Treatment Of Secondary Mitral Regurgitation Research Articles

Papillary Muscle Maneuvers: Pathophysiology-based Approach in Secondary Mitral Regurgitation.

The treatment of secondary mitral regurgitation (SMR) remains challenging despite the implementation of modern heart failure medication and established catheter-based techniques. Only a subgroup of SMR patients benefit from mitral valve (MV) intervention, and the long-term prognostic benefit of different therapeutic approaches in SMR remains controversial. A literature search was conducted through PubMed and Embase databases to identify relevant studies addressing the pathophysiological background for papillary muscle maneuvers in SMR and currently available surgical techniques. Furthermore, the studies evaluating patients' selection criteria for papillary muscle maneuvers were specifically considered. Articles were selected based on quality and relevance. Over the last two decades, papillary muscle maneuvers have evolved as a pathophysiology-based treatment strategy to address left ventricular (LV) remodeling in SMR. In particular, patients with severe leaflet tenting and moderate heart failure phenotype seem to benefit most from papillary muscle maneuvers that improve LV geometry and thereby the durability of MV repair. We conclude that papillary muscle maneuvers are an evolving pathophysiology-based treatment strategy of ventricular SMR which target papillary muscle displacement due to LV remodeling.

Transcatheter mitral valve replacement or repair for secondary mitral regurgitation: a propensity score-matched analysis.

This study aimed to compare outcomes after transcatheter mitral valve replacement (TMVR) and mitral valve transcatheter edge-to-edge repair (M-TEER) for the treatment of secondary mitral regurgitation (SMR). The CHOICE-MI registry included 262 patients with SMR treated with TMVR between 2014 and 2022. The EuroSMR registry included 1065 patients with SMR treated with M-TEER between 2014 and 2019. Propensity score (PS) matching was performed for 12 demographic, clinical and echocardiographic parameters. Echocardiographic, functional and clinical outcomes out to 1 year were compared in the matched cohorts. After PS matching, 235 TMVR patients (75.5 years [70.0, 80.0], 60.2% male, EuroSCORE II 6.3% [interquartile range 3.8, 12.4]) were compared to 411 M-TEER patients (76.7 years [70.1, 80.5], 59.0% male, EuroSCORE II 6.7% [3.9, 12.4]). All-cause mortality was 6.8% after TMVR and 3.8% after M-TEER at 30 days (p=0.11), and 25.8% after TMVR and 18.9% after M-TEER at 1year (p=0.056). No differences in mortality after 1year were found between both groups in a 30-day landmark analysis (TMVR: 20.4%, M-TEER: 15.8%, p=0.21). Compared to M-TEER, TMVR resulted in more effective mitral regurgitation (MR) reduction (residual MR ≤1+ at discharge for TMVR vs. M-TEER: 95.8% vs. 68.8%, p < 0.001), and superior symptomatic improvement (New York Heart Association class ≤II at 1year: 77.8% vs. 64.3%, p=0.015). In this PS-matched comparison between TMVR and M-TEER in patients with severe SMR, TMVR was associated with superior reduction of MR and superior symptomatic improvement. While post-procedural mortality tended to be higher after TMVR, no significant differences in mortality were found beyond 30 days.

Extracardiac basal annuloplasty for the treatment of secondary mitral regurgitation.

Extracardiac basal annuloplasty for the treatment of secondary mitral regurgitation.

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.

Standardized papillary muscle relocation for type IIIb secondary mitral regurgitation improves 2-year outcome.

The major drawback of isolated annuloplasty for treatment of secondary mitral regurgitation (SMR) with restricted leaflet motion during systole (type IIIb) is the recurrence of SMR, leading to adverse clinical outcome. Additional papillary muscle relocation (PMR) specifically addresses leaflet tethering to restore mitral valve geometry. We aimed to compare the 2-year outcome of annuloplasty with additional PMR vs isolated annuloplasty. A total of 105 consecutive type IIIb SMR patients with preoperative left ventricular (LV) ejection faction <45%, left ventricular end-diastolic diameter >55 mm and a tenting height >10 mm reached 2-year postoperative follow-up after mitral valve repair and were included in the current analysis. A total of 51 patients underwent annuloplasty and additional PMR (study group). A total of 54 patients underwent isolated annuloplasty (control group). Primary composite study end point comprised death or recurrence of mitral regurgitation≥2 at 2 years postoperatively. Echocardiographic baseline variables indicating the severity of LV dysfunction and mitral leaflet tethering were similar. Procedural and periprocedural outcome was comparable in both groups. The primary composite end point was significantly improved in the study group (19.6% [10/51]) in comparison to the control group (44.4% [24/54]; P = 0.009). Two-year all-cause mortality was 7.8% [4/51] in the study group vs 18.5% [10/54] in the control group (P = 0.098). After 2 years, a significant improvement in New York Heart Association functional class as compared to the baseline values was observed in the study group. Additional PMR to treat SMR type IIIb resulted in an improved 2-year outcome in comparison to isolated annuloplasty. PMR specifically addressing mitral leaflet tethering represents a valid therapeutic option for heart failure patients with SMR type IIIb.

New ESC/EACTS guideline recommendations for the treatment of secondary mitral regurgitation: reflections on the evidence

New <scp>ESC</scp>/<scp>EACTS</scp> guideline recommendations for the treatment of secondary mitral regurgitation: reflections on the evidence

Percutaneous mitral edge-to-edge repair

Functional mitral regurgitation, now better known as secondary mitral regurgitation, is the most common acquired heart disease in the world. In most cases, patients with secondary mitral regurgitation have a rather poor prognosis, for example, about 50% of patients are at high risk of surgery or are inoperable, while mortality within 1 year without surgery is 57%. The tactics of treating these patients is the subject of much debate. According to the American Association for Thoracic Surgery (Ischemic Mitral Regurgitation Consensus Guidelines Writing Committee), mitral valve reconstruction is accompanied by a large number of relapses of mitral insufficiency in the long term after surgery, and mitral valve replacement is characterized by high mortality (≥ 13%). With the optimal selected conservative therapy (Guideline-directed medical therapy), in most patients, there is no significant improvement in their condition. Since the 2000s the development of methods of interventional influence on the mitral valve for the treatment of such patients is underway. In the 2010s, interventional treatment techniques began to be widely used, and recommendations for their use began to be developed. In some cases, the results of using the techniques are superior to open surgery. Is it possible to say that the problem of treating patients with functional mitral insufficiency of high operative risk has been solved? In order to answer this question, a literature review was carried out on the interventional treatment of secondary mitral regurgitation using the "edge-to-edge" technique.We used PICO strategy (Patient, Intervention, Comparison, Outcome) for searching articles. A systematic search for information on the research topic was carried out in the PubMed and Google Scholar databases using search queries, keywords, and logical operators AND, OR. Key words: mitral regurgitation, functional mitral regurgitation, chronic mitral regurgitation, MitraClip, percutaneous mitral repair, mitral insufficiency, mitral valve, Edge-to-Edge repair. In the initial selection, 1,180 publications were received. After analyzing the titles and abstracts, 94 articles were selected, and full-text copies were studied. The final analysis included 43 articles and 2 randomized clinical trials. We have compiled a literature review on the interventional treatment of secondary mitral regurgitation using the "edge-to-edge" technique.Received 13 July 2021. Revised 4 August 2021. Accepted 9 August 2021.Funding: The study did not have sponsorship.Conflict of interest: Authors declare no conflict of interest.Contribution of the authors: The authors contributed equally to this article.

November 2021 at a glance: focus on prevention, comorbidities, cardiogenic shock and novel devices.

November 2021 at a glance: focus on prevention, comorbidities, cardiogenic shock and novel devices.

Mitral Valve Translocation: A Novel Operation for the Treatment of Secondary Mitral Regurgitation

BackgroundConventional annuloplasty repair of secondary (functional) ischemic mitral regurgitation (IMR) is associated with a 60% recurrence of moderate or greater mitral regurgitation at 2 years. We developed a novel repair technique for IMR that addresses the underlying geometric alterations of the mitral valve apparatus and compared outcomes with those of conventional repair in a swine model. MethodsChronic IMR was induced by percutaneous embolization of the circumflex artery. Swine with severe IMR (median 9 weeks after infarction) underwent undersized rigid annuloplasty (n = 5) or translocation repair (n = 6). Translocation repair consisted of detaching the mitral valve en bloc at the annulus, creating a 1 cm wide frustum-shaped pericardial patch, and suturing the outer circumference of the patch to the annulus and inner circumference to the mitral valve. ResultsOperative survival was 92% (11 of 12). All animals had none/trace residual central mitral regurgitation, and mean inflow gradients were similar (1 mm Hg [interquartile range, 1 to 2] vs 2 mm Hg [interquartile range, 1 to 2]; P = .75) in the annuloplasty and translocation groups, respectively. Median coaptation length marginally improved in conventional swine (3 to 4 mm, P = .05), but dramatically improved in translocation swine (3 to 8 mm, P = .003). Posterior leaflet angle increased from 39 to 80 degrees (P = .05) in annuloplasty swine but decreased from 50 to 31 degrees (P = .03) in translocation swine. The posterior leaflet was immobile after annuloplasty but had preserved motion after translocation (excursion, 1 degree vs 24 degrees; P = .045). ConclusionsMitral valve translocation effectively treats mitral regurgitation by relieving leaflet tethering. Compared with annuloplasty, mitral valve translocation creates a larger surface of coaptation and preserves leaflet mobility without compromising diastolic function.

Integrative echocardiographic assessment of patients with secondary mitral regurgitation undergoing transcatheter edge-to-edge repair.

To investigate whether the integrative echocardiographic criteria used in the cardiovascular outcomes assessment of the mitraclip percutaneous therapy (COAPT) for heart failure patients with functional mitral regurgitation study predict outcomes after edge-to-edge trancatheter mitral valve repair (TMVr) for the treatment of secondary mitral regurgitation (SMR). Two randomized controlled trials comparing TMVr to medical treatment reported conflicting findings. Differences in patient selection criteria may have contributed to these diverging results. Patients undergoing TMVr were stratified following the integrative COAPT echocardiographic criteria in noneligible and eligible patients who were further classified into three tiers according to effective regurgitant orifice (EROA) (Tier 1: EROA ≥ 0.3cm2 ; Tier 2: EROA 0.2cm2 and 0.29cm2 ; Tier 3: EROA<0.2cm2 ) combined with several other severity criteria. We assessed between group differences in all-cause mortality, successful SMR reduction, and symptom relief from baseline to 2-year follow-up. Between March 2011 and March 2018, 138 patients (mean age 75 years) satisfying the inclusion criteria underwent TMVr for treatment of symptomatic SMR. The mean EROA area was 0.35 ± 0.17 mm2 . Ten patients (7%) died within 30 days, 29 (21%) within 12 months, and 41 (30%) within 2 years. After stratification according to the COAPT echocardiographic criteria that were fulfilled in 72% of the studied population, Tier 2 patients (45%), as well as noneligible patients (38%) had a higher mortality rate compared to those in Tier 1 (19%). SMR patients stratified into tiers according to the COAPT integrative echocardiographic criteria have diverging prognostic and symptomatic benefit after edge-to-edge TMVr.

Treatment of secondary mitral regurgitation in patients with heart failure: when left ventricular ejection fraction may become not crucial.

Treatment of secondary mitral regurgitation in patients with heart failure: when left ventricular ejection fraction may become not crucial.

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.

An observational, prospective study on surgical treatment of secondary mitral regurgitation: The SMR study. Rationale, purposes, and protocol.

The natural history of secondary mitral regurgitation (MR) is unfavorable. Nevertheless, there are no evidence that its correction can improve the outcome. If from one side the original cause of secondary MR can be such to limit the possibilities of improvement, from the other side it is possible that the surgical technique widely applied to repair, restrictive mitral annuloplasty, is not adequate to correct the regurgitation. The addition of valvular and/or subvalvular techniques has been considered a possible technical solution. However, we do not know the prevalence of each technique, how many times mitral replacement is used to correct secondary MR. This aspect is of particular importance, as we know that a successful mitral repair causes a better left ventricular systolic remodeling than a unsuccessful repair or replacement. This study is a prospective, observational registry, conceived to understand what is done in the real world. Any surgeon will use the technique he thinks the most suitable for the patient. Every year, for 5 years, patients will have a clinical and echocardiographic follow-up, to evaluate the risk factors for a worse result (death, rehospitalization for heart failure, reoperation for MR return, moderate, or more MR return). This knowledge will give us the possibility to understand which is the technique, or the strategy, more efficient to treat this disease and the real efficacy of the surgical treatment.

Treatment of Secondary Mitral Regurgitation in Heart Failure: A Shifting Paradigm in the Wake of the COAPT Trial

Secondary mitral regurgitation (MR) is common in patients with left heart dysfunction and it is associated with poor outcomes. Findings from the Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation (COAPT) trial, published in 2018, suggest that in a subset of people with heart failure with secondary MR that persists despite optimization of guideline-directed medical therapies, there is now a role for percutaneous mitral valve repair using the MitraClip device. Defining which patients are most likely to benefit from MitraClip, and when, requires both a multidisciplinary approach centered on heart failure, as well as a recognition of the need for further research in this area.

The Treatment of Heart Failure with Reduced Ejection Fraction.

Chronic congestive heart failure is a common condition that, if untreated, markedly impairs the quality of life and is associated with a high risk of recurrent hospitalization and death. This review is based on articles retrieved by a selective search in PubMed, as well as on relevant guidelines. Evidence-based treatment options are available only for congestive heart failure with a low ejection fraction. Pharma - cotherapy is based on neurohumoral inhibition of the renin-angiotensin-aldosterone system and the adrenergic system. The prognosis of patients with this condition has been further improved recently through the introduction of combined angiotensin receptor antagonists and neprilysin inhibitors. Modern implantable devices are a further component of treatment. Implantable defibrillators and special pacemakers for cardiac resynchronization are well established; the utility of alternative devices (baroreflex modulation or cardiac contractility modulation) needs to be investigated in further studies. It was recently shown that the catheter-based treatment of secondary mitral regurgitation with a MitraClip improves the outcome of selected patients. The treatment of chronic systolic heart failure as recommended in the relevant guidelines, with drugs and implanted devices if indicated, can significantly improve the clinical outcome.

Mitral regurgitation: lessons learned from COAPT and MITRA-Fr.

Recent studies about percutaneous treatment of secondary mitral regurgitation (MR) underlined the importance of left ventricular geometry and features of mitral valve as determinants of procedural and long-term success. Guideline-directed medical therapy (GDMT), transcatheter mitral valve treatment (TMVT) and surgical procedures (mitral valve replacement, mitral valve repair at level of the annulus or subvalvular apparatus) have been extensively evaluated but not adequately compared in current clinical studies. A detailed analysis of the results of the study about transcatheter mitral valve repair would allow to evaluate the safety and effectiveness of such procedure and would provide potential indications for improving the quality of percutaneous and surgical repair in patients with moderate-to-severe secondary MR. Patients with proportionate MR (i.e., MR severity is proportional to the amount of left ventricular dilatation) are prone to respond to the optimization of medical therapy, while patients with disproportionate MR (i.e., MR severity is disproportionately higher than predicted by left ventricular dilatation, with high EROA and small left ventricle) are likely to benefit from additional repair. The identification of specific subpopulation of "high responders", based on the anatomic characteristics of the mitral valve and the relative dimensions of the annulus, the regurgitation and the left ventricle, can also apply to medical therapy. However, some pivotal component of MR (such as the symmetry of tethering and the differences in biomechanical features of leaflets) are not adequately investigated in current studies and warrant further evaluation.

What do MITRA-FR and COAPT teach us about the percutaneous treatment of secondary mitral regurgitation?

What do MITRA-FR and COAPT teach us about the percutaneous treatment of secondary mitral regurgitation?

Long-term results of surgical treatment of secondary severe mitral regurgitation in patients with end-stage heart failure: Advantage of prosthesis insertion

Surgical treatment of secondary mitral regurgitation (SMR) is controversial. To analyse outcome after undersizing annuloplasty (UA) and mitral valve replacement (MVR). Consecutive patients operated on for severe SMR, with left ventricular ejection fraction (LVEF)<40% and refractory CHF, were included. Endpoints were in-hospital mortality, mid-term cardiovascular (CV) mortality, evolution of LV variables and recurrence of mitral regurgitation (MR). 59 patients were included (mean age 65±10 years, preoperative LVEF 36±6%; effective regurgitant orifice [ERO] 41±17 mm2), 41 with ischaemic disease: 12 underwent UA and 47 underwent MVR; only eight had concomitant coronary revascularization. In-hospital mortality was 3.3% (8.3% in UA group; 2.1% in MVR group). Eight-year CV mortality was 39±13% (40±18% in UA group; 27±10% in MVR group). Older age (hazard ratio 1.14, 95% confidence interval 1.07 to 1.22; P<0.001) and LV end-systolic diameter (hazard ratio 1.18, 95% confidence interval 1.09 to 1.27; P<0.001) independently predicted CV mortality. LVEF did not change between the preoperative and follow-up transthoracic echocardiograms in the MVR group (36±6% vs. 35±10%; P=0.6) or the UA group (36±5% vs. 31±12%; P=0.09). Conversely, LV end-diastolic diameter decreased significantly in the MVR group (64±8m to 59±9mm; P=0.002), but not in the UA group (61±7m to 64±10mm; P=0.2). Recurrence of significant MR occurred in 81% of patients in the UA group (mean postoperative ERO 19±6 mm2) versus none in the MVR group. Surgical treatment of SMR can be performed with acceptable operative risk and mid-term survival in severe heart failure, even if there is no indication for revascularization. MVR is associated with significant reverse remodelling, and UA with prohibitive risk of MR recurrence.

Surgical treatment of secondary mitral regurgitation: is repair a reasonable option?

The optimal approach for treating secondary mitral regurgitation (MR) is debated. Since annuloplasty alone has resulted in 30% or more recurrent MR in the mid-term, recent studies suggest mitral valve replacement. However, subvalvular repair strategies as an adjunct to annuloplasty in order to prevent recurrent MR due to ongoing left ventricle (LV) remodeling are becoming increasingly popular. In this study we present short term results of patients with secondary MR who underwent mitral repair using a novel subvalvular repair approach and address the questions whether mitral repair is a reasonable option in these patients. Ten patients presenting with functional MR underwent ring annuloplasty and a subvalvular approximation of the papillary muscles using a technique where the distance between both papillary muscles was adjusted with a Polytetrafluoroethylene (PTFE) string during the saline test (Ring-Noose-String technique). Nine of ten patients had none-mild MR while in one patient mild-moderate MR due to ongoing leaflet tethering was diagnosed at discharge. In this patient, insufficient adjustment of the PTFE string is hypothesized as the primary mechanism for suboptimal repair. There were no complications related to the novel surgical technique. No patient died during the follow up period. The Ring-Noose-String technique provides acceptable repair results in the short term. A longer follow-up is needed to proof its long-term efficacy. Subvalvular techniques such as this may allow a durable repair in patients with secondary MR.

The role of papillary muscle approximation in mitral valve repair for the treatment of secondary mitral regurgitation.

Secondary mitral regurgitation (MR) is present in up to half of patients with dilated cardiomyopathy, and is associated with a poor prognosis. It primarily results from progressive left ventricular remodelling, papillary muscle displacement and tethering of the mitral valve leaflets. Mitral valve repair with an undersized ring annuloplasty is the reparative procedure of choice in the treatment of secondary MR. However, this technique is associated with a 30-60% incidence of recurrent moderate or greater MR at mid-term follow-up, which results in progressive deterioration of left ventricular function and increased morbidity. Combined mitral valve repair and papillary muscle approximation has been applied in order to address both the annular and subvalvular dysfunction that coexist in secondary MR, which include graft and suture-based techniques. Herein, we provide a systematic review of the published literature regarding the technical aspects, clinical application, and outcomes of mitral valve repair with combined ring annuloplasty and papillary muscle approximation for the treatment of secondary MR.