Transmitral Pressure Research Articles

Dimensionless index of the mitral valve for evaluation of degenerative mitral stenosis.

Degenerative mitral stenosis (DMS) is an increasingly recognized cause of mitral stenosis. The goal of this study was to compare echocardiographic differences between DMS and rheumatic mitral stenosis (RMS), identify echocardiographic variables reflective of DMS severity, and propose a dimensionless mitral stenosis index (DMSI) for assessment of DMS severity. This is a single-center, retrospective cohort study. We included patients with at least mild MS and a mean transmitral pressure gradient (TMPG) ≥4mmHg. Mitral valve area by the continuity equation (MVACEQ ) was used as an independent reference. The DMSI was calculated as follows: DMSI=VTILVOT / VTIMV. All-cause mortality data were collected retrospectively. A total of 64 patients with DMS and 24 patients with RMS were identified. MVACEQ was larger in patients with DMS (1.43±0.4cm2 ) than RMS (0.9±0.3 cm2 ) by ~0.5cm2 (P=<.001), and mean TMPG was lower in the DMS group (6.0±2 vs 7.9±3mmHg, P=.003). A DMSI of ≤0.50 and ≤0.351 was associated with MVACEQ ≤1.5 and MVACEQ ≤1.0cm2 (P<.001), respectively. With the progression of DMS from severe to very severe, there was a significant drop in DMSI. There was a nonsignificant trend toward worse survival in patients with MVACEQ ≤1.0cm2 and DMSI ≤0.35, suggesting severe stenosis severity. Our results show that TMPG correlates poorly with MVA in patients with DMS. Proposed DMSI may serve as a simple echocardiographic indicator of hemodynamically significant DMS.

Determinants of clinical outcomes in patients with mixed mitral valve disease.

Although significant stenosis and regurgitation can be observed on a single heart valve, studies on the outcome predictors for mixed valve disease are limited. The purpose of the current study was to investigate the fate and determinants of clinical outcomes in patients with mixed single mitral valve disease who have concomitant mitral stenosis (MS) and mitral regurgitation (MR). We retrospectively reviewed 82 consecutive patients with rheumatic heart disease who had both significant MS (MVA≤1.5cm2 ) and at least moderate MR, excluding patients with significant aortic valve stenosis or regurgitation. The primary endpoint was a composite of all-cause mortality during follow-up, mitral valve replacement, heart failure admission, and stroke. There were 37 events (45.1%), 5 all-cause deaths (6.0%), and 32 mitral valve replacements (39.0%). In a multivariable Cox regression analysis, a transmitral mean pressure gradient (TMPG) over 6mmHg was the only independent echocardiographic predictor for events (hazard ratio 3.69, 95% confidential interval 1.31-10.44, P=.014), after adjusting for sex, age, symptoms, and the severity of MS and MR. The estimated 6-year event-free survival rate was significantly lower in patients with TMPG≥6mmHg than in those with TMPG<6mmHg (76.3% vs 22.9%, log-rank P<.001). Transmitral mean pressure gradient, which reflects the hemodynamic burden of the mitral valve lesion, appears to be the most important echocardiographic predictor of clinical outcomes in patients with mixed mitral valve disease.

Long-term results of the edge-to-edge repair for failed mitral valve repair as a bailout option.

We evaluate the long-term clinical and echocardiographic outcomes of edge-to-edge (E2E) repair combined with mitral annuloplasty in our institute with degenerative mitral regurgitation (MR) up to 10years. Twenty-six consecutive patients undergoing E2E mitral repair after failure of other conventional mitral repair technique. There were 16 (61.5%) male and the mean age was 52.2 ± 10.4years. Mitral regurgitation was due to anterior leaflet prolapse in 12 (46.2%) patients, bileaflet prolapse in 9 (34.6%), and multiple segment posterior leaflet prolapse in 5 (19.2%). There were no perioperative deaths. Follow-up was 100% complete. The mean length of follow-up was 8.7 ± 0.9years (median 8.4years, 6.8-10.1years). Two patients required reoperation of the MV. The freedom from reoperation and ≥ Moderate MR at 10years was 69.9 ± 11.7%. The freedom from reoperation, ≥ Moderate MR and mitral stenosis (MS) at 10years was (59.6 ± 10.0) %. The mean transmitral pressure gradient (TMPG) was 6.1 ± 2.5mmHg, which was significantly elevated compared with preoperative TTE (P = 0.004). The freedom from ≥ Moderate MS at 10years was 76.9 ± 8.3%. There were no differences between patients with and without MS at follow-up regarding the echocardiographic parameters and clinical status. There is a slowly progressive elevation of TMPG after E2E mitral repair, while mildly elevated TMPG can be tolerated in most patients. In appropriate patients, the E2E repair combined with annuloplasty provides an effective "bailout" choice.

Edge-to-Edge Repair Versus Secondary Cord Cutting During Septal Myectomy in Patients With Hypertrophic Obstructive Cardiomyopathy: A Pilot Randomised Study

To evaluate whether the Alfieri technique improves clinical and haemodynamic results and compare it with transaortic mitral valve secondary cord cutting in patients scheduled for septal myectomy for severely symptomatic hypertrophic obstructive cardiomyopathy. Forty-eight (48) patients with moderate-to-severe systolic anterior motion (SAM)-mediated mitral regurgitation were randomly assigned to the Alfieri or Cutting groups in addition to septal myectomy. The primary endpoint was postoperative mean transmitral pressure gradient (TPG). The secondary endpoints were residual left ventricular outflow tract (LVOT) gradient after procedure, residual mitral regurgitation (MR), postoperative SAM, repeating bypass, and survival. There were no 30-day mortality and ventricular septal defects. The postoperative LVOT gradient was 15.4±7.6 mmHg and 11.1±4.9 mmHg (p=0.078) in the Alfieri and Cutting groups, respectively. The Alfieri technique was associated with higher peak (7.8±3.3 vs 4.7±2.8 mmHg; p=0.014) and mean (3.9±1.7 vs 2.1±1.6 mmHg; p=0.013) TPG. The Cutting group was associated with higher mild MR rate at discharge (six vs no patients; p=0.009). One (1) patient (4.2%) in the Alfieri group required pacemaker implantation owing to conduction disturbances (p=0.312). Two-year (2-year) freedom from late mortality and sudden cardiac death rates were 95.5%±4.4% and 100% for the Alfieri and Cutting groups, respectively (log rank, p=0.317). No patients had New York Heart Association functional class III or IV or moderate or severe MR. The maximum LVOT gradient was 20.4±15.2 mmHg and 16.7±10.4 mmHg, respectively (p=0.330). There were no reoperations during follow-up. Both techniques with septal myectomy effectively eliminated SAM-induced MR and LVOT obstructions in hypertrophic cardiomyopathy patients.

Prognostic Impact of Redo Transcatheter Mitral Valve Repair for Recurrent Mitral Regurgitation

There is little known about the prognostic impact of a redo transcatheter mitral valve repair (TMVR) for residual or recurrent mitral regurgitation (MR). From January 2011 to March 2019, we identified 43 consecutive patients who underwent a redo TMVR procedure with the MitraClip system. A control cohort was treated medically for MR ≥2+ after the first TMVR and was propensity score 1:1 matched using age, gender, MR severity, trans-mitral pressure gradient, and etiology of MR. To investigate the association of redo TMVR with 1-year mortality, we fitted a Cox proportional hazard model. The technical success rate of redo TMVR was 95%. A reduction in MR to ≤2+ was achieved in 79% of patients, with a significant decline of tricuspid regurgitation pressure gradient and improvement of the New York Heart Association class. After matching was performed, 43 well-matched pairs of patients were analyzed. Redo TMVR patients showed lower 1-year mortality (10.5% vs 37.6%, p = 0.01) compared with the control patients. Redo TMVR was associated with better survival (hazard ratio [HR] 0.26, 95% confidence interval [CI] 0.08 to 0.79, p = 0.02) and lower risk of the composite end point (mortality and rehospitalization due to HF: HR 0.34, 95% CI 0.15 to 0.78; p = 0.01) at 1-year follow-up. The association with the primary end point remained significant after accounting for the New York Heart Association class III/IV, TR ≥severe, the type of MR (i.e., recurrent or residual MR), or the type of previous implanted TMVR device. In conclusion, redo TMVR in selected patients with residual or recurrent MR may be associated with lower 1-year mortality than medical therapy alone.

Influences of mitral annuloplasty on left ventricular flow dynamics assessed with 3-dimensional cine phase-contrast flow magnetic resonance imaging

ObjectivesWe assessed the influence of annuloplasty procedures in mitral repair on left ventricular (LV) vortex flow patterns and aortic outflow patterns, and flow energy loss (EL). MethodsTwenty healthy volunteers and 14 patients who had undergone mitral valve repair were examined using 3-dimensional cine phase-contrast magnetic resonance imaging. A band group included 7 patients with semi-rigid and 2 with flexible partial bands. The ring group included 5 patients with semi-rigid complete rings. LV vortex flow patterns, aortic outflow patterns, EL, and aortic annulus changes during one cardiac cycle were evaluated. ResultsMitral repair induced different vortex flow patterns compared with that of healthy volunteers. The vortex beneath the anterior mitral leaflet with semi-rigid devices was double-stranded in early diastole, and it was single-stranded with flexible bands with a large shift toward the apex during diastole. LVEL in patients who underwent mitral repair (0.84 ± 0.42 mW) was greater than that in healthy volunteers (0.47 ± 0.10 mW). Complete rings disturbed aortic outflow patterns, with EL distribution changes. Smaller devices relative to patient body size disturbed LV flow patterns and caused high EL. No significant relationship was found between indexed ring orifice area and transmitral mean pressure gradient (r = −0.25, P = .414), but a negative relationship exists between indexed ring orifice area and LVEL (r = −0.84, P < .001). ConclusionsMitral repair, especially with relatively small annuloplasty rings, induced abnormal LV flow patterns and EL elevation, which have the potential to be a novel hemodynamic evaluation method after mitral repair.

Hypo-attenuated leaflet thickening in surgically-implanted mitral bioprosthesis

BackgroundHypo-attenuated leaflet thickening (HALT) in bioprosthetic aortic valve has been studied, but its equivalent in bioprosthetic mitral valve (bMV) remains uncharacterized. We sought to identify the prevalence, hemodynamic characteristics, and significance of anticoagulation therapy in bMV HALT.MethodsA single-center cross-sectional study of 53 consecutive patients who underwent mitral valve replacement (MVR) with bMV between 2007 and 2017 was conducted. Cardiac-gated contrasted CT scans were obtained. Anticoagulant and antiplatelet therapy use were ascertained at the time of hospital discharge and CT scanning. Patient characteristics, postoperative stroke, and hemodynamic profile by echocardiogram were obtained to descriptively characterize the prevalence and characteristics associated with bMV HALT.ResultsThree patients (5.7%) were found to have a HALT on bMV. The mean time from index MVR to CT scan was 3.4 ± 0.8 years in HALT cohort and 3.4 ± 2.7 years in non-HALT cohort. Fifty patients (94.3%) were discharged on warfarin, and 37 patients (69.8%) were on warfarin at the time of CT scans. One patient with HALT was on therapeutic warfarin at the time of the CT scan that identified HALT. All three patients were asymptomatic at the time of CT scan. In patients with HALT, mean transmitral pressure gradient were 8, 5, and 2.7 mmHg, all with trivial or mild mitral regurgitation.ConclusionsIn this study, the prevalence of HALT was low at 5.7%, all presenting without symptoms. One patient presented with HALT while on therapeutic oral anticoagulation, which may suggest thrombotic etiology may not adequately explain HALT.

Impact of type and size of annuloplasty prosthesis on hemodynamic status after mitral valve repair for degenerative disease

ObjectiveThe aim of this study is to evaluate mitral valve hemodynamics after mitral valve repair for degenerative disease, and seek the impact of type/size of annuloplasty prosthesis on resting cardiac hemodynamics. MethodsBetween October 2012 and June 2019, 301 patients underwent isolated mitral valve repair for degenerative disease were enrolled. Correlation between postoperative mitral hemodynamics and type/size of annuloplasty prosthesis was evaluated. ResultsThere were significant correlations between annuloplasty size and peak velocity (r = −0.41, p < 0.001), peak transmitral pressure gradient (TMPG) (r = −0.40, p < 0.001), mean TMPG (r = −0.41, p < 0.001), effective orifice area (EOA) (r = 0.26, p < 0.001), and pulmonary artery systolic pressure (r = −0.15, p = 0.010). In patients with larger annuloplasty prostheses (≥30 mm), the type of annuloplasty prosthesis (band or ring) did not influence the mitral hemodynamics, however, mean TMPG was significantly greater in patients with a full ring (2.9 mmHg [2.1–3.7] vs. 4.0 mmHg [2.8–5.0], p < 0.001) in patients with smaller annuloplasty (<30 mm). Left ventricular ejection fraction and stroke volume were significantly associated with an increase of TMPG (r = 0.14, p = 0.016 and r = 0.24, p < 0.001). ConclusionsA larger partial band had the potential to improve mitral hemodynamics after mitral repair for degenerative disease. However, echocardiographic mitral hemodynamics was influenced by LV function. Therefore, a more accurate method is required to elucidate the true impact of mitral repair on hemodynamics.

PATIENT REPORTED OUTCOMES CAN BE PREDICTED BY CHANGE IN LEFT ATRIAL PRESSURE AND NOT CHANGE OF TRANSMITRAL GRADIENT FOLLOWING MITRACLIP

The association between the acute change in mean direct left atrial (LA) pressure and symptom improvement post MitraClip has been shown. Mean transmitral diastolic Doppler pressure gradient is routinely measured before and after MitraClip deployment and is used in assessing procedural success.

NeoChord System as an Alternative Option Upon Transmitral Pressure Gradient Elevation in the MitraClip Procedure

An 83-year-old woman presented with progressive dyspnea. She underwent an edge-to-edge mitral repair with the MitraClip-NTR system (Abbott Vascular, Santa Clara, California) for severe mitral regurgitation (MR) that was caused by posterior leaflet prolapse ([Figures 1A to 1C][1]) with calcification

Left Atrial Volume Index (LAVI) as an Indicator of Severity and Pulmonary Hypertension in Mitral Stenosis

Left Atrial (LA) pressure and the trans-mitral pressure gradient chronically increases in Mitral Stenosis (MS), which results in LA enlargement and Pulmonary Hypertension (PH). We investigate the Left Atrial Volume Index (LAVI) as an indicator of severity and PH in MS. Fifty-nine subjects with MS (27 men and 32 women) mean ages 41.3±9.51 y.o were included in this study. We examined the correlation of LAVI and parameters of MS severity, and PH (Planimetry, MVA-PHT, MVA-VTI, MV-PHT, MV meanPG, TRmaxPG, and EstPASP). Most of the subjects had severe MS (77%), mild PH (40%) and AF (80%). LAVI value markedly increased in this study (Mean: 83.79 ± 38.32 ml/m2). In subjects with severe MS, LAVI was significantly higher than that in moderate MS (91.88±38.41 vs 54.83±19.28, p<0.05). LAVI was significantly correlated with Planimetry, MVA-PHT, MVA-VTI, MV-PHT, MV MeanPG, and EstPASP (-0.40; -0.42; -0.29; 0.42; 0.27 and 0.29, p<0.05, respectively). LAVI cut-off value as an indicator for severe MS was 59.72 ml/m2, with the sensitivity and specificity was 75.3% and 66%, respectively. LAVI was correlated well with severity and PH parameters in MS. LAVI also can be used as an indicator for severe MS.

P297 Left atrial volume index is the best predictor of post-capillary pulmonary hypertension in patients with pure mitral valve stenosis

Abstract Background Mitral stenosis (MS) is characterized by a reduced mitral valve area (MVA) and an increased transmitral pressure gradient, with direct consequences on left atrial (LA) remodelling and pulmonary arterial systolic pressure (PASP). Post-capillary pulmonary hypertension (PH) has a main impact on the outcome in patients with MS. Purpose To evaluate determinants of post-capillary PH in patients with pure MS by using a combined approach of standard and advanced echocardiography. Methods From January 2018 to January 2019, 52 consecutive patients with MS were enrolled. Concomitant hemodynamically significant valve heart disease, primary PH, coronary artery and congenital heart diseases, primary cardiomyopathies, prosthetic valves and permanent/persistent atrial fibrillation were exclusion criteria. Twenty-three "pure" MS were selected (age: 63.9 ± 11.6 years, F/M= 17/6). Twenty-three healthy controls, matched by age and sex, were recruited as the control group. All participants underwent a complete echocardiographic examination, including determination of left ventricular ejection fraction (LVEF), speckle tracking derived global longitudinal strain (GLS, in absolute values), LA volume index (LAVi) and PASP. MS severity was assessed by continuous wave Doppler derived mean transmitral pressure gradient (MPG), pressure half time (PHT) and functional mitral valve area (MVA). Data were analysed offline by a dedicated workstation. Results No significant difference of body mass index, systolic and diastolic blood pressure was found between the two groups, while heart rate was higher in MR (p &amp;lt; 0.0001). In the pooled MS population, MPG was 5.7 ± 2.4 mmHg, PHT 127.7 ± 26.9 msec and MVA 1.76 ± 0.36 cm². Twelve patients (52.1%) had mild MS, 10 (43.5%) moderate MS and one (4.3%) severe MS. Patients with MS had larger LA volumes (LAVi = 45.0 ± 12.7 vs. 28.3 ± 7.3 ml/m², p &amp;lt; 0.0001), higher PASP (36.4 ± 8.9 vs. 30.4 ± 6.7 mmHg, p &amp;lt; 0.01), lower LVEF (58.5 ± 6.1 vs. 66.0 ± 3.5%. p &amp;lt; 0.0001) and lower GLS (18.8 ± 4.6 vs. 21.7 ± 2.5%, p &amp;lt; 0.01) than the healthy controls. By analyzing the MS group, LAVi had a significant univariate relation with MPG degree (r = 0.69, p &amp;lt; 0.002). PASP correlated with LAVi (r = 0.60, p = 0.003) and MPG (r = 0.51, p &amp;lt; 0.01) but not with PHT (r = 0.28, p = 0.54) and functional MVA (r=-0.31, p = 0.33). By a multlinear regression analysis, including heart rate, MPG, LVEF and GLS as potential determinants, LAVi (standardized beta coefficient =0.65, p= &amp;lt;0.02) and GLS (beta =-0.62, p = 0.03) were both independently associated with PASP degree, whereas the association of MPG and PASP was not significant (cumulative R²=0.47, SEE = 5.9 mmHg, p &amp;lt; 0.01) in the MS group. Conclusions In patients with pure MS, by using a multi-parametric echocardiographic approach, LA dilation appears to be the best predictor of post-capillary PH, independent on the magnitude of LV systolic dysfunction and valvular disease severity. Particular care should be devoted to determine LA size in this clinical setting. Abstract P297 Figure. Relation between LAVi and PASP in MS

Novel Trigone-Based Sizing Method for Mitral Ring Annuloplasty

We devised a novel trigone-based sizing method, setting the trigones at one-quarter of the annular circumference, and used it for mitral annuloplasty in patients with mitral regurgitation (MR). Between 1999 and 2017, 436 patients with degenerative (n= 192), nonischemic functional (n= 124), or ischemic (n= 120) MR underwent mitral valvuloplasty at our institution using an incomplete ring. The intertrigonal distance and prerepair and postrepair annular diameter were measured. Then the diameters predicted from body surface area, the intertrigonal distance, and the ratios of these diameters to observed data were computed. We investigated the influence of these measurements on MR recurrence, transmitral pressure gradient, and systolic anterior motion. Initial repair was successful in 433 patients (99%), but 3 patients with systolic anterior motion and MR required conversion to valve replacement. After 1, 5, and 10 years (mean follow-up, 6.3 years), the rate of freedom from grade 2 or higher recurrent MR was 96%, 92%, and 86% in the degenerative group, 99%, 97%, and 90% in the nonischemic functional group, and 95%, 90%, and 79%, respectively, in the ischemic group (P= .052). The observed/body surface area predicted diameter ratio was negatively correlated with the mean transmitral pressure gradient (mm Hg); 12.3 - 8.2× (ratio) (R=-0.37, P < .001), despite a smaller ratio (<0.9) not being associated with less recurrence of MR. In the degenerative group, systolic anterior motion developed in 7 of 71 patients (10%) with an observed/intertrigonal distance predicted diameter ratio of less than 0.9 (P < .001). Our trigone-based sizing method achieved satisfactory control of MR, while avoiding functional mitral stenosis and systolic anterior motion.

P2715Diastolic dysfunction in women with ischemia and no obstructive coronary artery disease: novel insight from left atrial feature tracking

Abstract Background Women with signs and symptoms of ischemia but no obstructive coronary artery disease (INOCA) are at increased risk of developing heart failure with preserved ejection fraction (HFpEF); however, the exact mechanism for HFpEF progression remains to be elucidated. Prior studies have focused specifically on impaired left ventricular diastolic function in INOCA. We hypothesized that extending our evaluation to include the left atrium (LA)– a key constituent of the transmitral pressure gradient and left ventricular filling– would provide additional, novel, pathophysiological insight. Purpose To evaluate LA function in women with INOCA using cardiac MRI (CMR). Methods We performed retrospective feature tracking analysis of cine images from CMR (Figure 1A), to evaluate LA strain, in 58 INOCA women with normal sinus rhythm (three were excluded due to suboptimal image quality). All strain measurements were performed in duplicate by an experienced investigator blinded to clinical status. We subdivided the cohort by an established threshold of resting left ventricular end diastolic pressure (LVEDP) &lt;12 mmHg vs &gt;12 mmHg, performed invasively within a median of 27 days of the CMR. As illustrated in Figure 1B, LA function was divided into three established phases: (1) reservoir strain, passive expansion of the left atrium from the pulmonary circulation while the mitral valve is closed; (2) conduit strain, passive emptying of the atrium into the ventricle; and (3) booster strain, active emptying of the left atrium following atrial depolarization. Results Reservoir strain was higher in the elevated LVEDP group (n=20, 26.1 + 1.3%) vs. not elevated group (n=35, 22.8 + 0.9%, p=0.03; Figure 1C). In contrast, we observed no group difference in conduit strain (16.5 + 1.0 and 16.5 + 0.7, p=0.78, respectively; Figure 1D), resulting in significantly higher atrial booster strain in the elevated LVEDP group (10.0 + 1.1% and 7.0 + 0.6, p&lt;0.01, respectively; Figure 1E). Conclusions To our knowledge, this is the first report of LA function in women with INOCA. That reservoir strain was higher in subjects with elevated LVEDP provides important pathophysiologic insight regarding diastolic hemodynamics of the LA. The similar conduit function between groups– despite different LVEDP's– strongly suggests a ventricular contribution to the impaired transmitral pressure gradient. Together, these initial proof-of-concept data support the evaluation of LA function in our quest to better understand heart failure progression in INOCA.

P4718Inadequate response of pulmonary artery pressure after percutaneous mitral valvuloplasty: determinant factors and prognostic impact

Abstract Introduction Pulmonary hypertension (HP) has long been known to be a marker of poor outcome in patients with mitral stenosis (MS). Percutaneous mitral valvuloplasty (PMV) is currently the treatment of choice for MS, which results in improvement in HP. However, despite the successful valve opening, the regression of PH may be incomplete. This has been attributed to irreversible morphologic changes within the pulmonary vasculature. Purpose To assess the clinical, echocardiographic and hemodynamic parameters associated with an inadequate response of the pulmonary artery pressure (PAP) immediately after a successful PMV, and also the impact of residual PH on long-term outcome in these patients. Methods 181 patients undergoing PMV for rheumatic MS were enrolled. Invasive hemodynamic and echocardiographic measures were examined in all patients. Inadequate response of PAP was defined as the mean pulmonary artery pressure (mPAP) values unchanged at the end of the procedure. Long-term outcome was a composite endpoint of death, mitral valve replacement, repeat PMV, new onset of atrial fibrillation (AF), or stroke. Results The mean age was 44.1±12.6 years, and 157 patients were women (86.7%). In the overall population, mPAP decreased from 33.4±13.1 mmHg pre to 27.6±9.8 mmHg post (p&lt;0.001), as mitral valve increased from 0.96±0.2 cm2 pre to 1.68±0.2 cm2 post (p&lt;0.001) PMV. Following PMV, 10 patients developed severe mitral regurgitation and were excluded from the analysis. Of the 171 patients analyzed, 52 (30%) did not present reduction of mPAP immediately after the PMV. Transmitral pressure gradients were significantly greater and mitral valve area was smaller in those patients with unchanged mPAP after PMV than in those whose PAP had decreased. Systolic, diastolic and mPAP pressures as well as left atrial pressure were higher in those patients who had improvement in pulmonary pressures after PMV. Multivariate analysis revealed the following independent predictors of unchanged mPAP: AF (Odds ratio [OR] 2.7, 95% [confidence interval] CI 1.1 to 6.4), mitral valve area (OR 1.3, 95% CI 1.1 to 1.5), maximum mitral valve leaflets displacement (OR 0.8, 95% CI 0.7 to 0.9), and left ventricular compliance after PMV (OR 0.8, 95% CI 0.6 to 0.9). During a mean follow-up of 28 months, the endpoint was reached in 48 patients (26%). The pulmonary pressure response to PMV was not predictor of long-term events. Conclusions In a large cohort of patients with MS undergoing PMV, mean pulmonary artery pressure values do not reduce immediately after the procedure in 30% of the cases, despite adequate opening of the valve. The factors associated with inadequate PAP response following PMV were presence of AF, larger mitral valve area, reduced valve leaflets mobility and post procedural low left ventricular compliance. The early non-reduction of mPAP after PMV is not associated with adverse outcome.

Platelet distribution width can be a useful marker of decreased platelet activity after percutaneous mitral balloon valvuloplasty

Aim: Increased platelet activity and elevated mean platelet volume (MPV) has been demonstrated in patients with rheumatic mitral stenosis (RMS). However, platelet distribution width (PDW) and the impact of percutaneous mitral balloon valvuloplasty (PMBV) on PDW has never been studied. Therefore, we aimed to investigate whether PMBV decreases PDW in patients with RMS.Material and Methods: Symptomatic patients with severe RMS undergoing PMBV were included. Echocardiographic characteristics and hematologic parameters was measured just before and 1 month after the PMBV procedure.Results: A total of 30 patients (24 female, mean age: 49.8±13.2 years) were included the study. Mean transmitral pressure gradient, pulmonary artery pressures and left atrium diameter decreased but mitral valve area increased significantly after PMBV. PMBV procedure significantly decreased PDW in patients with RMS (13.5±2.3 vs 12.4±1.9 fL, before and after procedure, respectively; p&amp;lt;0.0001). MPV was decreased after PMBV but it was not statistically significant (10.9±0.8 vs 10.6±0.9 fL, p=0.056). Platelet count was significantly increased after procedure (250±62.6 vs 273.5±78.6 x103/ul, p=0.035). In linear regression analysis, an independent relationship was found in magnitude of PDW decrease and magnitude of increase in mitral valve area (ẞ:0.491, p=0.046). Conclusion: PMBV is associated with a significant decrease in PDW 1 month after the procedure. There was a significant correlation between the magnitude of decrease in PDW and magnitude of increase in mitral valve area after PMBV.

Predicting functional mitral stenosis after restrictive annuloplasty for ischemic mitral regurgitation.

Although it has been realized that restrictive mitral valve annuloplasty (MVA) may re-sult in clinically significant functional mitral stenosis (MS), it still cannot be predicted. The purpose of this study was to identify risk factors for clinically significant functional MS following restrictive MVA surgery for chronic ischemic mitral regurgitation (CIMR). One hundred and fourteen patients who underwent restrictive MVA with coronary artery bypass grafting (CABG) for treatment of CIMR were retrospectively reviewed. Clinically significant functional MS was defined as resting transmitral peak pressure gradient (PPG) ≥ 13 mmHg. During the follow-up period (range 6-12 months), 28 (24.56%) patients developed clinically significant functional MS. The PPG at follow-up was significantly higher than that measured in the early postoperative stage (3-5 days after surgery). Moreover, there was a linear correlation between the two measurements (r = 0.398, p < 0.001). Annuloplasty size ≤ 27 mm and early postoperative PPG ≥ 7.4 mmHg could predict clinically significant functional MS at 6-12 months postoperatively. Chronic ischemic mitral regurgitation patients treated with restrictive MVA and CABG have significant increases in PPG postoperatively. Annuloplasty size ≤ 27 mm and early postopera-tive PPG ≥ 7.4 mmHg can predict clinically significant functional MS at 6-12 months after surgery.

Interscallop indentation closure as an adjunctive technique in mitral valve repair for degenerative mitral valve disease.

Interscallop indentation closure is a useful adjunctive technique which presents several different effects in repairing degenerative mitral regurgitation. However, there are some concerns that it might reduce mitral valve area by restricting the posterior leaflet mobility. We aim to assess postoperative echocardiographic findings after mitral valve repair using this technique. Between January 2009 and December 2015, 897 patients underwent mitral valve repair for degenerative mitral regurgitation at our institutions. We reviewed 98 patients in which we used indentation closure technique, and we analyzed operative and echocardiographic data. Ring annuloplasty and concomitant repair techniques such as leaflet resection and neochordal placement were used in all patients. Specific purposes of indentation closure included gap closure (n = 57), prolapse repair (n = 11), leaflet redundancy repair (n = 16), and leaflet deficiency repair (n = 12). Eleven patients had double indentation closure. Postoperative pre-discharge echocardiography showed no moderate or greater residual mitral regurgitation, mean transmitral pressure gradient of 3.4 ± 1.4mmHg, and mitral valve area of 2.7 ± 0.7cm2. Follow-up echocardiography performed at 43.7 ± 23.9months after surgery showed six cases (6.4%) with recurrent moderate or greater mitral regurgitation, mean transmitral pressure gradient of 3.3 ± 1.3mmHg, and mitral valve area of 2.5 ± 0.6cm2. Interscallop indentation closure is a simple and effective adjunctive technique which can be used for several different purposes. It achieves excellent control of mitral regurgitation with preserved mitral valve area when it is used in addition to standard mitral valve repair techniques in selected cases.

Impact of transcatheter aortic valve replacement on hemodynamic status in patients with aortic stenosis and mitral stenosis: Doppler echocardiographic study

BackgroundMitral stenosis (MS) is often concomitant with aortic stenosis (AS). However, little is known about the functional status following transcatheter aortic valve replacement (TAVR) alone in patients with severe AS and MS and the impact of TAVR for AS on MS hemodynamics. MethodsWe enrolled 11 patients (age 83.6±4.7 years, eight women) with severe AS and MS who underwent TAVR. We compared New York Heart Association (NYHA) functional class and mean transmitral pressure gradient (MPG), mitral valve area (MVA), and stroke volume (SV) measured by transthoracic Doppler echocardiography between baseline and after TAVR. We also examined the calcification of the mitral annulus and mitral leaflet opening. ResultsNYHA functional class improved after TAVR in all 11 patients. As SV increased after TAVR (52±12mL to 63±18mL, p=0.041), MPG decreased and MVA increased (6.9±3.8mmHg to 5.1±2.5mmHg, p=0.011 for MPG and 1.12±0.25cm2 to 1.49±0.43cm2, p=0.035 for MVA). However, MPG increased in one patient in whom calcification extended into the entire anterior mitral leaflet (AML) and AML mobility was severely reduced. ConclusionsNYHA functional class and hemodynamic status of MS improved after TAVR in patients with severe AS and MS. TAVR might provide therapeutic efficacy for selected symptomatic severe AS patients with MS.

Impact of non-severe degenerative mitral stenosis on morbidity and mortality in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement

Severe degenerative mitral stenosis (DMS) is a known predictor of mortality in patients with symptomatic aortic stenosis (AS) considered for transcatheter aortic valve replacement (TAVR) but little data exist regarding mild to moderate DMS. We assessed the association of DMS with mitral annulus calcification (MAC) and evaluated the association of non-severe DMS and MAC with morbidity and mortality in patients with severe AS undergoing TAVR. In a retrospective cohort of 346 patients with isolated severe AS undergoing TAVR, we evaluated the association of different DMS severities (based on transmitral mean pressure gradient (TMPG, mmHg)) and MAC severity with all-cause mortality and cardiovascular (CV) hospitalization/death. Severe DMS (TMPG > 10 mmHg) was excluded from the analysis. Non-severe DMS (TMPG > 2 mmHg) was present in 42% of patients (n = 147) and moderate to severe MAC in 46% (n = 131). Patients with TMPG > 2 mmHg were predominantly female (66.7% vs. 41.7%, P < 0.001) with a higher LVEF and smaller diastolic LV volume than patients with no DMS (P < 0.05). In a multivariate analysis, TMPG (> 2 mmHg) and MAC (moderate to severe) were found to be independent predictors of mortality (HR = 1.17 [1.02–1.35], P = 0.0245 and HR = 2.01 [1.18–3.44], P = 0.01 respectively). Non-severe DMS is frequently associated with MAC in patients with severe AS undergoing TAVR. In the challenging context of DMS and MAC in patients undergoing TAVR, TMPG > 2 mmHg appears as an independent prognostic factor that discriminates high-risk patients.