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

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.

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

Heart ◽  
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.

Secondary mitral regurgitation (part 1): volumetric quantification and analysis

Heart ◽  
2017 ◽  
Vol 104 (8) ◽  
pp. 634-638 ◽  
Author(s):  
William H Gaasch ◽  
Theo E Meyer
Keyword(s):  
Mitral Regurgitation ◽  
Left Ventricular ◽  
Volume Data ◽  
Regurgitant Volume ◽  
Optimal Method ◽  
End Diastolic Volume ◽  
Volumetric Quantification ◽  
Secondary Mitral Regurgitation ◽  
Lv Volume ◽  
Secondary Mr

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.

scholarly journals Transcatheter Mitral Valve Replacement and Thrombosis: A Review

2021 ◽  
Vol 8 ◽  
Author(s):  
Guido Ascione ◽  
Paolo Denti
Keyword(s):  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Valve Replacement ◽  
Mitral Valve Replacement ◽  
Anticoagulation Therapy ◽  
Unmet Need ◽  
Left Ventricular ◽  
Current Evidence ◽  
Thrombotic Risk ◽  
Transcatheter Mitral Valve Replacement

Mitral regurgitation is the most prevalent form of moderate or severe valve disease in developed countries. Surgery represents the standard of care for symptomatic patients with severe mitral regurgitation, but up to 50% of patients are denied surgery because of high surgical risk. In this context, different transcatheter options have been developed to address this unmet need. Transcatheter mitral valve replacement (TMVR) is an emergent field representing an alternative option in high complex contexts when transcatheter mitral valve repair is not feasible or suboptimal due to anatomical issues. However, TMVR is burdened by some device-specific issues (device malposition, migration or embolization, left ventricular outflow tract obstruction, hemolysis, thrombosis, stroke). Here we discuss the thrombotic risk of TMVR and current evidence about anticoagulation therapy after TMVR.

scholarly journals Multimodality Imaging in Secondary Mitral Regurgitation

2020 ◽  
Vol 7 ◽  
Author(s):  
Harish Sharma ◽  
Boyang Liu ◽  
Hani Mahmoud-Elsayed ◽  
Saul G. Myerson ◽  
Richard P. Steeds
Keyword(s):  
Heart Failure ◽  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Multimodality Imaging ◽  
Left Ventricular ◽  
Adverse Outcomes ◽  
Functional Mitral Regurgitation ◽  
Term Survival ◽  
Percutaneous Therapy ◽  
Secondary Mitral Regurgitation

Secondary mitral regurgitation (sMR) is characterized by left ventricular (LV) dilatation or dysfunction, resulting in failure of mitral leaflet coaptation. sMR complicates up to 35% of ischaemic cardiomyopathies (1) and 57% of dilated cardiomyopathies (2). Due to the prevalence of coronary artery disease worldwide, ischaemic cardiomyopathy is the most frequently encountered cause of sMR in clinical practice. Although mortality from cardiovascular disease has gradually fallen in Western countries, severe sMR remains an independent predictor of mortality (3) and hospitalization for heart failure (4). The presence of even mild sMR following acute MI reduces long-term survival free of major adverse events (1). Such adverse outcomes worsen as the severity of sMR increases, due to a cycle in which LV remodeling begets sMR and vice versa. Current guidelines do not recommend invasive treatment of the sMR alone as a first-line approach, due to the paucity of evidence supporting improvement in clinical outcomes. Furthermore, a lack of international consensus on the thresholds that define severe sMR has resulted in confusion amongst clinicians determining whether intervention is warranted (5, 6). The recent Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation (COAPT) trial (7) assessing the effectiveness of transcatheter mitral valve repair is the first study to demonstrate mortality benefit from correction of sMR and has reignited interest in identifying patients who would benefit from mitral valve intervention. Multimodality imaging, including echocardiography and cardiovascular magnetic resonance (CMR), plays a key role in helping to diagnose, quantify, monitor, and risk stratify patients for surgical and transcatheter mitral valve interventions.

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

Heart ◽  
2018 ◽  
Vol 104 (8) ◽  
pp. 639-643 ◽  
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.

Abstract 15604: Staging Cardiac Damage in Patients With Secondary Mitral Regurgitation

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Gurpreet Singh ◽  
Farnaz Namazi ◽  
Kensuke Hirasawa ◽  
Nina A Ajmone Marsan ◽  
Victoria Delgado ◽  
...  
Keyword(s):  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Censored Data ◽  
Significant Risk ◽  
Left Ventricular ◽  
Cardiac Damage ◽  
Stage 4 ◽  
All Cause Mortality ◽  
Secondary Mitral Regurgitation ◽  
Stage 1

Introduction: Patients with secondary mitral regurgitation (SMR) often show extra-mitral valvular cardiac damage which can influence the prognosis. SMR can be defined according to stages of extra-mitral valvular cardiac damage. The present study evaluated the prevalence of different stages of extra-mitral valvular cardiac damage and the prognostic implications in moderate and severe SMR patients. Methods: A total of 648 patients with moderate and severe SMR were classified according to the extent of cardiac damage on echocardiography: left ventricular damage (Stage 1), left atrial damage (Stage 2), pulmonary artery vasculature damage (Stage 3) or right ventricular damage (Stage 4). Cox proportional hazards analyses were performed, both on, non-censored and censored data (included till the occurrence of mitral valve intervention). The primary endpoint was all-cause mortality. Results: The prevalence of each stage of the proposed classification was, 10% in Stage 1, 7% in Stage 2, 16% in Stage 3 and 67% in Stage 4. In the censored data, cardiac damage classification was independently associated with all-cause mortality (HR: 1.182, CI :1.019-1.370; P=0.027), and this was mainly driven by Stage 4 (HR: 1.726 CI: 1.034-2.881; p=0.037, Figure 1A). The non-censored data, showed that Stage 3 was independently associated with all-cause mortality (HR: 1.795 CI:1.121-2.876; P= 0.015), whereas Stage 4 showed an increased non-significant risk for all-cause mortality (HR: 1.472 CI:0.973-2.227; P=0.067, Figure 1B). Conclusions: A new proposed staging classification for moderate and severe SMR showed, that cardiac damage staging was independently associated with all-cause mortality in patients censored for mitral valve intervention, and this was mainly determined by RV dysfunction.

Clinical implications of mitral valve geometric alterations in children with dilated cardiomyopathy

2015 ◽  
Vol 26 (7) ◽  
pp. 1365-1372 ◽  
Author(s):  
Taiyu Hayashi ◽  
Ryo Inuzuka ◽  
Takahiro Shindo ◽  
Hiroshi Ono ◽  
Yukihiro Kaneko ◽  
...  
Keyword(s):  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Dilated Cardiomyopathy ◽  
Surface Area ◽  
Body Surface Area ◽  
Body Surface ◽  
Left Ventricular ◽  
Z Scores ◽  
Mitral Valve Geometry ◽  
Secondary Mitral Regurgitation

AbstractWe aimed to elucidate the relationship between severity of secondary mitral regurgitation and mitral valve geometry in children with dilated cardiomyopathy. The medical records of 16 children with dilated cardiomyopathy (median age, 1.2 years; range, 0.4–12.3 years) were reviewed. Mitral valve geometry was evaluated by measuring coaptation depth using echocardiographic apical four-chamber views at the initial presentation. Patients were dichotomised according to the mitral regurgitation severity: patients with moderate or severe secondary mitral regurgitation (n=6) and those with mild secondary mitral regurgitation (n=10). A total of 58 healthy children were considered as normal controls, and a regression equation to predict coaptation depth by body surface area was derived: coaptation depth [mm]=4.37+1.34×ln (body surface area [m2]) (residual standard error, 0.49; adjusted R2, 0.68; p<0.0001). Compared with patients with mild secondary mitral regurgitation, those with moderate or severe secondary mitral regurgitation had significantly larger coaptation depth z-scores (6.4±2.3 versus 1.9±1.4, p<0.005), larger mitral annulus diameter z-scores (3.6±2.6 versus 0.9±1.8, p<0.05), higher left ventricular sphericity index (0.89±0.07 versus 0.79±0.06, p<0.005), and greater left ventricular fraction shortening (0.15±0.05 versus 0.09±0.05, p<0.05). In conclusion, geometric alteration in the mitral valve and the left ventricle is associated with the severity of secondary mitral regurgitation in paediatric dilated cardiomyopathy, which would provide a theoretical background to surgical intervention for secondary mitral regurgitation in paediatric populations.

Mitral Valve Repair for Ischemic Mitral Regurgitation in Dilated Cardiomyopathy

2005 ◽  
Vol 13 (3) ◽  
pp. 267-270
Author(s):  
Vijay Kohli ◽  
Harpreet Wasir ◽  
Sanjay Mittal ◽  
Anil Karlekar ◽  
Yatin Mehta ◽  
...  
Keyword(s):  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Dilated Cardiomyopathy ◽  
Mitral Valve Repair ◽  
Artery Bypass ◽  
Left Ventricular ◽  
Ischemic Mitral Regurgitation ◽  
Left Ventricular Ejection ◽  
Valve Repair ◽  
Severe Left Ventricular Dysfunction

Ischemic mitral regurgitation contributes to poor survival in patients with heart failure. The intermediate-term outcome of mitral reconstruction in 15 patients who had ischemic dilated cardiomyopathy with mitral regurgitation requiring surgical intervention was studied. They underwent mitral valve repair along with coronary artery bypass surgery. The mitral valve coaptation depth was considered an important parameter in deciding on repair. Ages ranged from 43 to 72 years. Left ventricular ejection fractions were 15–38% (mean, 26.5% ± 4.3%). The operative technique in all 15 patients was posterior annuloplasty using Dacron felt. At a mean follow-up of 4.6 ± 1.2 months (1–8 months), postoperative transesophageal echocardiography revealed mild mitral regurgitation in 2 patients and none in 13. There was a significant improvement in New York Heart Association functional class from 3.9 ± 1.1 to 1.9 ± 0.3. Mitral valve repair by posterior felt annuloplasty provides favorable results in the intermediate-term in selected patients with ischemic cardiomyopathy and severe left ventricular dysfunction.

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