Secondary Mitral Regurgitation Repair Techniques and Outcomes: Subannular Repair Techniques in Secondary MR type IIIb

Secondary mitral regurgitation (MR) develops as a consequence of left ventricular (LV) dilatation and dysfunction, which complicates its evaluation and management. The goal of this article is to review the assessment of secondary MR with special emphasis on quantification and analysis of LV volume data. At the present time, the optimal method for making these measurements appears to be cardiac MRI. In severe MR (both primary and secondary), the regurgitant fraction (RF) exceeds 50%, and as a result, the LV end diastolic volume (EDV) is increased. In secondary MR, the ejection fraction is depressed (generally <40%) and despite an RF >50%, the regurgitant volume (RegV) rarely meets the current published criteria for severe MR (>60 mL). The ratio of the RegV to EDV, which is very low in secondary MR, reflects the effect of the RegV on the ventricle and it may be predictive of the fractional change in LV size that can be expected after correction of MR. Accurate measurement of the volumetric parameters is essential to proper management of patients with secondary MR.

Download Full-text

Selection of the Optimal Candidate to MitraClip for Secondary Mitral Regurgitation: Beyond Mitral Valve Morphology

Frontiers in Cardiovascular Medicine ◽

10.3389/fcvm.2021.585415 ◽

2021 ◽

Vol 8 ◽

Author(s):

Tanya Salvatore ◽

Fabrizio Ricci ◽

George D. Dangas ◽

Bushra S. Rana ◽

Laura Ceriello ◽

...

Keyword(s):

Mitral Valve ◽

Mitral Regurgitation ◽

Artery Bypass ◽

Underlying Disease ◽

Left Ventricular ◽

Current Evidence ◽

Secondary Mitral Regurgitation ◽

Secondary Mr ◽

Optimal Candidate ◽

Selection Of

Secondary mitral regurgitation (MR) occurs despite structurally normal valve apparatus due to an underlying disease of the myocardium leading to disruption of the balance between tethering and closing forces with ensuing failure of leaflet coaptation. In patients with heart failure (HF) and left ventricular dysfunction, secondary MR is independently associated with poor outcome, yet prognostic benefits related to the correction of MR have remained elusive. Surgery is not recommended for the correction of secondary MR outside coronary artery bypass grafting. Percutaneous mitral valve repair (PMVR) with MitraClip implantation has recently evolved as a new transcatheter treatment option of inoperable or high-risk patients with severe MR, with promising results supporting the extension of guideline recommendations. MitraClip is highly effective in reducing secondary MR in HF patients. However, the derived clinical benefit is still controversial as two randomized trials directly comparing PMVR vs. optimal medical therapy in severe secondary MR yielded virtually opposite conclusions. We reviewed current evidence to identify predictors of PMVR-related outcomes in secondary MR useful to improve the timing and the selection of patients who would derive maximal benefit from MitraClip intervention. Beyond mitral valve anatomy, optimal candidate selection should rely on a comprehensive diagnostic workup and a fine-tuned risk stratification process aimed at (i) recognizing the substantial heterogeneity of secondary MR and its complex interaction with the myocardium, (ii) foreseeing hemodynamic consequences of PMVR, (iii) anticipating futility and (iv) improving symptoms, quality of life and overall survival.

Download Full-text

Reconstructive operations on subvalvular structures of the mitral valve during remodelling of the left ventricle. Papillary muscle interventions

Patologiya krovoobrashcheniya i kardiokhirurgiya ◽

10.21688/1681-3472-2020-3-32-44 ◽

2020 ◽

Vol 24 (3) ◽

pp. 32

Author(s):

I. I. Skopin ◽

M. S. Latyshev

Keyword(s):

Mitral Valve ◽

Left Ventricle ◽

Mitral Regurgitation ◽

Papillary Muscle ◽

Conflict Of Interest ◽

Reconstruction Technique ◽

Type Iiib ◽

Reconstructive Operations ◽

Reverse Remodelling ◽

Secondary Mitral Regurgitation

The optimal treatment strategy for secondary mitral regurgitation of type IIIb (A. Carpentier classification) remains debatable. The use of a standard surgical technique for treating secondary mitral regurgitation and undersized ring annuloplasty demonstrates suboptimal results in several patients (about 30% of the patients exhibit postoperative hemodynamically significant mitral regurgitation with the absence of effective reverse remodelling of the left ventricle). Such suboptimal results are associated with the unification of only the mitral valve reconstruction technique, irrespective of the state of the left ventricle (degree of dysfunction, dilatation, tethering/tenting, and papillary muscle displacement); this is not entirely justified because of the disease complexity (valve and ventricular), and it is crucial to influence both the components of the disease. Particularly, modern researchers are inclined toward the need of using additional reconstructive interventions on the subvalvular structures that contribute to a more effective reverse remodelling of the left ventricle. Here, we present a review of recent studies on the surgical treatment of functional mitral insufficiency of type IIIb (A. Carpentier classification) with effects on the subvalvular structures (pupillary muscle relocation and approximation).Revised 19 April 2020. Revised 5 May 2020. Accepted 28 May 2020.Funding: The study did not have sponsorship.Conflict of interest: Authors declare no conflict of interest.

Download Full-text

Secondary mitral regurgitation (part 2): deliberations on mitral surgery and transcatheter repair

Heart ◽

10.1136/heartjnl-2017-312002 ◽

2018 ◽

Vol 104 (8) ◽

pp. 639-643 ◽

Cited By ~ 7

Author(s):

William H Gaasch ◽

Theo E Meyer

Keyword(s):

Mitral Regurgitation ◽

Symptomatic Improvement ◽

Left Ventricular ◽

Adverse Outcomes ◽

Regurgitant Flow ◽

Lv Dysfunction ◽

Salutary Effect ◽

Secondary Mitral Regurgitation ◽

Secondary Mr ◽

Mitral Surgery

Secondary mitral regurgitation (MR) develops as a consequence of postinfarction remodelling of the ventricle or other causes of left ventricular (LV) dilatation and dysfunction. The presence of MR amplifies the poor prognosis of the failing ventricle, but it has not been established whether the adverse outcomes stem from the MR or whether the MR is simply a marker of progressive LV dysfunction. In this article, an attempt will be made to clarify the clinical impact of mitral surgery and transcatheter repair in patients with secondary MR. Observational studies indicate symptomatic improvement, but the results of randomised trials are mixed. Furthermore, neither mitral surgery nor transcatheter repair consistently leads to reversal of the adverse LV remodelling. There is, however, general agreement that these procedures do not have a salutary effect on survival. Certainly mitral surgery and transcatheter repair can substantially reduce the mitral regurgitant flow, but inconsistencies and uncertainties regarding clinical outcomes persist in the published literature. Some such problems could be resolved by utilisation of more accurate and reproducible imaging modalities in randomised studies of patients who are most likely to benefit from a reduction in the regurgitant volume—namely those with the most severe MR.

Download Full-text

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

US Cardiology Review ◽

10.15420/usc.2020.05 ◽

2020 ◽

Vol 14 ◽

Author(s):

Kelly H Schlendorf ◽

Jared O’Leary ◽

JoAnn Lindenfeld

Keyword(s):

Heart Failure ◽

Mitral Regurgitation ◽

Multidisciplinary Approach ◽

Functional Mitral Regurgitation ◽

Valve Repair ◽

Percutaneous Therapy ◽

Percutaneous Mitral Valve Repair ◽

Secondary Mitral Regurgitation ◽

Poor Outcomes ◽

Secondary Mr

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.

Download Full-text

Outcome and durability of mitral valve annuloplasty in atrial secondary mitral regurgitation

Heart ◽

10.1136/heartjnl-2021-319045 ◽

2021 ◽

pp. heartjnl-2021-319045

Author(s):

Sébastien Deferm ◽

Philippe B Bertrand ◽

David Verhaert ◽

Jeroen Dauw ◽

Jan M Van Keer ◽

...

Keyword(s):

Mitral Valve ◽

Mitral Regurgitation ◽

Patient Characteristics ◽

Left Ventricular ◽

Type I ◽

Therapeutic Implications ◽

Mitral Valve Annuloplasty ◽

All Cause Mortality ◽

Secondary Mitral Regurgitation ◽

Secondary Mr

ObjectivesAtrial secondary mitral regurgitation (ASMR) is a clinically distinct form of Carpentier type I mitral regurgitation (MR), rooted in excessive atrial and mitral annular dilation in the absence of left ventricular dysfunction. Mitral valve annuloplasty (MVA) is expected to provide a more durable solution for ASMR than for ventricular secondary MR (VSMR). Yet data on MR recurrence and outcome after MVA for ASMR are scarce. This study sought to investigate surgical outcomes and repair durability in patients with ASMR, as compared with a contemporary group of patients with VSMR.MethodsClinical and echocardiographic data from consecutive patients who underwent MVA to treat ASMR or VSMR in an academic centre were retrospectively analysed. Patient characteristics, operative outcomes, time to recurrence of ≥moderate MR and all-cause mortality were compared between patients with ASMR versus VSMR.ResultsOf the 216 patients analysed, 97 had ASMR opposed to 119 with VSMR and subvalvular leaflet tethering. Patients with ASMR were typically female (68.0% vs 33.6% in VSMR, p<0.001), with a history of atrial fibrillation (76.3% vs 33.6% in VSMR, p<0.001), paralleling a larger left atrial size (p<0.033). At a median follow-up of 3.3 (IQR 1.0–7.3) years, recurrence of ≥moderate MR was significantly lower in ASMR versus VSMR (7% vs 25% at 2 years, overall log-rank p=0.001), also when accounting for all-cause death as competing risk (subdistribution HR 0.50 in ASMR, 95% CI 0.29 to 0.88, p=0.016). Moreover, ASMR was associated with better overall survival compared with VSMR (adjusted HR 0.43 95% CI 0.22 to 0.82, p=0.011), independent from baseline European System for Cardiac Operative Risk Evaluation II surgical risk score.ConclusionPrognosis following MVA to treat ASMR is better, compared with VSMR as reflected by lower all-cause mortality and MR recurrence. Early distinction of secondary MR towards underlying ventricular versus atrial disease has important therapeutic implications.

Download Full-text

Prognostic value of pre-operative atrial fibrillation in patients with heart failure and secondary mitral regurgitation undergoing percutaneous mitral valve repair with MitraClip

European Heart Journal ◽

10.1093/ehjci/ehaa946.1973 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

A Sisinni ◽

C Godino ◽

C.A Pivato ◽

M Adamo ◽

M Taramasso ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Mitral Valve ◽

Mitral Regurgitation ◽

Mitral Valve Repair ◽

Cardiac Death ◽

Valve Repair ◽

Patients With Heart Failure ◽

Secondary Mitral Regurgitation ◽

Secondary Mr

Abstract Background Limited data are available regarding the independent prognostic role of atrial fibrillation (AF) after transcatheter mitral valve repair with MitraClip. Aims We sought to evaluate the real impact of pre-operative AF in a wide series of patients with heart failure (HF) and secondary mitral regurgitation (MR) after MitraClip treatment. Methods The study included 605 patients with severe secondary MR from a multicenter international registry. Patients were stratified into two groups according to the presence or absence of pre-operative AF. The overall prevalence of pre-operative AF was 44%. Primary endpoint was 5-year overall death, secondary endpoints were 5–year cardiac death and first re-hospitalization for acute HF. Results At 5-year Kaplan-Meier (KM) analysis conducted in the entire study cohort, compared to patients without AF those with AF had significantly more adverse events in term of overall death (67% vs. 43%; p<0.001) (KM curve A) and cardiac death (65% vs. 37%; p=0.001) (KM curve B) and, moderately more re-hospitalization for acute HF (64% vs. 50%; p=0.048) (KM curve C). To account for baseline differences, patients were propensity score matched 1:1. After matching, 342 adequately matched patients were identified: compared to patients without AF, those with AF had higher rates of death and cardiac mortality but similar rates of re-hospitalization for acute HF. Conclusion In this large 5-year analysis of patients with HF undergoing MitraClip treatment for severe secondary MR, AF is common and associated with higher rates of both overall- and cardiac-death. However, AF doesn't seem to affect the benefit of the procedure in term of re-hospitalization for HF. Funding Acknowledgement Type of funding source: None

Download Full-text