 500 (56%), 266 (29%), and 140 patients (15%) had EuroSCORE-II of <2, 2–5, and >5, respectively. Low EuroSCORE-II (<2) had a mortality rate of 1.4%. Complications included stroke (0.7%), acute renal failure (6.5%), return to theatre (5.8%), and dialysis (1%), with an average in-hospital stay of 10.8 days. High EuroScore-II (>5) had a mortality rate of 21.7%. Complications included stroke (4.2%), acute renal failure (47.5%), return to theatre (24%), and dialysis (17%), with an average in-hospital stay of 20.4 days. Mitral valve replacement had higher mortality and complication rates. There was a predictive increased risk of mortality and complication rates in those with high EuroSCORE-II. An alternative solution for mitral valve intervention, such as a transcatheter solution, should be considered.

Multi-modality imaging for pre-procedural planning of transcatheter mitral valve interventions.

Transcatheter mitral valve interventions (TMVI), either repair or replacement, are established alternative options for patients with mitral regurgitation (MR) deemed not suitable for conventional open-heart surgery. Multi-modality imaging plays a pivotal role in the selection of patients, gaining insights into the anatomy of the mitral valve the mechanism and the severity of MR, which are essential to predict the success of these procedures. The aim of this review is to provide an overview on the role of multi-modality imaging in the patient selection and pre-procedural planning of TMVI.

The Use of Three-Dimensional Printing in Cardiac Structural Disease: A Review.

Three-dimensional printing (3DP), or additive fabrication, is a process in which a physical 3D model is created using a multitude of 2-dimensional images. This process has been applied to numerous surgical subspecialties with growing interest for the use of 3DP in adult structural heart disease. This scoping review evaluates the use of 3DP in transcatheter and surgical aortic and mitral valve interventions as well as left atrial appendage occlusion in terms of its practical and clinical application. Articles were identified through PubMed and Embase using MeSH search terms as well as independent searches. A total of 645 articles were screened, and 37 were retained for qualitative analysis. Operative planning was coded in 100% of articles, complication prevention in 43%, medical education in 5.4%, patient education in 0%, and simulation in 5.4%. The main uses of 3DP in acquired structural heart disease are centered around operative planning and complication prevention, with moderate use regarding surgical simulation and infrequent use regarding medical and/or patient education. Although patient anatomy varies greatly, deploying 3DP as a large-scale tool remains a possibility. The more 3D models are made, the more can be learned about demographic subsets of patient populations. Due to the lack of standard operating procedures for the creation of 3DP models, the cost-effectiveness of these models is hard to determine and likely center specific. More research into this facet could inform centers that wish to implement this tool.

Application of and Prospects for 3-Dimensional Printing in Transcatheter Mitral Valve Interventions.

ClinicalTrials.gov Protocol Registration System (NCT02917980).

The evolution of technical prerequisites and local boundary conditions for optimization of mitral valve interventions-Emphasis on skills development and institutional risk performance.

This viewpoint report describes how the evolution of transcatheter mitral valve intervention (TMVI) is influenced by lessons learned from three evolutionary tracks: (1) the development of treatment from mitral valve surgery (MVS) to transcutaneous procedures; (2) the evolution of biomedical engineering for research and development resulting in predictable and safe clinical use; (3) the adaptation to local conditions, impact of transcatheter aortic valve replacement (TAVR) experience and creation of infrastructure for skills development and risk management. Thanks to developments in computer science and biostatistics, an increasing number of reports regarding clinical safety and effectiveness is generated. A full toolbox of techniques, devices and support technology is now available, especially in surgery. There is no doubt that the injury associated with a minimally invasive access reduces perioperative risks, but it may affect the effectiveness of the treatment due to incomplete correction. Based on literature, solutions and performance standards are formulated with an emphasis in technology and positive outcome. Despite references to Heart Team decision making, boundary conditions such as hospital infrastructure, caseload, skills training and perioperative risk management remain underexposed. The role of Biomedical Engineering is exclusively defined by the Research and Development (R&D) cycle including the impact of human factor engineering (HFE). Feasibility studies generate estimations of strengths and safety limitations. Usability testing reveals user friendliness and safety margins of clinical use. Apart from a certification requirement, this information should have an impact on the definition of necessary skills levels and consequent required training. Physicians Preference Testing (PPT) and use of a biosimulator are recommended. The example of the interaction between two Amsterdam heart centers describes the evolution of a professional ecosystem that can facilitate innovation. Adaptation to local conditions in terms of infrastructure, referrals and reimbursement, appears essential for the evolution of a complete mitral valve disease management program. Efficacy of institutional risk management performance (IRMP) and sufficient team skills should be embedded in an appropriate infrastructure that enables scale and offers complete and safe solutions for mitral valve disease. The longstanding evolution of mitral valve therapies is the result of working devices embedded in an ecosystem focused on developing skills and effective risk management actions.

Usefulness of computed tomography to predict residual mitral regurgitation after transcatheter mitral valve edge-to-edge repair

BackgroundMultidetector computed tomography (MDCT) can provide valuable information for preprocedural planning of transcatheter mitral valve interventions. However, no data exist on MDCT parameters predicting residual mitral regurgitation (MR) post-MitraClip (Abbott Laboratories, Abbott Park, IL, USA). MethodsWe analyzed preprocedural MDCTs of 78 consecutive patients with secondary MR undergoing MitraClip implantation at our institution. Moderate-or-severe mitral leaflet calcification (MLC) was defined as calcification, with-or-without mitral annular calcification, extending beyond the mitral leaflet base. Residual MR was assessed by postprocedural transesophageal echocardiography, and clinical outcomes were assessed at 1-year. ResultsFifteen patients (19 %) had residual MR ≥2+. Compared to patients with none-or-mild residual MR, MDCT-derived mitral valve orifice area (MVOA) to mitral annulus area (MAA) ratio was significantly lower (0.32 ± 0.06 vs. 0.39 ± 0.09; p = 0.003), and the prevalence of MLC was higher (40 % vs. 18 %; p = 0.057) in those with residual MR ≥2+. Furthermore, the MVOA/MAA ratio and MLC were independent predictors of residual MR ≥2+ post-MitraClip [adjusted odds ratio (ORadj): 0.88 (0.80–0.97) and 5.50 (1.16–26.23), respectively]. On receiver-operating-characteristic-curve analysis, MVOA/MAA ratio <0.31 had a sensitivity of 87 % and a specificity of 60 % for residual MR ≥2+. When patients were classified according to the presence of MLC and an MVOA/MAA ratio <0.31, those with both parameters had significantly higher rates of postprocedural residual MR ≥2+ and mitral reintervention at 1-year than those with only one, and those without both parameters. ConclusionsIn patients with secondary MR undergoing the MitraClip procedure, preprocedural MDCT parameters, specifically MVOA/MAA ratio and MLC, are useful to predict postprocedural residual MR.

Transesophageal Echocardiography For The Assessment of Left Atrial Pressure After Trans-Septal Mitral Valve Interventions

The measure of left atrial pressure (LAP) is an ideal marker for the clinical efficacy of transcatheter mitral valve intervention. Currently, only the invasive measurement of LAP (i-LAP) is available and no echocardiographic methods are reliable in the setting of transcatheter mitral valve intervention. This study sought to validate a new echocardiographic method for the estimation of LAP (e-LAP) by comparing it with i-LAP. During percutaneous edge-to-edge procedure with MitraClip, the i-LAP was routinely monitored. Across the iatrogenic interatrial septum defect, the flow was sampled with continuous-wave Doppler echocardiography for deriving the mean pressure gradient between the left atrium and the right atrium, and the central venous pressure was added to obtain the e-LAP. The correlation between the measures derived from these 2 methods was explored. A total of 34 consecutive patients were included. Intraclass correlation coefficient between e-LAP and i-LAP was high (intraclass correlation coefficient [95% confidence interval] 0.809 [0.625 to 0.902], R Pearson 0.6, p <0.001); a bias of -1.3 mm Hg for e-LAP versus i-LAP was found (p=0.32). The median follow-up was 108 days (interquartile range 40 to 264). No death occurred and 6 patients were rehospitalized for heart failure. Postimplant e-LAP was correlated with rehospitalization at follow-up (hazard ratio 1.46, 95% confidence interval 1.022 to 2.1, p=0.038). A cut-off value of 9.5 mm Hg for the e-LAP was identified as predictor of rehospitalization for heart failure. The evaluation of e-LAP has optimal reliability compared with i-LAP; a value more than 9.5 mm Hg was found to be related to higher risk of events at short follow-up.

Minimally invasive mitral valve surgery after failed transcatheter mitral valve repair in an intermediate-risk cohort.

OBJECTIVESAlthough clinical experience with transcatheter mitral valve interventions is rapidly increasing, there is still a lack of evidence regarding surgical treatment options for the management of recurrent mitral regurgitation (MR). This study provides guidance for a minimally invasive surgical approach following failed transcatheter mitral valve repair, which is based on the underlying mitral valve (MV) pathology and the type of intervention.METHODSA total of 46 patients who underwent minimally invasive MV surgery due to recurrent or residual MR after transcatheter edge-to-edge repair or direct interventional annuloplasty between October 2014 and March 2021 were included.RESULTSThe median age of the patients was 78 [interquartile range, 71–82] years and the EuroSCORE II was 4.41 [interquartile range, 2.66–6.55]. At the index procedure, edge-to-edge repair had been performed in 45 (97.8%) patients and direct annuloplasty in 1 patient. All patients with functional MR at the index procedure (n = 36) underwent MV replacement. Of the patients with degenerative MR (n = 10), 5 patients were eligible for MV repair after removal of the MitraClip. The 1-year survival following surgical treatment was 81.3% and 75.0% in patients with functional and degenerative MR, respectively. No residual MR greater than mild during follow-up was observed in patients who underwent MV repair.CONCLUSIONSMinimally invasive surgery following failed transcatheter mitral valve repair is feasible and safe, with promising midterm survival. The surgical management should be tailored to the underlying valve pathology at the index procedure, the extent of damage of the MV leaflets and the type of previous intervention.

First-in-Human Study of the Novel Transcatheter Mitral Valve Repair Systemfor Mitral Regurgitation.

Transcatheter mitral valve intervention treatment is a promising alternative therapy for patients with severe mitral regurgitation (MR). This is a multicenter, prospective, first-in-human study of transcatheter edge-to-edge repair (TEER) using a novel device for severe MR. Safety and efficacy were assessed immediately after the procedure and at 30-day follow-up. Twenty-three patients (age 70.0 ± 5.2 years) who were at high/prohibitive surgical risk underwent successful procedures without major periprocedural complications. All patients achieved residual MR≤2+ at discharge, with 73.9% with 1+ residual MR. The left ventricular end-systolic diameter improved from 4.1cm at baseline to 3.4cm at 30-day follow-up. New York Heart Association functional class I/II after TEER was achieved in 87% of patients. This study demonstrated that TEER with the device was feasible and safe for the treatment of patients with severe MR. (Dragonfly-M Transcatheter Mitral Valve Repair System Early Feasibility Study; NCT04528576).

Geometric differences of the mitral valve apparatus in atrial and ventricular functional mitral regurgitation

BackgroundFunctional mitral regurgitation (FMR) occurs in patients with annular dilation (atrial, aFMR) or patients with left ventricular (LV) disease (ventricular, vFMR). Meticulous understanding of the mechanisms underpinning regurgitation is crucial to optimize therapeutic strategies. MethodsPatients with moderate-severe FMR were identified from a registry of patients referred for transcatheter mitral valve intervention. In addition, controls without cardiovascular disease were identified. Differences in the geometry of the LV and mitral valve apparatus (including leaflet and tenting geometry, papillary muscle displacement and movement, annular dimensions, and dynamism) between atrial and ventricular FMR, and control subjects, were assessed using multiphasic cardiac CT. ResultsOf 183 FMR patients, 18 patients (10%) were found to have aFMR. The remaining patients had either ischemic or non-ischemic ventricular FMR. In aFMR, both increasing LV end-systolic volume (rho 0.701, p ​< ​0.01) and left atrial volume (rho 0.909, p ​< ​0.01) were associated with larger annular area. By contrast, in vFMR larger annular area was most strongly associated with larger left atrial volume (rho 0.63, p ​< ​0.01). In controls, increased annular area was associated with larger LVEDV (rho 0.78, p ​< ​0.01) and LVESV (rho 0.824, p ​< ​0.01), but not left atrial size (rho 0.16, p ​= ​0.45).Ventricular FMR comprised apicolaterally displaced, akinetic posteromedial papillary muscles, resulting in pronounced leaflet tethering, leaflet elongation compared to controls, and only modest relative LA dilatation. Compared to vFMR, aFMR was characterised by marked relative annular dilation, smaller but discernible mitral valve tenting, shorter leaflet lengths when related to annular size, but normal papillary geometry. ConclusionFMR is characterised by multiple changes within the mitral valve complex. Atrial and ventricular FMR differ significantly in terms of the drivers of annular size, and geometry and function of the subvalvular apparatus. This highlights the need to consider these as separate disease entities.

Abstract 13256: Factors Determining Mitral Valve Dysfunction in Patients Who Underwent Surgical Mitral Valve Replacement With Bio-Prosthetic Valves

Introduction: There is increasing interest in bio-prosthetic MVD as recent advances in transcatheter MV interventions, but there is limited data. We sought to identify the factors determining mitral valve (MV) dysfunction (MVD) in patients who underwent MV replacement with bio-prosthetic valves and sought to clinical outcomes in patients with bio-prosthetic MVD. Hypothesis: MVD was related to younger age, renal dysfunction, postoperative elevated mean diastolic pressure gradient across the bio-prosthetic MV and anemia. Methods: A total of 233 patients underwent surgical bio-prosthetic MV replacement between June 1996 and May 2015. Finally, 226 patients (mean age 66.9±11.5 years, 74.3% of women) were analyzed. MVD was defined as an increase in mean gradient ≥ 5 mmHg with leaflet motion limitation and/or newly developed MV regurgitation during follow-up. Clinical outcome was defined as a composite of CV death, redo MV surgery or intervention, and hospitalization for heart failure. Results: During a median of 102 months (IQR 72 to 132 months), 65 patients (28.8%) revealed MVD. Factors associated with bio-prosthetic MVD were young age at operation (HR 0.97, 95% CI 0.95-0.99, p=0.001), end-stage renal disease (HR 4.29, 95% CI 1.45-12.71, p=0.007), elevated MDPG &gt;5.5 mmHg early after operation (HR 1.86, 95% CI 0.97-3.74, p=0.063) and anemia after operation (HR 0.84, 95% CI 0.74-0.95, p=0.007). Kaplan-Meier curves revealed significant differences in event-free survivals for the occurrence of bio-prosthetic MVD according to each factor ( Figure 1 ). Patients with bio-prosthetic MVD showed significantly poor clinical outcomes compared with those without bio-prosthetic MVD (EFS 43.1% vs. 91.9%, log-rank p&lt;0.001) during the follow-up. Conclusions: Young age at operation, ESRD, elevated MDPG and anemia after operation were associated with bio-prosthetic MVD in patients who underwent bio-prosthetic MV replacement.

A Practical Approach to Combined Transcatheter Mitral and Tricuspid Valve Intervention.

Concomitant tricuspid regurgitation (TR) is common in patients with mitral regurgitation (MR). While current guidelines recommend repair of both valves at the time of surgery when feasible, high risk patients are often undertreated, leading to significant morbidity and mortality. With advances in transcatheter edge-to-edge repair (TEER) devices and technique, combined TEER for treating significant MR and TR has emerged as a new tool for heart failure management. Recent evidence has shed light on which patients with severe TR should be targeted for transcatheter intervention either in isolation or in combination with a MV TEER procedure and allows for expanded treatment options in patients who otherwise would be limited to medical management. Technological advancements remain ahead of robust clinical data, and thus randomized clinical studies in patients with severe MR and TR will be instrumental in determining the best approach in treating these patients with transcatheter therapies.