Transmitral Pressure Gradient Research Articles

Midterm Outcomes After Surgical Management for Mitral Valve Regurgitation in Infancy.

Mitral valve repair is preferred for pediatric mitral valve disease. However, it is technically difficult because of complex lesions, poor surgical exposure, and tissue fragility, especially in infants. We investigated the midterm outcomes of mitral valve surgery for mitral regurgitation in infancy. We retrospectively reviewed 18 patients (aged <12 months old) undergoing mitral valve surgery for mitral regurgitation at our institution between October 2005 and March 2019. The patients had 10 acquired and 8 congenital valve lesions as follows: torn chordae (n = 6), leaflet prolapse (n = 4), posterior leaflet hypoplasia (n = 3), anterior leaflet cleft (n = 2), infective endocarditis (n = 1), papillary muscle rupture (n = 1), and hammock valve (n = 1). All patients initially underwent mitral valve repair. There was no operative mortality, and 1 case of late death. The median follow-up period was 7 years and 9 months. Reoperation was performed in 3 patients, re-repair (twice) in 1 patient with a hammock valve, and mitral valve replacement in 2 patients. Fifteen patients had at most mild mitral regurgitation at the last follow-up. A transmitral mean pressure gradient of over 5 mm Hg was observed in 3 cases, including the patient with a hammock valve. Postoperative mitral annular diameter increased within the normal range in all patients. Survival and reoperation-free rates at 5 and 10 years were 94.4% and 83.0%, respectively. Mitral valve repair for mitral regurgitation in infancy is safe and feasible with satisfactory midterm outcomes, even under serious preoperative conditions.

Determinants of exercise-induced pulmonary hypertension in rheumatic mitral stenosis: a study with exercise stress and speckle tracking echocardiography

Abstract Backgrounds Exercise stress echocardiography is helpful in assessing hemodynamic consequence of mitral stenosis (MS) and in guiding treatment. Exercised-induced pulmonary hypertension (PH) is result of severity of MS, but myocardial function of left ventricle and clinical factors can also have effect. Purpose We aimed to evaluate the associated factors with the pulmonary artery systolic pressure (PASP) in exercise stress echocardiography through 2D, Doppler, and speckle tracking imaging in patients with rheumatic MS. Methods A total of 164 patients with rheumatic MS underwent a graded, symptom-limited, supine bicycle exercise with echocardiography. After exclusion of patients who had very severe MS (valve area &amp;lt;1.0 cm2), a history of surgery or recent percutaneous mitral valvotomy, combined significant aortic valve dysfunction, left ventricular (LV) ejection fraction &amp;lt;50%, we analyzed 113 patients (77.6% female; mean age, 56±9 years). Echocardiographic parameters at rest, each stage (25 watt increment every 3 minutes), and peak exercise were obtained. Exercised induced PH was defined as present if PASP &amp;gt;60 mmHg at peak exercise. LV global longitudinal strain (LV-GLS) and left atrial (LA) strain were analyzed by software. The subjects were divided into 4 groups according to mean transmitral pressure gradient (MG) (15 mmHg) and PASP (60 mmHg) at peak exercise (Group 1, MG &amp;lt;15 mmHg and PASP &amp;lt;60 mmHg, n=29; Group 2, MG &amp;lt;15 mmHg and PASP ≥60 mmHg, n=9; Group 3, MG ≥15 mmHg and PASP &amp;lt;60 mmHg, n=23; Group 4, MG ≥15 mmHg and PASP ≥6 0mmHg, n=52). Results The mean mitral valve area was 1.30±0.23 cm2. PASP increased from 30.0±8.0 mmHg at rest to 61.0±14.8 mmHg at peak exercise, along with increase MG. 61 (53.9%) subjects had PASP&amp;gt;60 mmHg at peak exercise. Compared to group 1, group 2 had higher incidence of diabetes mellitus (DM) and significantly elevated PASP at baseline and impaired LV-GLS. However, there was no statical difference in LA strain between the two groups. In subjects with MG above 15 mmHg (Group 3 and 4), a similar trend was observed in occurrence of exercise-induced PH. On logistic multivariate regression, exercised induced PH was independently associated with female (HR: 5.35, 95% CI: 1.51–24.95; p=0.032), DM (HR: 10.05, 95% CI, 1.35–74.45; p=0.024), MG at peak exercise (HR: 1.17, 95% CI, 1.02–1.34; p=0.002), PASP at rest (HR: 1.17, 95% CI, 1.05–1.30; p=0.002), and LV-GLS (HR: 1.45, 95% CI, 1.09–1.91; p=0.009), but not with LA strain. The predictive value for exercised induced PH was highest when adding LV-GLS to the clinical factor (age, sex, DM) and echocardiographic parameters (Figure 1). Conclusions Exercised induced PH is affected by not only hemodynamic consequence of MS, but also myocardial function of left ventricle and clinical factors. Therefore, when determining the optimal timing of intervention based on exercise-induced PH in rheumatic MS patients, LV-GLS should be evaluated comprehensively along with MS characteristics. Funding Acknowledgement Type of funding sources: Private hospital(s). Main funding source(s): Yonsei University College of Medicine

Prognostic significance of mean transmitral pressure gradient in degenerative non-rheumatic mitral valve: insights from a vast echocardiographic database

Abstract Background The incidence and prevalence of senile, non-rheumatic mitral valve disease are increasing and there is a renewed interest in new transcatheter structural cardiac interventions intended to treat that valvular disorder. While the severity of rheumatic mitral valve disease can be accurately assessed by echocardiography using various parameters, including mean transmitral pressure gradient, these methods have been questioned for quantifying senile mitral valve disorder and their prognostic significance is still unknown. Aims The current study aims to document the natural history of patients with elevated senile mean transmitral pressure gradient (MG) and assess its prognostic significance. Methods A vast institutional echocardiography database was retrospectively analyzed from 2009 to 2020 for all patients aged over 60 years with a detailed echocardiography report with valid measurement of transmitral gradients. Patients with rheumatic valvular disease or who underwent surgical or transcatheter valvular replacement/repair were excluded. All-cause mortality was set to be the primary outcome, and survival models utilizing univariable and adjusted multivariable analysis for various clinical and echocardiographic variables were applied. Results A total of 5524 patients consisted of the final cohort. They were stratified by the MG into three groups: MG &amp;lt;3 (2914 patients, 53%), 3≤MG&amp;lt;6 (2079 patients, 37.6%) and MG ≥6 mmHg (531 patients,9.6%). The mean age of the total cohort was 77.2±7.9 years; 60.5% were female, 33.3% with diabetes mellitus, 15.1% with chronic kidney disease, and 14.1% with ischemic heart disease. An Adjusted Cox proportional hazard regression model demonstrated that MG is independently associated with all-cause mortality (adjusted HR 1.04 per 1 mmHg increase, 95% CI 1.02–1.05, p&amp;lt;0.001). Moreover, an elevated MG was associated with a rise in all-cause mortality (HR of 1.15 and 1.4 for patients with 3≤MG&amp;lt;6 and MG ≥6 mmHg, respectively (Fig. 1). Conclusion The elevated mean transmitral gradient in senile non-rheumatic valves is an independent predictor for all-cause mortality. Interventions and prospective trials intended to mitigate that risk should be needed. Funding Acknowledgement Type of funding sources: None.

Left Atrial Remodeling after Mitral Valve Repair for Primary Mitral Regurgitation: Evolution over Time and Prognostic Significance.

Left atrial (LA) dilatation is associated with worse outcomes in primary mitral regurgitation (MR). However, the effects of mitral valve repair on LA size and its prognostic implications are not well known. In the current study, LA volume index (LAVi) and LA reservoir strain (LASr) were evaluated immediately before and after surgery, and during long-term follow-up in 226 patients undergoing mitral valve repair for primary MR (age 62 ± 13 years, 66% male). Mean LAVi was reduced significantly after surgery and at long-term follow-up (from 56 ± 28 to 38 ± 21 to 32 ± 17 mL/m2; p < 0.001). LASr reduced significantly after surgery but increased again during the long-term (from 23.6 ± 9.4 to 11.5 ± 5.0 to 17.3 ± 7.5%; p < 0.001). Age, pre-operative LAVi, MR severity, and postoperative transmitral pressure gradient were associated with LA reverse remodeling by the long-term check-up. During a median follow-up of 72 (40–114) months, 43 (19%) patients died. Patients with LAVi ≥ 42 mL/m2 at long-term follow-up showed significant higher mortality rates compared to patients with LAVI < 42 mL/m2 (p < 0.001), even after adjusting for clinical covariates. In conclusion, significant LA reverse remodeling was observed both immediately and at long-term follow-up after mitral valve repair. LA dilatation at long term follow-up after surgery was still associated with all-cause mortality.

Maternal and Fetal Outcomes Following Percutaneous Transluminal Mitral Commissurotomy in Pregnant Women with Critical Mitral Stenosis: An Experience of a Tertiary Care Center from Northern India.

Background:Rheumatic mitral stenosis is the common valvular heart disease seen during pregnancy. Percutaneous transvenous mitral commissurotomy is an effective, safe, and recommended treatment for critical mitral stenosis during pregnancy. We hereby report the maternal and fetal outcomes of pregnant women subjected to percutaneous transvenous mitral commissurotomy at our institute. Methods:Seventy consecutive pregnant women with critical mitral stenosis, who underwent PTMC during the last 10 years, were retrospectively analyzed. All patients had a detailed clinical and obstetric evaluation and were optimally managed with drugs, before the intervention. A comprehensive pre- and post-percutaneous transvenous mitral commissurotomy transthoracic echocardiographic evaluation was performed. Detailed obstetric and fetal outcomes were noted at the time of delivery. Six weeks of post-­partum follow-up was noted in all patients. Results:The mean gestational age at the time of percutaneous transvenous mitral commissurotomy was 29.5 ± 6.68 weeks. Percutaneous transvenous mitral commissurotomy was successful in 97% of patients. Post-percutaneous transvenous mitral commissurotomy New York Heart Association functional class, mitral valve area, trans-mitral pressure gradient, and left atrial pressure had a significant improvement (P < .001). The mean gestational age at the time of delivery was 36.92 ± 3.02 weeks. The mean birth weight of live newborn was 2.29 ± 0.55 kg. The fetal complications include growth restriction in 62.85%, preterm delivery in 34.37%, and low birth weight in 67.21%. A delayed percutaneous transvenous mitral commissurotomy at about 30 weeks of gestation did not affect the maternal and fetal outcomes. Conclusion:Percutaneous transvenous mitral commissurotomy is safe and efficacious in managing pregnant women with critical mitral stenosis. There was a significant improvement in clinical symptoms and echocardiographic parameters following percutaneous transvenous mitral commissurotomy.

Treatment of secondary mitral regurgitation by transcatheter edge-to-edge repair using MitraClip.

Transcatheter edge-to-edge repair (TEER) is becoming the standard invasive treatment for ventricular functional mitral regurgitation (MR). It is necessary to determine the severity of MR before treatment with MitraClip; however, the severity of secondary MR is usually underestimated compared with that of primary MR and varies temporally. Therefore, to accurately determine the severity of MR, it is important to correctly use the algorithm of the guidelines for valvular heart disease and aggressively perform stress echocardiography. Before performing TEER, the difficulty of the procedure should be evaluated. First, morphological features that make TEER unsuitable, such as cleft of the mitral leaflet, mitral stenosis (MS), or perforation of the mitral leaflet, should be checked. The mitral valve orifice area, transmitral valve pressure gradient, coaptation depth, coaptation length, and posterior leaflet length should be measured to determine the difficulty of the procedure based on the inclusion criteria of Endovascular Valve Edge-to-Edge Repair Study II and the German consensus. After MitraClip implantation, in addition to assessing the severity of MS and residual MR, the pulmonary venous flow pattern and stroke volume should be evaluated to comprehensively assess whether TEER improves the hemodynamics. MitraClip has also been used to treat atrial functional MR, another type of secondary MR. Several reports suggest that MitraClip is effective for atrial functional MR; however, evidence is still being accumulated.

Patient–Prosthesis Mismatch Associated With Somatic Growth After Mechanical Mitral Valve Replacement in Small Children: Metrics for Reoperation and Outcomes

Reoperation after pediatric mitral valve replacement (MVR) is inevitable due to patient-prosthesis mismatch (PPM) associated with somatic growth. We analyzed potential metrics for PPM and outcomes of redo MVR for valve upsizing. Between 1999 and 2018, 15 children without obstructive left heart lesions other than mitral stenosis underwent initial MVR with a 16-mm ATS-Advanced Performance valve. We analyzed hemodynamic data from 28 postoperative catheterizations and concomitant echocardiograms. The median age and body weight at initial MVR were 4.9 months (25th, 75th percentile: 3.6, 6.6) and 5.9 kg (5.0, 7.3). Redo MVR was planned when patients had congestive heart failure and postcapillary pulmonary hypertension (PH) due to PPM: systolic pulmonary arterial pressure (SPAP) >35 mm Hg and pulmonary capillary wedge pressure (PCWP) >15 mm Hg on catheterization. Indexed effective orifice area (iEOA) and mean transmitral pressure gradient (TMPG) were strongly correlated with SPAP (r = -0.72, P < 0.001 and r = 0.75, P < 0.001) and PCWP (r = -082, P < 0.001 and r = 0.84, P < 0.001). Cut-off values for detecting postcapillary PH due to PPM were 1.0 cm2/m2 for iEOA and 18 mm Hg for mean TMPG. Nine patients underwent redo MVR for postcapillary PH due to PPM at a median postoperative interval of 10 years (9.2, 11.9). All the patients survived, and PH was improved one year after surgery. iEOA and mean TMPG can be metrics for PPM in children after MVR. Careful follow-up is required to confirm the improvement of preoperatively existing PH after redo MVR for valve upsizing.

Clinical and echocardiographic differences in three different etiologies of severe mitral stenosis.

In our institute, the causes of mitral stenosis (MS) are generally categorized into three main etiologies-rheumatic MS (RMS), degenerative MS with annular and leaflet calcification, and post-clip MS as a consequence of transcatheter mitral valve repair with clips for treating mitral regurgitation. However, clinical differences among the three etiologies are uncertain. We retrospectively assessed 293 consecutive patients (53 with RMS, 118 with degenerative MS, and 122 with post-clip MS) who had a three-dimensional (3D) transesophageal echocardiography (TEE) derived mitral valve orifice area (MVA) of ≤1.5cm2 , and a mean transmitral pressure gradient of ≥5 mmHg on transthoracic echocardiography. Although there was no difference in 3D-TEE-derived MVA among the three groups, patients with post-clip MS had a significantly lower mean transmitral pressure gradient compared to those with either of the other two types of MS (10.8 ([7.9-15.2] mmHg vs. 9.6 [7.3-12.5] mmHg vs. 6.9 [6.0-9.2] mmHg; p<.001). Patients with RMS had a higher prevalence of dyspnea. The independent determinants of dyspnea were pressure half time in RMS, 3D-TEE-derived MVA and estimated right atrial pressure in degenerative MS, and left ventricle ejection fraction in post-clip MS. Patients with post-clip MS had the lowest mean transmitral pressure gradient, and patients with RMS had the highest prevalence of dyspnea, despite having a similar 3D-TEE-derived MVA. The determinants of dyspnea were different among the three etiologies of MS.

Results After Left Ventricular Assist Device Implantation in Patients with Status Post Transcatheter Edge-to-Edge Repair

Purpose Transcatheter edge-to-edge repair (TEER) represents a valid therapeutic option for symptomatic heart failure (HF) patients with secondary mitral regurgitation (SMR). However, based on the progression of the underlying cardiomyopathy, consecutive LVAD implantation may become necessary. The prognostic impact of TEER prior to LVAD implantation remains unknown. Methods 125 consecutive patients with advanced HF underwent LVAD implantation at our institution between 2014 and 2020. Out of 67 patients with preexisting moderate to severe SMR, 21 patients underwent TEER prior to LVAD implantation (study group) and were compared to the remaining 46 patients (control group). Clinical baseline and follow-up parameters such as re-hospitalization rates, adverse events and all-cause mortality after 12 months were retrospectively analyzed. Results Predominantly male patients (81.6%) were mainly treated with the Medtronic HVAD device (73.1%). Prevalence of cardiovascular comorbidities was similar, although patients in the study group were older (64.0 vs. 56.0 years, p=0.002) and more likely to undergo destination LVAD therapy (61.9% vs. 28.2%, p=0.009). Severity of LV dysfunction (study vs. control group: LVEF 20.0% vs. 18.0%, p=0.178; LVEDD: 67.6 mm vs. 70.5 mm p=0.316) was similar, but patients in the study group had increased transmitral pressure gradients (9.5/3.0mmHg vs. 5.0/2.0 mmHg, p=0.001) and more severe impairment of RV function (TAPSE: 12.5mm vs. 16.0mm, p=0.033). Despite a lower frequency of preoperative short-term circulatory support devices within the study group (0% vs. 67.4%, p=0.003), periprocedural outcome, including the need for temporary RVAD implantation (28.2% vs. 9.5%, p=0.119) was similar. We found no perioperative complications associated with preceded TEER. Re-hospitalization rate during the first postoperative year was increased within the study group compared to the control group (100% vs. 69.6%, p=0.004). Furthermore, 1-year survival was impaired in the study group (42.8% vs. 71.7%; p=0.023). Conclusion LVAD implantation after TEER is feasible and safe. However, 1-year outcome among LVAD recipients with prior TEER is poor. Further studies are needed, to compare TEER against early LVAD implantation in patients at advanced heart failure stages and concomitant relevant SMR. Transcatheter edge-to-edge repair (TEER) represents a valid therapeutic option for symptomatic heart failure (HF) patients with secondary mitral regurgitation (SMR). However, based on the progression of the underlying cardiomyopathy, consecutive LVAD implantation may become necessary. The prognostic impact of TEER prior to LVAD implantation remains unknown. 125 consecutive patients with advanced HF underwent LVAD implantation at our institution between 2014 and 2020. Out of 67 patients with preexisting moderate to severe SMR, 21 patients underwent TEER prior to LVAD implantation (study group) and were compared to the remaining 46 patients (control group). Clinical baseline and follow-up parameters such as re-hospitalization rates, adverse events and all-cause mortality after 12 months were retrospectively analyzed. Predominantly male patients (81.6%) were mainly treated with the Medtronic HVAD device (73.1%). Prevalence of cardiovascular comorbidities was similar, although patients in the study group were older (64.0 vs. 56.0 years, p=0.002) and more likely to undergo destination LVAD therapy (61.9% vs. 28.2%, p=0.009). Severity of LV dysfunction (study vs. control group: LVEF 20.0% vs. 18.0%, p=0.178; LVEDD: 67.6 mm vs. 70.5 mm p=0.316) was similar, but patients in the study group had increased transmitral pressure gradients (9.5/3.0mmHg vs. 5.0/2.0 mmHg, p=0.001) and more severe impairment of RV function (TAPSE: 12.5mm vs. 16.0mm, p=0.033). Despite a lower frequency of preoperative short-term circulatory support devices within the study group (0% vs. 67.4%, p=0.003), periprocedural outcome, including the need for temporary RVAD implantation (28.2% vs. 9.5%, p=0.119) was similar. We found no perioperative complications associated with preceded TEER. Re-hospitalization rate during the first postoperative year was increased within the study group compared to the control group (100% vs. 69.6%, p=0.004). Furthermore, 1-year survival was impaired in the study group (42.8% vs. 71.7%; p=0.023). LVAD implantation after TEER is feasible and safe. However, 1-year outcome among LVAD recipients with prior TEER is poor. Further studies are needed, to compare TEER against early LVAD implantation in patients at advanced heart failure stages and concomitant relevant SMR.

Flow adjusted transmitral pressure gradient as a modified indicator of functional mitral stenosis after repair for degenerative mitral regurgitation.

Background and AimAfter repair of degenerative mitral regurgitation (DMR), the focus is on functional mitral stenosis (FMS) when there is a decline of mitral hemodynamics. Yet, the clinical impacts and a standardized definition are still undecided. Since common mitral hemodynamic parameters are influenced by transmitral flow, the aim of this study is to seek the impact of flow adjusted transmitral pressure gradient (TMPG) by left ventricular stroke volume (LVSV) on the midterm outcomes.MethodsThree hundred one patients who had undergone isolated mitral valve repair for degenerative lesions with annuloplasty prosthesis between October 2012 and June 2019 were included. Postoperative adverse events occurred in 20 patients (6.6%). Flow adjusted TMPG was defined as TMPG/LVSV.ResultsCommon mitral hemodynamic parameters were not associated with adverse events. By multivariable analysis, patients’ age, left ventricular ejection fraction (LVEF) and mean TMPG/LVSV were isolated as independent predictors (adjusted hazard ratio: 1.05, 0.95, and 1.16; p = .037, .005, and .035). Flow adjusted TMPG was significantly higher in the full ring group compared to the partial band group (0.051 mmHg/ml, [0.038–0.068] vs. 0.041 mmHg/ml, [0.031–0.056]; p < .001) and had a significantly negative correlation with the size of the annuloplasty prosthesis (r = −0.37, p < .001).ConclusionsConventional mitral hemodynamic parameters were not associated with adverse cardiac events after repair for DMR. Adjustment by flow has a potential to advance pressure gradient to a more sensitive indicator of FMS associated with clinical outcomes.

Three-dimensional echocardiography for predicting mitral stenosis after MitraClip for functional mitral regurgitation.

Postprocedural mitral stenosis (MS), or increased transmitral mean pressure gradient (TMPG), is one of the limitations of transcatheter edge-to-edge mitral valve repair using MitraClip (Abbott Vascular Inc., Santa Clara, USA); however, the usefulness of three-dimensional transesophageal echocardiography (3D-TEE) for predicting postprocedural MS in functional mitral regurgitation (MR) has not been fully elucidated. Eighty-two consecutive functional MR patients who underwent transcatheter mitral valve repair using MitraClip were retrospectively studied. Postprocedural MS was defined as TMPG ≥ 5mmHg by echocardiography. Ten patients had postprocedural MS, and 3D-TEE showed that patients with postprocedural MS had smaller preprocedural mitral valve orifice area (MVOA), anteroposterior and mediolateral diameter, leaflet area, and annulus area. Receiver operating characteristic analysis showed that leaflet area (area under the curve (AUC) 0.829), annulus area (AUC 0.813), anteroposterior diameter (AUC 0.797) and mediolateral diameter (AUC 0.803) evaluated using 3D-TEE were predictors of postprocedural MS, and their predictive abilities were higher than those of preprocedural MVOA (AUC 0.756) and preprocedural TMPG (AUC 0.716). Adding leaflet area to TMPG and MVOA resulted in higher C-statistics for predicting postprocedural MS (from0.716to0.845 and from0.756to0.853, respectively). In functional MR patients treated with MitraClip, leaflet area and annulus area evaluated using 3D-TEE had high predictive values for postprocedural MS, and their predictive abilities were higher than those of preprocedural TMPG or MVOA.

Measurement of mitral valve area by direct three dimensional planimetry compared to multiplanar reconstruction in patients with rheumatic mitral stenosis.

Mitral valve area (MVA) measurement by three-dimensional transesophageal echocardiography (3D-TEE) has a crucial role in the evaluation of mitral stenosis (MS) severity. Three-dimensional direct (3D-direct) planimetry has been proposed as a new technique to measure mitral valve area. This study aimed to compare the 3D-direct mitral valve planimetry to conventional three-dimensional multiplanar reconstruction (3D-MPR) in severe MS using 3D-TEE. In this cross-sectional, prospective study; 149 patients with severe MS who were referred for transesophageal echocardiography in Shahid Madani Hospital (Tabriz Iran), just before percutaneous transmitral commissurotomy (PTMC), recruited consecutively. All patients underwent 2D transthoracic echocardiography (2D-TTE) and 3D-TEE in a single session before PTMC. During 2D-TTE planimetry, pressure half time (PHT), and proximal isovelocity surface area (PISA) were applied to measure the MVA. Transmitral mean pressure gradient (MPG) was measured. During 3D-TEE, MVA planimetry was carried out with both 3D-direct and 3D-MPR methods. 3D-direct was applied from both atrial and ventricular views. The consistency of MVA measurements with 3D-direct, 3D-MPR, and 2D-TTE methods was statistically investigated. Our sample consisted of 109 (73.2%) women and 40 (26.8%) men. The mean age was 51.75 ± 9.81years. The agreement between 3D-direct and 3D-MPR planimetry was significant and moderate (0.99 ± 0.29cm2 vs. 1.12 ± 0.26cm2, intraclass correlation = 0.716, p value = 0.001).The accuracy of the 3D-direct method reduced significantly compared to the MPR method at MVA > 1.5cm2. The maximum difference between two methods was observed in cases with MVAs larger than 1.5cm2. MVA measured with the 3D-MPR method was significantly correlated with a 2D-TTE method, with a moderate agreement (intraclass correlation = 0.644, p value = 0.001). Also, 2D-TTE and 3D-direct TEE techniques yielded significantly consistent measurements of the MVA (1.06 ± 0.026cm2 vs. 0.99 ± 0.29cm2, intraclass correlation = 0.787, p value = 0.001); however, with a slight overestimation of the MVA by the former with a net difference of 0.06 ± 0.013cm2. Mitral valve pressure gradient (MPG) had no significant correlation with planimetry results. A significant inverse correlation was seen between the MVA and pulmonary arterial systolic pressure. 3D-direct planimetry has an acceptable agreement with 3D-MPR planimetry at MVA less than 1.5cm2, but their correlation decreases significantly at MVA above 1.5cm2. 3D-direct planimetry underestimates MVA compared to 3D-MPR, especially at MVA above 1.5cm2. It seems that the saddle shape of mitral valve, interferes with 3D-direct measurement of commissures at moderate MS. The 2D-TTE planimetry has generally acceptable accuracy, but its correlation to the 3D-TEE methods is significantly reduced in cases with moderate to severe MS (i.e. MVA > 1.0cm2).

Prediction of procedural success of transcatheter mitral valve repair with normal and extended clip arms

TMVR using different clip sizes is a treatment option for selected patients with mitral regurgitation (MR). This study sought to identify predictors of successful transcatheter mitral valve repair (TMVR) by 3-dimensional (3D) echocardiography and to compare different effects of the larger XTR and the smaller NT/NTR devices. 3D transesophageal echocardiography was performed on 54 patients with secondary MR undergoing TMVR with one clip (55.6% NT/NTR, 44.4% XTR). All NT/NTR and 96% of XTR patients had MR reduction ≤ 2+. Despite more severe baseline MR (3D vena contracta area (VCA): 0.67 ± 0.34 cm2 vs. 0.43 ± 0.19 cm2, p = 0.004) and greater mitral valve area (MVA) (6.8 ± 2.1 cm2 vs. 5.1 ± 1.6 cm2, p = 0.001) in the XTR group, MR severity after TMVR was not different between XTR and NT/NTR patients (3D VCA: 0.19 ± 0.14 vs. 0.17 ± 0.10, p = 0.51). Baseline 3D VCA > 0.45 cm2 in NT/NTR (AUC = 0.802, 95% CI 0.602 to 1.000) and 3D VCA > 0.54 cm2 in XTR devices (AUC = 0.868, 95% CI 0.719 to 1.000) were associated with ineffective MR reduction defined as residual VCA ≤ 0.2 cm2. Baseline MVA ≤ 4.2 cm2 in NT/NTR (AUC = 0.920, 95% CI 0.809 to 1.000) and MVA ≤ 6.0 cm2 in XTR devices (AUC = 0.865, 95% CI 0.664 to 1.000) were associated with postprocedural transmitral pressure gradient (TMPG) ≥ 5 mmHg. TMVR using the XTR device resulted in an equally effective reduction of MR despite of a greater baseline MR. Distinct cut-off values of baseline 3D VCA and MVA for prediction of successful MR reduction and postprocedural increase of TMPG were identified for the different devices.

Abstract 11497: Echocardiographic Features of Severe Mitral Stenosis in Three Different Etiologies

Background: In our Heart Center, the cause of mitral stenosis (MS) is usually classified into 3 different categories/etiologies, namely, rheumatic disease, degenerative disease with annular or leaflet calcification, and MS as a consequence of a transcatheter mitral repair with clips for mitral regurgitation. However, differences in the morphology and echocardiographic evaluation among the three etiologies have not been fully elucidated. The aim of this study is therefore to investigate differences in echocardiographic features of these three etiologies of MS. Method: We retrospectively studied 157 patients who underwent three-dimensional transesophageal echocardiography (3D TEE) at Cedars-Sinai Medical Center between January 2012 and December 2020, and had severe mitral stenosis defined as 3D TEE derived mitral valve orifice area (MVA) of ≤ 1.0 cm 2 .These patients also had a mean transmitral pressure gradient of ≥ 5 mmHg on transthoracic echocardiography which was performed within 6 months before and after TEE. Other clinical and echocardiographic characteristics were obtained from medical records. Result: Of 157 patients, 37 patients had rheumatic MS, 60 patients had degenerative calcific MS and 60 patients had post-clip MS. There was no significant difference among the three groups in 3D TEE derived MVA (Table). Despite comparable 3D derived MVA, patients with post-clip MS had significantly lower mean transmitral pressure gradient than those with other 2 types of MS. Patients with rheumatic MS had larger indexed left atrial volume than patients with other 2 types of MS. Patients with degenerative calcific MS and those with post-clip MS had larger MVA both by pressure half time and by continuity equation than patients with rheumatic MS. Conclusion: There were distinct differences in echocardiographic features among the three MS etiologies. The optimal evaluation method and multi-parameter determined grading of MS severity may differ depending on the etiology.

Prevalence of mitral annular calcification and its association with mitral valvular disease.

Mitral annular calcification (MAC) is increasingly observed in elderly population. The purpose of this study was to investigate incidence of MAC and its association with mitral valvular disease (MVD). A total of 13,483 consecutive patients who underwent echocardiography were enrolled. MAC was defined as an echo-dense, shelf-like structure with an irregular, lumpy appearance involving the mitral valve annulus, with acoustic shadowing. Prevalence of MAC and its association with significant mitral stenosis (MS) or mitral regurgitation (MR) were studied. Significant (≥moderate) MS was defined as mean transmitral valvular pressure gradient>5mm Hg and significant MR was defined as ≥moderate MR based on quantitative or semi-quantitative Doppler methods. MAC was present in 1881 of 13,483 patients (14%). Patients with MAC (MAC group) was older and more female gender than those without MAC (non-MAC group). Significant MS was present in 2.2% of MAC and in .6% of the non-MAC group (p<0.0001). Significant MR was present in 11.9% of MAC and in 5.0% of the non-MAC group (p<0.0001). Co-existence of MAC and aortic valve replacement (AVR) was associated with increased prevalence of MVD (MS:11.4%, MR:17.2%, respectively). MAC was present in 14% of the patients and was associated with significant MVD. Co-existence of MAC and AVR may increase the risk of MVD.

Sex Differences in Mitral Annular Calcification and the Clinical Implications.

Background: Heterogeneous mechanisms may contribute to the occurrence of mitral annular calcification (MAC), however, little is known about the sex differences in MAC and the clinical implications of these differences. This study aimed to investigate clinical and imaging differences of MAC according to sex.Methods: In total, 537 patients (221 men) with MAC were identified by transthoracic echocardiography at a single center from January 2012 to June 2016. Moderate-to-severe MAC was defined as calcification extent ≥120° of the mitral annulus. Significant functional mitral stenosis (MS) was defined as a transmitral mean diastolic pressure gradient ≥5 mmHg.Results: Women more frequently had moderate-to-severe MAC and concomitant mitral regurgitation than men; however, significant functional MS was comparable between sexes. In the logistic regression analysis, old age, uncontrolled hypertension, end-stage renal disease (ESRD), and obstructive hypertrophic cardiomyopathy were significantly associated with moderate-to-severe MAC in women, whereas ESRD and moderate-to-severe aortic stenosis were in men. In the Cox regression analysis, significant functional MS was associated with all-cause death in both sexes, although an independent association was found in only women.Conclusion: Women had more extended MAC than men. Significant functional MS was independently associated with unfavorable clinical outcomes in patients with MAC, which was more pronounced in women than in men.

Transcatheter mitral valve repair (TMVR) using MitraClip in patients younger than 65 years: a multicenter analysis of 2-years outcomes

Abstract Background TMVR using MitraClip became a well-established interventional therapy for severe MR. However, TMVR has been almost only applied to old aged patients rejected from surgical therapy. Objective To present 2-years outcomes of 36 patients younger than 65 years with no surgical options treated by TMVR. Methods A retrospective clinical and TEE study was conducted to evaluate 36 patients younger than 65 years treated by TMVR in 3 heart centers. Results Mean age of the 36 study patients was 56.3±6.6 years, male gender was 72.2%. High operative risk was estimated by STS score (mean = 8.73±2.97) and EuroSCORE (mean = 24.71±12.79). All patients were refused for surgery by heart team decision, therefore admitted to TMVR. Baseline severity of MR was assessed by 3D-TEE based biplane vena contracta width (mean = 8.35±1.87 mm). Baseline transmitral mean pressure gradient was 1.81±0.78 mmHg. 21 patients showed mitral annular dilatation as the main cause of MR, 8 patients had leaflet prolapse, 4 patients exhibited papillary muscle displacement leading to leaflet tethering and 3 patients showed mitral leaflet thickening and/or retraction due to fibrosis. Procedural success was achieved in all patients with 1/2/3 clips implanted in 52.8%/44.4%/2.8% of cases with a mean of 1.5 clip per case. Two grades or more reduction in severity of MR (MR grade ≤ II/IV) was accomplished in 88.9% of patients. Mean postprocedural MPG was 3.78±1.96 mmHg. Average follow-up (FU) period was 25,8 months and the median was 20 months (25th–75th percentile: 12–36 months). During 2-years FU, statistically significant difference (p value &amp;lt;0.002) was detected for NT-proBNP levels compared to baseline (mean = 9870±10819, median = 7748, 25th–75th percentile: 2702–14237 pg/ml) and at follow up visits (mean = 7645±11292, median = 3263, 25th-75th percentile: 883–8078 pg/ml). Furthermore, persistent symptomatic improvement during FU, defined as NYHA functional class improvement by 2 or more Grades, was achieved in 69% of patient in parallel with efficient reduction of MR in 34 patients so that a second intervention by reclipping was required in 2 patients to correct recurrent significant MR. Only two patients experienced procedure-related complications by large puncture site hematoma. No procedure-related mortality during the first 30 days was detected. However, mortality was recorded in 2 patients during the first month and was attributed to severe advanced heart failure in one case and septicemia after exclusion of infective endocarditis in another case. Over 2 years FU, other 5 patients passed away, 3 cases owing to advanced heart failure, one case due to multi-organ failure and one because of tumor disease. Conclusion TMVR in patients younger than 65 years refused from surgical repair provides satisfactory clinical and echocardiography outcomes at 2 years. Future studies should evaluate the outcomes of MitraClip in this population in a larger cohort. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Hassan M.H. Mohammed received a scholarship grant from the Egyptian ministry of higher education and Minia University, Egypt.

Left atrial remodeling after mitral valve repair for primary mitral regurgitation: evolution over time and prognostic significance

Abstract Background Although preoperative left atrial (LA) dilation is a well-known predictor of adverse cardiovascular events in patients with severe, primary mitral regurgitation (MR), little is known about LA reverse remodeling after mitral valve (MV) surgery and its prognostic value. Purpose This study sought to systematically investigate the changes in LA volume in patients undergoing MV repair for severe, primary MR and the association between LA volume after surgery and long-term outcome. Methods In patients undergoing MV repair for severe, primary MR, echocardiography was evaluated at three different time points: pre-operatively, immediate postoperatively (5 [4–6] days) and within 1–3 years (19 [14–24] months) follow-up. Outcome was all-cause mortality happening after the third echocardiographic evaluation. Results A total of 226 patients (mean age 62±13 years, 66% male) were included. Mean pre-operative LA volume index (LAVi) was 56±28 ml/m2 and significantly decreased immediately after surgery (to 38±21 ml/m2; p&amp;lt;0.001) as well as at long-term follow-up (to 32±17 ml/m2; p&amp;lt;0.001). Significant correlations were found between reduction in LAVi at long-term follow-up and age (R=−0.139; p=0.037), pre-operative left ventricular end-diastolic volume index (R=0.199; p=0.003), preoperative LAVi (R=0.498; p&amp;lt;0.001), preoperative effective regurgitant orifice area (R=0.205; p=0.004), preoperative regurgitant volume (R=0.222; p=0.002) and postoperative transmitral mean pressure gradient at long-term follow-up (R=−0.150; p=0.026). Patients were subsequently divided into 3 groups: patients with a preoperative LAVi &amp;lt;42 ml/m2 (n=68), based on the definition of moderately dilated LA; patients with a LAVi 42–59 ml/m2 (n=88) and patients with a LAVi ≥60 ml/m2 (n=70), based on the current class IIaC indication for intervention in primary MR. Although patients with a LAVi ≥60 ml/m2 at baseline showed the most pronounced reduction in LAVi, their values of LAVi at long-term follow-up remained above the range of normality (figure 1). During a median follow-up of 72 (40–114) months, 43 (19.0%) patients died. Patients who had a LAVi ≥42 ml/m2 at long-term follow-up (3rd echocardiographic evaluation) showed significantly higher mortality rates as compared to patients with a LAVi &amp;lt;42 ml/m2 (p&amp;lt;0.001) (figure 2). Multivariable Cox regression analysis showed that, after adjusting for age, sex and coronary artery disease, postoperative LAVi ≥42ml/m2 at long-term follow-up remained independently associated with all-cause mortality (HR 2.494; CI 1.292 to 4.815; p=0.006). Conclusions In patients with severe primary MR, LA reverse remodeling occurs immediately after MV repair, with a further reduction in LAVi during follow-up. Patients in whom LAVi does not remodel to normal values present worse long-term prognosis as compared to patients who achieve normal LAVi values. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): ESC Training Grant (Appehab724.011664741). Changes in LA volume over timeKM curve for all-cause mortality

Transcatheter mitral valve-in-valve and valve-in-ring replacement: Lessons learned from bioprosthetic surgical valve failures.

Limited data are available about the outcomes of transcatheter mitral valve replacement (TMVR) using transseptal approach in patients with prior mitral valve repair (valve-in-ring) or replacement (valve-in-valve) (TMViVR) and on modes of the prior surgical valve failures. We report our tertiary center TMVR experience in high surgical risk patients with prior mitral valve repair or replacement. From December 2016 to January 2020, patients with symptomatic severe mitral valve stenosis and/or insufficiency at increased redo surgical risk were included. TMViVR was performed off-label with Sapien S3 valve (Edwards Lifesciences). Patients were followed within 30-days and 1-year from the procedure. Twenty-seven patients underwent transcatheter mitral valve-in-valve (n = 21) or valve-in-ring (n = 6) replacement. Mean ± SD age was 71.8 ± 11 years with Society of Thoracic Surgeons' calculated mortality 7.1 ± 4.6%. The etiology of valve failure was stenosis in 17 (63%) patients, insufficiency in 4 (14.8%) patients, and both in 6 (22.2%) patients. TMViVR technical success was 100% in all patients. Left ventricular outflow track (LVOT) obstruction was observed in only one (3.7%) patient. Zero patients had moderate or severe central mitral valve regurgitation or paravalvular leak. All patients had symptomatic improvement at 30 days. The mean transmitral diastolic pressure gradient decreased from 14.1 ± 4.6 to 6.9 ± 4.6 mm Hg (p < .001) at 30 days. The one patient with LOVT obstruction required readmission at 5-months. One-year survival was 95%. At 1-year mean gradients remained lower than the baseline (7.0 ± 3.0 vs. 12.4 ± 4.0, p = .002). Transcatheter mitral valve-in-valve and valve-in-ring replacement is feasible and safe. The improvement in mitral valve hemodynamics appears to be durable.

Usefulness of Computed Tomography to Predict Mitral Stenosis After Transcatheter Mitral Valve Edge-to-Edge Repair

Multidetector computed tomography (MDCT) can provide valuable information for preprocedural planning of transcatheter mitral valve interventions. However, no data exists on pre-MDCT parameters predicting high transmitral pressure gradient (TMPG) post-MitraClip procedure. We analyzed the preprocedural MDCTs of 156 consecutive patients with mitral regurgitation undergoing MitraClip implantation at our institution. The mean TMPG was assessed by periprocedural transesophageal and pre-discharge transthoracic echocardiography. MDCT-derived mitral annulus area (MAA), anterior-posterior (AP) and medial-lateral (ML) mitral annulus diameters, and mitral valve orifice area (MVOA) were smaller in patients with mean TMPG ≥5 mmHg than those with mean TMPG <5 mmHg after 1-or 2-clip implantation. Small MAA, AP and ML diameters, and MVOA were moderately correlated with high TMPG post-MitraClip, in which MAA and MVOA had the highest degree of correlation after 1-clip (r=-0.46 both), whereas MAA and ML had the strongest degree of correlation after 2-clip (r=-0.39 both) and at discharge (r=-0.38 both). From the receiver-operating-characteristic curve analyses, no significant differences in the area under the curve were observed among these MDCT parameters for low TMPG after MitraClip implantation, except for those between MAA and AP diameter at discharge (p=0.026). For optimal cutoff values, MAA ≥1100 and ≥1300 mm2 had positive predictive values of 89% and 91%, while both MAA ≥750 and ≥900 mm2 had negative predictive values of 100%, for mean TMPG <5 mmHg after 1-and 2-clip implantation, respectively. In conclusion, in patients undergoing the MitraClip procedure, preprocedural MDCT parameters are useful to predict postprocedural mitral stenosis.