Treatment Of Functional Mitral Regurgitation Research Articles

Functional Mitral Valve Regurgitation: Mitral Valve Repair or Replacement? Our "Road Map" for the Appropriate Strategy.

Objectives: The optimal surgical approach for the treatment of functional mitral regurgitation (FMR) remains controversial. Current guidelines suggest that the surgical approach has to be tailored to the individual patient. The aim of the present study was to clarify further aspects of this tailored treatment. Methods: From 01/2006 to 12/2015, 390 patients underwent mitral valve (MV) surgery for FMR (ischemic n = 241, non-ischemic n = 149) at our institution. A regression analysis was used to determine the effect of MV repair or replacement on survival. The patients were analyzed according to the etiology of the MR (ischemic or non-ischemic), different age groups (<65 years, 65-75 years, and >75 years), LV function, and LV dimensions, as well as the underlying heart rhythm. Results: The overall survival rates for the repair group at 1, 5, and 8 years were 86.1 ± 1.9%, 70.6 ± 2.6%, and 55.1 ± 3.1%, respectively. For the same intervals, the survival rates in patients who underwent MV replacement were 75.9 ± 4.5%, 58.6 ± 5.4%, and 40.9 ± 6.4%, respectively (p = 0.003). Patients younger than 65 years, with an ischemic etiology of FMR, poor ejection fraction (<30%), severe dilatation of left ventricle (LVEDD > 60mm), and presence of atrial fibrillation had significantly higher mortality rates after MV replacement (HR, 3.0; CI, 1.3-6.9; p = 0.007). Patients between 65 and 75 years of age had a higher risk of death when undergoing mitral valve replacement (HR, 1.7; CI, 1.0-2.8; p = 0.04). In patients older than 75 years, the surgical approach (MV repair or replacement) had no effect on postoperative survival (HR, 0.8; CI, 0.4-1.3; p = 0.003). Conclusions: Our data demonstrate that, in patients younger than 65 years, the treatment of choice for FMR should be MV repair. This advantage was even more evident in patients with an ischemic origin of MR, a poor ejection fraction, a severe LV dilatation, and atrial fibrillation.

Evaluation of the Efficacy of Transcatheter Intervention, Surgery, and Pharmacological Treatment of Functional Mitral Regurgitation — A Bayesian Network Meta-Analysis with ≥12-Month Follow-up

Aim: Evaluate, using a Bayesian network meta-analysis system, the long-term prognosis of patients with functional mitral regurgitation (FMR) undergoing individual or combined treatment with percutaneous intervention, surgical intervention, or optimal medical therapy. Compare the prognostic outcomes of the different treatment modalities. Methods: Computerized searches of Embase, PubMed, and the Cochrane Library databases were performed. Randomized controlled trials (RCTs) and observational studies were searched to compare prognoses following transcatheter interventions, surgery, and optimal pharmacological treatment for FMR, all with a construction timeframe of 21 October 2023. The primary endpoint event was all-cause mortality. The secondary endpoint events were heart failure readmission rate, mitral regurgitation (MR) ≤2+ improvement rate, New York Heart Association (NYHA) improvement rate (improvement to I–II), and degree of left ventricular ejection fraction (LVEF) improvement. Results: Twenty-six (26) papers were included, comprising 10 RCTs and 16 observational studies involving 5443 patients. A network meta-analysis showed no significant difference in prognosis for all-cause mortality among transcatheter interventions, surgical procedures, and optimal pharmacological treatments. For heart failure readmission rates, mitral valve surgery was superior to MitraClip (odds ratio (OR) = 11.82; 95% confidence interval (CI): 1.67, 90.13). For NYHA (improvement to I–II) improvement rates, the results showed no significant differences for the various mitral interventions. For MR ≤2+ improvement rates, the MitraClip (OR = 3.07; 95% CI: 2.42, 3.76), MitraClip+Guideline-directed medical therapy (GDMT) (OR = 2.93; 95% CI: 2.38, 3.52), mitral valve surgery (OR = 3.01; 95% CI: 2.24, 3.8), and annuloplasty (OR = 4.31; 95% CI: 3.12, 5.58) were superior to GDMT, and mitral valve surgery (OR = 0.07; 95% CI: –0.45, 0.62) was superior to MitraClip+GDMT. For the degree of improvement in LVEF, Carillon+GDMT (mean difference (MD) = –0.97; 95% CI: –1.72, –0.22) was superior to GDMT, mitral valve surgery was superior to Carillon+GDMT (MD = 4.67; 95% CI: 0.92, 8.39); MitraClip+GDMT (MD = 4.01; 95% CI: 1.28, 6.66), GDMT (MD = 3.71; 95% CI: 0.04, 7.35), and annuloplasty were superior to mitral valve surgery (MD = –6.42; 95% CI: –11.96, –0.78). Conclusion: There were no significant differences among the three treatment modalities of transcatheter intervention, surgery, and optimal drug therapy in improving all-cause mortality hard endpoint events, and no significant differences were seen in the rates of heart failure readmission and NYHA improvement (improvement to I–II). However, surgery was superior to transcatheter intervention and optimal drug therapy in terms of improvement in the degree of regurgitation and LVEF.

The effect of a smaller spacer in the PASCAL Ace on residual mitral valve orifice area.

Mitral transcatheter edge-to-edge repair (M-TEER) is an established treatment for functional mitral regurgitation (FMR) associated with a risk of creating iatrogenic stenosis. To investigate the impact of the P10 and its larger spacer compared to the narrower Ace and its smaller spacer on reduction of mitral valve orifice area (MVOA) during M-TEER. Consecutive patients undergoing M-TEER for treatment of severe FMR were screened retrospectively. Patients with a single PASCAL device implantation within the central segments of the MV leaflets, non-complex anatomy, and baseline MVOA ≥ 3.5cm2 were selected. Intraprocedural transesophageal echocardiography was used to compare MVOA reduction with 3D multiplanar reconstruction and direct planimetry. Device selection did not follow a prespecified MVOA threshold. Seventy-two patients (81.0 years, IQR {74.3-85.0}) were included. In 32 patients, the P10 was implanted (44.4%). MR severity (p = 0.66), MR reduction (p = 0.73), and body surface area (p = 0.56) were comparable. Baseline MVOA tended to be smaller in P10 patients with the larger spacer (5.0 ± 1.1 vs. 5.4 ± 1.3cm2, p = 0.18), however, residual MVOA was larger in these patients (2.7 ± 0.7 vs. 2.3 ± 0.6cm2, p = 0.03). Accordingly, relative MVOA reduction was significantly less in P10 patients (- 45.9 ± 7.6 vs. - 56.3 ± 7.0%, p < 0.01). Indirect annuloplasty was more pronounced in Ace patients whereas mean transmitral gradients were similar. In FMR patients with non-complex anatomy, the larger spacer of the P10 maintains greater MVOA with similar MR reduction. Hence, the use of the PASCAL Ace device in patients with small MVOAs might correlate with a risk of both clinically relevant orifice reduction and even iatrogenic stenosis.

Contemporary Surgical Treatment for Functional Mitral Regurgitation

Contemporary Surgical Treatment for Functional Mitral Regurgitation

The CINCH-FMR postmarket registry: Real-world long-term outcomes with percutaneous mitral valve repair with the Carillon Mitral Contour System®

BackgroundThe Carillon® Mitral Contour System® has been studied in 4 prospective controlled studies in the treatment of functional mitral regurgitation (FMR) where it has been found to reduce mitral regurgitation, reduce left ventricular and atrial volumes, and be associated with improvements in clinical parameters. AimsThe CINCH post-market registry is designed to evaluate immediate, mid-term and long-term outcomes from a post-approval study of the Carillon® device evaluated in real-world practice. MethodsThe CINCH post-market registry is a single-arm study of percutaneous mitral annuloplasty with the Carillon device in patients with functional (secondary) mitral regurgitation and symptomatic congestive heart failure when utilized in real-world conditions. Patient selection, echocardiographic hemodynamic measurements, and patient follow-up requirements were performed per standard of care at each institution. ResultsA total of 101 patients treated with the Carillon device at 13 sites in Germany were enrolled in the CINCH registry. The mean age was 75 ± 9 years, 57 % were male, and patient presentation included primarily NYHA class III (69 %) with MR grade 3 (68 %). Over 5 years of follow-up, all-cause mortality was 40.1 %, the incidence of HFH was 53.9 %, and the composite outcome of HFH or death was 66.4 %. At each follow-up interval through 5 years, statistically significant reductions in NYHA class (p < 0.05) and MR grade (p < 0.01) were reported. ConclusionsIn this “real world” registry of the Carillon Mitral Contour System, procedural safety and medium-term follow-up outcomes is similar to the outcomes seen in the prospective, controlled clinical trials, despite being used in populations of patients that extend outside of those studied in the trials. The use of this therapy in patients with atrial functional mitral regurgitation, and heart failure with preserved ejection fraction, was notable, since these types of patients were excluded from the prospective, controlled trials. This supports possible additional patient populations who might benefit from this type of mechanical therapy. The safety profile of this therapy in this registry and in the earlier trials may support a potential role in earlier forms of secondary mitral regurgitation.

Transcatheter edge-to-edge-repair of functional mitral regurgitation induces significant remodeling of mitral annular geometry.

Mitral annular alterations in the context of heart failure often lead to severe functional mitral regurgitation (FMR), which should be treated with transcatheter edge-to-edge repair (M-TEER) according to current guidelines. M-TEER's effects on mitral valve (MV) annular remodeling have not been well elucidated. 141 consecutive patients undergoing M-TEER for treatment of FMR were included in this investigation. Comprehensive intraprocedural transesophageal echocardiography was used to assess the acute effects of M-TEER on annular geometry. Average patient age was 76.2 ± 9.6 years and 46.1% were female patients. LV ejection fraction was reduced (37.0% ± 13.7%) and all patients had mitral regurgitation (MR) grade ≥III. M-TEER achieved optimal MR reduction (MR ≤ I) in 78.6% of patients. Mitral annular anterior-posterior diameters (A-Pd) were reduced by -6.2% ± 9.5% on average, whereas anterolateral-posteromedial diameters increased (3.7% ± 8.9%). Overall, a reduction in MV annular areas was observed (2D: -1.8% ± 13.1%; 3D: -2.7% ± 13.7%), which strongly correlated with A-Pd reduction (2D: r = 0.6, p < 0.01; 3D: r = 0.65, p < 0.01). Patients that achieved A-Pd reduction above the median (≥6.3%) showed significantly lower rates of the composite endpoint rehospitalization for heart failure or all-cause mortality than those with less A-Pd reduction (9.9% vs. 28.6%, p = 0.037, log-rank p = 0.039). Furthermore, patients reaching the composite endpoint had an increase in annular area (2D: 3.0% ± 15.4%; 3D: 1.9% ± 15.3%), whereas those not reaching the endpoint showed a decrease (2D: -2.7% ± 12.4%; 3D: -3.6% ± 13.3%), although residual MR after M-TEER was similar between these groups (p = 0.57). In multivariate Cox regression adjusted for baseline MR, A-Pd reduction ≥6.3% remained a significant predictor of the combined endpoint (OR: 0.35, 95% CI: 0.14-0.85, p = 0.02). Our findings indicate that effects of M-TEER in FMR are not limited to MR reduction, but also have significant impact on annular geometry. Moreover, A-Pd reduction, which mediates annular remodeling, has a significant impact on clinical outcome independent of residual MR.

Functional Mitral and Tricuspid Regurgitation across the Whole Spectrum of Left Ventricular Ejection Fraction: Recognizing the Elephant in the Room of Heart Failure.

Functional mitral regurgitation (FMR) and tricuspid regurgitation (FTR) occur due to cardiac remodeling in the presence of structurally normal valve apparatus. Two main mechanisms are involved, distinguishing an atrial functional form (when annulus dilatation is predominant) and a ventricular form (when ventricular remodeling and dysfunction predominate). Both affect the prognosis of patients with heart failure (HF) across the entire spectrum of left ventricle ejection fraction (LVEF), including preserved (HFpEF), mildly reduced (HFmrEF), or reduced (HFrEF). Currently, data on the management of functional valve regurgitation in the various HF phenotypes are limited. This review summarizes the epidemiology, pathophysiology, and treatment of FMR and FTR within the different patterns of HF, as defined by LVEF.

Percutaneous reduction of septal-to-lateral mitral annular distance to increase mitral leaflet coaptation length: Preclinical study results.

Percutaneous indirect annuloplasty has emerged as a treatment strategy for functional/ischemic mitral regurgitation. This study sought to evaluate the feasibility of percutaneous indirect annuloplasty technique using a new device. The device has 3 components: the "saddle" inserted into the great cardiac vein, the "plug" positioned in the left ventricular outflow tract, and the "bridge," a transatrial suture connecting the 2 holding elements. The aim was to shorten the septal-to-lateral distance of the mitral annulus by pulling on the saddle element. The procedure was performed through venous access in healthy adult sheep. A dedicated catheter holding a needle was used to deploy the saddle into the great cardiac vein and pierce its wall toward the left atrium to deploy the expanded polytetrafluoroethylene suture that is part of the bridge. A catheter for transseptal puncture was inserted for crossing the interatrial septum and piercing the aortic-mitral curtain, thereby allowing the plug to be deployed. The plug was held in place by the second part of the expanded polytetrafluoroethylene bridge. The 2 parts of the bridge were then joined to reduce the septal-to-lateral mitral annular distance. The septal-to-lateral distance and the coaptation length at P2 level were measured before and after the procedure using echocardiography. Overall, 10 animals were treated, 7 successfully. The mean procedure duration was 110±81minutes. Septal-to-lateral distance decreased from 3.8mm to 2.6mm (30%), and maximum increase of mitral leaflet coaptation was 4mm. This new approach seems promising for percutaneous treatment of functional mitral regurgitation.

Comparison of transcatheter edge-to-edge and surgical repair in patients with functional mitral regurgitation using a meta-analytic approach.

Evidence regarding favorable treatment of patients with functional mitral regurgitation (FMR) using transcatheter edge-to-edge repair (TEER) is constantly growing. However, there is only few data directly comparing TEER and surgical mitral valve repair (SMVr). To compare baseline characteristics, short-term and 1-year outcomes in FMR patients undergoing mitral valve (MV) TEER or SMVr using a meta-analytic approach. Systematic database search identified 1,703 studies reporting on TEER or SMVr for treatment of FMR between January 2010 and December 2020. A meta-analytic approach was used to compare outcomes from single-arm and randomized studies based on measures by means of their corresponding 95% confidence intervals (CI). Statistical significance was assumed if CIs did not overlap. A total of 21 TEER and 37 SMVr studies comprising 4,304 and 3,983 patients were included. Patients in the TEER cohort presented with higher age (72.0 ± 1.7 vs. 64.7 ± 4.7 years, p < 0.001), greater burden of comorbidities like hypertension (p < 0.001), atrial fibrillation (p < 0.001), lung disease (p < 0.001) and chronic renal disease (p = 0.005) as well as poorer left ventricular ejection fraction (30.9 ± 5.7 vs. 36.6 ± 5.3%, p < 0.001). In-hospital mortality was significantly lower with TEER [3% (95%-CI 0.02-0.03) vs. 5% (95%-CI 0.04-0.07)] and 1-year mortality did not differ significantly [18% (95%-CI 0.15-0.21) vs. 11% (0.07-0.18)]. NYHA [1.06 (95%-CI 0.87-1.26) vs. 1.15 (0.74-1.56)] and MR reduction [1.74 (95%-CI 1.52-1.97) vs. 2.08 (1.57-2.59)] were comparable between both cohorts. Despite considerably higher age and comorbidity burden, in-hospital mortality was significantly lower in FMR patients treated with TEER, whereas a tendency toward increased 1-year mortality was observed in this high-risk population. In terms of functional status and MR grade reduction, comparable 1-year results were achieved.

Medical Therapy for Functional Mitral Regurgitation

Functional mitral regurgitation (FMR) can be broadly categorized into 2 main groups: ventricular and atrial, which often coexist. The former is secondary to left ventricular remodeling usually in the setting of heart failure with reduced ejection fraction or less frequently due to ischemic papillary muscle remodeling. Atrial FMR develops due to atrial and annular dilatation related to atrial fibrillation/flutter or from increased atrial pressures in the setting of heart failure with preserved ejection fraction. Guideline-directed medical therapy is the first step and prevails as the mainstay in the treatment of FMR. In this review, we address the medical therapeutic options for FMR management and highlight a targeted approach for each FMR category. We further address important clinical and echocardiographic characteristics to aid in determining when medical therapy is expected to have a low yield and an appropriate window for effective interventional approaches exists.

Properly Downsized Annuloplasty for Functional Mitral Regurgitation: Unbeaten in the Right Patient

Treatment of functional mitral regurgitation (FMR) has 2 objectives: restoring mitral valve competence and initiating sustained reverse remodeling of the left ventricle. The use of surgical correction of FMR by means of mitral valve repair, aiming at both goals, has declined in recent years, and current guidelines have only a class IIB recommendation for this procedure in patients without an indication for revascularization. This reduced popularity is mainly the result of poor outcomes in terms of mitral regurgitation (MR) recurrence in the Cardiothoracic Surgery Network Trials, showing “recurrent” MR in 59% of patients 2 years after surgery.

Evaluation of percutaneous annuloplasty for treatment of functional mitral regurgitation: A retrospective study.

The management of severe functional mitral regurgitation (FMR) in patients with heart failure (HF) and low ejection fraction is controversial, but percutaneous transcatheter procedures are promising. In this retrospective analysis, we aimed to assess the efficacy of the Carillon Mitral Contour System in patients with "inoperable" severe FMR. Seventy three patients (mean age 66.89, range 31-90 years) with congestive heart failure (CHF), severe FMR, and reduced ejection fraction (<35%) who underwent Carillon device implantation were examined. The study group consisted of patients with successfully implanted devices whereas the control group comprised patients in whom the device could not be deployed. The primary endpoint was combined all-cause mortality and first hospitalization for HF (whichever came first). The median (Q1, Q3) follow-up was 31 (11-49) months. The device was deployed successfully in 50 patients (implant group) and not in 23 patients (non-implant group). Both the primary endpoint and all-cause mortality were lower in the "implant" group, but the differences were not significant. The median to primary endpoint was 21 [95% confidence interval (CI) 8.8-33.2] and six (95% CI 0.1-11.9) months for the implant group and the non-implant group, respectively (p=0.078). Carillon Mitral Contour System implantation is a safe procedure and results in the reduction of all-cause mortality and combined endpoint of mortality and hospitalizations for HF in inoperable patients with severe FMR and low ejection fraction, although the difference did not meet the significance level.

Should SGLT2i be used prior to transcatheter edge-to-edge repair for secondary mitral regurgitation?

Should SGLT2i be used prior to transcatheter edge-to-edge repair for secondary mitral regurgitation?

Surgical treatment of secondary mitral regurgitation in heart failure: a present-day view

Rationale.Secondary, or functional, mitral regurgitation is the most common complication of heart failure. Dysfunctionof one or more mitral valve structures occurs in 39–74% of patients thus complicating the course of the disease andsignificantly worsening the prognosis in patients with left ventricle dilatation. An unfavorable prognosis in patientswith the development of mitral regurgitation is conditioned by the progressive changes that form a vicious circle: thecontinuing volume overload and dilatation of the left ventricle cause its remodeling, leading to further dilatation ofthe mitral valve annulus. Dysfunctions of the papillary muscles lead to the increased tension of the left ventricle walland increased mitral regurgitation. Clinically, this process is manifested by the congestive heart failure progression andworsened prognosis of the further course, which in the future may lead to considering the inclusion of this patient groupon the waiting list for heart transplantation.Purpose.The purpose of this article is to review the role of surgical management in patients with heart failure complicatedby mitral regurgitation.Conclusions.The main principles of the treatment for functional mitral regurgitation include the reverse left ventricularremodeling and mitral valve repair or replacement surgery which lead to an improved quality of life, the transition ofpatients to a lower functional class, reduced hospital admission rates, and also to a regression or slower progression of theheart failure and to an improved survival.

Functional outcomes with Carillon device over 1year in patients with functional mitral regurgitation of Grades 2+ to 4+: results from the REDUCE-FMR trial.

AimsThe objective of this study was to compare functional outcomes through 1 year in patients with core‐lab verified moderate to severe (Grades 2+ to 4+) functional mitral regurgitation (FMR) treated with the Carillon device or control in the blinded sham‐controlled REDUCE‐FMR (Carillon Mitral Contour System for Reducing Functional Mitral Regurgitation) study.Methods and resultsThe main outcomes of this analysis were the change in 6 min walk test (6MWT) distance, incidence of heart failure hospitalization or death, change in New York Heart Association (NYHA) class, and change in Kansas City Cardiomyopathy Questionnaire (KCCQ) score through 1 year of follow‐up. The minimum clinically important difference (MCID) was defined as a ≥30 m increase in 6MWT distance, an NYHA decrease in ≥1 class, and a ≥3 point increase in KCCQ score. The proportion of patients achieving the MCID in each treatment group was compared using Fisher's exact test, and the number needed to treat (NNT) with the Carillon device was calculated. Among 83 patients (62 Carillon and 21 sham), no statistically significant group differences were observed in the baseline characteristics. All outcomes at 1 year numerically favoured the Carillon group, including MCID for the 6MWT distance (59% vs. 23%, P = 0.029; NNT = 2.8), NYHA class (48% vs. 33%, P = 0.38; NNT = 6.9), KCCQ score (69% vs. 47%, P = 0.14; NNT = 4.5), and freedom from heart failure hospitalization or death (60% vs. 48%, P = 0.45; NNT = 8.3).ConclusionsREDUCE‐FMR was the first blinded sham‐controlled trial to report outcomes with percutaneous therapy for the treatment of FMR. Trends towards improvement in mean 6MWT distance, KCCQ score, and NYHA class were observed with the Carillon device. A substantially higher number of patients achieved MCID for all patient‐centred outcomes with the Carillon device compared with the sham procedure.

Percutaneous Mitral Valve Intervention Using MitraClip for Functional Mitral Regurgitation and Heart Failure

Functional mitral regurgitation (FMR) frequently coexists with left ventricular systolic dysfunction and advanced heart failure, and typically has poor clinical outcomes. Although various therapeutic options including cardiac resynchronization therapy and surgical mitral intervention, have been proposed, an optimal treatment strategy for functional mitral regurgitation has not yet been established. Over the last decade, transcatheter mitral valve repair using MitraClip has emerged as a novel alternative therapeutic option for functional mitral regurgitation. In 2018, the COAPT trial demonstrated that MitraClip treatment reduced rehospitalization due to heart failure and all-cause death in patients with functional mitral regurgitation and heart failure. As a consequence, the MitraClip has become a very promising potential treatment for functional mitral regurgitation. In this review, we discuss and summarize the current status and future perspectives of the treatment for functional mitral regurgitation and heart failure.

Long-term prognosis of patients treated by coronary sinus-based percutaneous annuloplasty: single centre experience.

AimsThis study aims to report long‐term mortality, echocardiographic, and clinical outcomes of patients receiving treatment for functional mitral regurgitation (FMR) with the Carillon device.Methods and resultsThis was a single centre analysis of prospectively collected data from patients treated with the Carillon Mitral Contour System for symptomatic congestive heart failure despite guideline‐directed medical therapy, who were included from a single centre from the TITAN II study. All patients presented with New York Heart Association (NYHA) class 2 or greater symptoms, grade 2+ to 4+ FMR, left ventricular enlargement, and reduced ejection fraction. Surviving patients were evaluated for long‐term follow‐up post‐procedure, averaging 6.9 years. Fifteen (15) patients (mean age 72 years, 60% male, 100% NYHA class III or IV, 50% MR grade 3+ or 4+) were treated with the Carillon device. The Kaplan–Meier mortality rate was 40% at 6 years of follow‐up. Long‐term survival through 6 years was associated with echocardiographic improvement in mitral regurgitation (change in effective regurgitant orifice area in survivors versus non‐survivors from baseline to 1 year follow‐up, −9.0 ± 5.6 vs. −1.7 ± 1.5, P = 0.02) and clinical status at 12 months (difference in NYHA at 1 year follow‐up between survivors versus non‐survivors, P = 0. 05) which was sustained throughout follow‐up. All patients at 6 year follow‐up had ≤2+ MR, with 6 of 7 having 0–1+ MR. Left ventricular end‐diastolic volume was reduced from 154.0 ± 65.7 mL at baseline to 104.5 ± 59.2 mL at 6 year follow‐up, P = 0.03 in survivors with both measurements.ConclusionsAmong patients with congestive heart failure treated with the Carillon device, long‐term survival is associated with favourable 1 year and sustained improvements in mitral regurgitation, left ventricular volume, ejection fraction, and clinical status.

Outcomes with percutaneous mitral repair vs. optimal medical treatment for functional mitral regurgitation: systematic review.

Functional mitral regurgitation (MR) could be defined as a ventricular disease where mitral valve is structurally normal, left chambers are enlarged and mitral annulus is dilated with lack of coaptation of leaflets. Transcatheter mitral valve repair technique has broadened the therapeutic range in the treatment of severe MR. The aim of this study was to review outcomes of MitraClip vs. medical treatment for functional MR. We also planned to review the concept of functional MR, assessment of the degree, prognosis and therapy options. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The Medline through PubMed database was used to search. The present review included manuscripts published between January 2009 and September 2019. Two authors independently screened titles and abstracts of all publications, and performed the selection of studies and data extraction. In the case of disagreements, consensus meetings reached the final decision. Inclusion criteria were: (I) randomized controlled trials and (II) works must compare MitraClip versus optimal medical treatment. Transcatheter mitral valve repair along optimal medical treatment has been compared with optimal medical therapy in two different randomized trials. In the COAPT trial, the MitraClip group showed a significant reduction in mortality and heart failure (HF) hospitalizations. In the MITRA-FR trial, no significant differences were observed between both groups. We reviewed important aspects of functional MR and performed a comprehensive review of both trials comparing them and focusing on their differences.

Clinical Outcomes of a Customized Mitral Valve Plasty for Functional Mitral Regurgitation with a Low Ejection Fraction and Implications for Preoperative Right Ventricular Function.

Purpose: To evaluate clinical outcomes of customized mitral valve plasty (MVP) for the treatment of functional mitral regurgitation (FMR) with a low ejection fraction (EF) and to determine which preoperative factors affected the clinical outcome.Methods and Results: MVP was adjusted according to the degree of left ventricle (LV) remodeling. We performed mitral annuloplasty (MAP) alone in 14 patients and added subvalvular procedures (SVPs) in 22 patients at a high risk of recurrent MR. During follow-up, reverse LV remodeling was obtained and the 3-year and 5-year non-recurrence rates of MR grade ≥2 were 94% and 89%, respectively. Two patients died during their hospital stay, and four more patients died of cardiac causes during follow-up. The 3-year and 5-year rates of freedom from cardiac-related mortality were 86% and 81%, respectively; no significant difference was observed between the two treatment groups. Right ventricular fractional area change (RVFAC) was a significant predictor of cardiac mortality. Patients with an RVFAC of <26% had significantly poorer cardiac-related mortality (71% at 3 years) than those with an RVFAC of ≥26% (95% at 3 years).Conclusion: Customized MVP provided durable mitral competence and reverse LV remodeling. Preoperative RV function was associated with cardiac-related mortality.

Computed tomography angiography imaging of the Carillon device topography after unsuccessful treatment of functional mitral regurgitation.

Figure 1. Imaging following unsuccessful Carillon device implantation. A) Transoesophageal echocardiography (TEE) at baseline, post Carillon implantation (post implant) and at nine-month follow-up (9-mo FU). B) Tracking the Carillon device (yellow line). C) MVA to Carillon device planes showing localisation of the device superior to the MVA. D) Aortic root (yellow line); AVP: aortic valve prosthesis; CS: coronary sinus (blue line); MVA: mitral valve annulus (red line). E) Left: topographical model indicating a Carillon device to MVA distance of 10.1 mm and a Carillon device to MVA angle of 18.3°. Right: AVP: aortic valve prosthesis, Carillon device plane vector (blue ...