scholarly journals Transcatheter Versus Surgical Valve Repair in Patients with Severe Mitral Regurgitation

2022 ◽  
Vol 12 (1) ◽  
pp. 90
Author(s):  
Matthias Koschutnik ◽  
Varius Dannenberg ◽  
Carolina Donà ◽  
Christian Nitsche ◽  
Andreas A. Kammerlander ◽  
...  
Keyword(s):  
Mitral Regurgitation ◽  
Cox Regression ◽  
Coronary Revascularization ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Severe Mitral Regurgitation ◽  
Valve Repair ◽  
Ventricular Ejection Fraction ◽  
Number Of Patients ◽  
Cox Analysis

Background. Transcatheter edge-to-edge mitral valve repair (TMVR) is increasingly performed. However, its efficacy in comparison with surgical MV treatment (SMV) is unknown. Methods. Consecutive patients with severe mitral regurgitation (MR) undergoing TMVR (68% functional, 32% degenerative) or SMV (9% functional, 91% degenerative) were enrolled. To account for differences in baseline characteristics, propensity score matching was performed, including age, EuroSCORE-II, left ventricular ejection fraction, and NT-proBNP. A composite of heart failure (HF) hospitalization/death served as primary endpoint. Kaplan-Meier curves and Cox-regression analyses were used to investigate associations between baseline, imaging, and procedural parameters and outcome. Results. Between July 2017 and April 2020, 245 patients were enrolled, of whom 102 patients could be adequately matched (73 y/o, 61% females, EuroSCORE-II: 5.7%, p > 0.05 for all). Despite matching, TMVR patients had more co-morbidities at baseline (higher rates of prior myocardial infarction, coronary revascularization, pacemakers/defibrillators, and diabetes mellitus, p < 0.009 for all). Patients were followed for 28.3 ± 27.2 months, during which 27 events (17 deaths, 10 HF hospitalizations) occurred. Postprocedural MR reduction (MR grade <2: TMVR vs. SMV: 88% vs. 94%, p = 0.487) and freedom from HF hospitalization/death (log-rank: p = 0.811) were similar at 2 years. On multivariable Cox analysis, EuroSCORE-II (adj.HR 1.07 [95%CI: 1.00–1.13], p = 0.027) and residual MR (adj.HR 1.85 [95%CI: 1.17–2.92], p = 0.009) remained significantly associated with outcome. Conclusions. In this propensity-matched, all-comers cohort, two-year outcomes after TMVR versus SMV were similar. Given the reported favorable long-term durability of TMVR, the interventional approach emerges as a valuable alternative for a substantial number of patients with functional and degenerative MR.

Transcatheter versus surgical valve repair in patients with severe mitral regurgitation

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
M Koschutnik ◽  
V Dannenberg ◽  
C Dona ◽  
C Nitsche ◽  
A A Kammerlander ◽  
...  
Keyword(s):  
Mitral Regurgitation ◽  
Cox Regression ◽  
Coronary Revascularization ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Severe Mitral Regurgitation ◽  
Valve Repair ◽  
Ventricular Ejection Fraction ◽  
Funding Sources ◽  
Number Of Patients

Abstract Background Transcatheter edge-to-edge mitral valve repair (TMVR) is increasingly performed, however, its efficacy in comparison with surgical MV treatment (SMV) is unknown. Methods Consecutive patients with severe mitral regurgitation (MR) undergoing TMVR (68% functional, 32% degenerative) or SMV (9% functional, 91% degenerative; 23% MV replacement) were enrolled. To account for differences in baseline characteristics, propensity score-matching including age, EuroSCORE-II, left ventricular ejection fraction, and NT-proBNP was performed. A composite of heart failure (HF) hospitalization/death was defined as primary endpoint. Kaplan-Meier curves and Cox-regression analyses were used to investigate associations between baseline, imaging, and procedural parameters and outcome. Results Between July 2017 and April 2020, 245 patients were enrolled, of which 102 patients could be adequately matched (73y/o, 61% females, EuroSCORE-II: 5.7%, p&gt;0.05 for all). Despite matching, TMVR patients were sicker at baseline (higher rates of prior myocardial infarction, coronary revascularization, pacemakers/defibrillators, and diabetes mellitus, p&lt;0.009 for all). Patients were followed for 28.3±27.2 months, during which 27 events (17 deaths, 10 HF hospitalizations) occurred.Postprocedural MR reduction (MR grade &lt;2: TMVR vs. SMV: 88% vs. 94%, p=0.487) and freedom from HF hospitalization/death (log-rank: p=0.221) were similar at two years. By multivariable Cox analyses, EuroSCORE-II (adj.HR 1.07 [95% CI: 1.00–1.13], p=0.027) and postprocedural MR severity (adj.HR 1.85 [95% CI: 1.17–2.92], p=0.009) emerged as independent predictors of outcome. Conclusions In this propensity matched, all-comers cohort, 2-year outcomes after TMVR versus SMV were similar. Given the reported favorable long-term durability of TMVR, the interventional approach emerges as valuable alternative for a substantial number of patients with functional and degenerative MR at high/prohibitive surgical risk. FUNDunding Acknowledgement Type of funding sources: None.

scholarly journals 559 An analysis of myocardial efficiency in patients with severe asymptomatic mitral regurgitation

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
R Cetin Guvenc ◽  
E Arugaslan ◽  
T S Guvenc ◽  
F Ozpamuk Karadeniz ◽  
H Kasikcioglu ◽  
...  
Keyword(s):  
Left Ventricular Ejection Fraction ◽  
Left Ventricle ◽  
Mitral Regurgitation ◽  
Ejection Fraction ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Severe Mitral Regurgitation ◽  
External Work ◽  
Ventricular Ejection Fraction ◽  
Myocardial Efficiency

Abstract Funding Acknowledgements None declared. Background and Aims It is difficult to determine left ventricular systolic performance in patients with severe mitral regurgitation (MR) since left ventricular ejection fraction (EF) could be preserved until the end stages of the disease. Myocardial efficiency describes the amount of external work (EW) done by the left ventricle per unit of oxygen consumed (mVO2). In the present study, we aimed to investigate MEf in patients with asymptomatic severe MR using a novel echocardiographic method. Methods: A total of 27 patients with severe asymptomatic MR and 26 healthy volunteers were included in this cross-sectional study. EW was measured using stroke volume and blood pressure, while mVO2 was estimated using double product and LV mass. Results: There were no differences between the groups with regards to EF (66%±5% vs. 69%±7%), while MEf was significantly reduced in patients with severe MR (25%±11% vs. 44%±12%, p &lt; 0.001) (Table 1). This difference was maintained even after adjustment for age, gender and body surface area (adjusted :0.44, 95%CI: 0.39–0.49 for controls and adjusted :0.24, 95%CI: 0.19–0.29 for patients with severe MR). Further analysis showed that this reduction was due to an increase in total mVO2 in the severe MR group (Figure 1). Conclusions: Myocardial efficiency was significantly lower in patients with asymptomatic severe MR and preserved EF. Table 1 Parameter Control Group (n = 26) Severe Mitral Regurgitation (n = 27) P Value Age (y) 36.5 ± 8.9 41.3 ± 14.2 0.23 Gender (%Male) 9 (35%) 10 (37%) 1.0 BSA (m2) 1.82 ± 0.20 1.76 ± 0.18 0.64 LV End-Diastolic Volume (ml) 83.13 ± 18.88 121.91 ± 37.63 &lt;0.001 LV End-Systolic Volume (ml) 28.07 ± 9.57 45.30 ± 17.42 &lt;0.001 Left Ventricular Ejection Fraction (%) 0.69 ± 0.07 0.66 ± 0.05 0.29 Systolic Mitral Velocity (cm/s) 7.88 ± 1.14 8.07 ± 1.81 0.66 Stroke Work (j) 1.14 ± 0.21 1.15 ± 0.36 0.91 Minute External Work (j) 65.96 ± 14.71 70.17 ± 23.15 0.85 mVO2 (ml.min-1.100g-1) 6.79 ± 1.93 9.48 ± 4.71 0.02 Total mVO2 (j) 166.58 ± 77.14 346.46 ± 202.71 &lt;0.001 Myocardial Efficiency (%) 44 ± 12 25 ± 11 &lt;0.001 Table 1. Demographic, anthropometric, echocardiographic and mechanoenergetic data for study groups. BSA, body surface area; LV, left ventricle; mVO2, myocardial oxygen consumption. Abstract 559 Figure 1

Improvement in the Severity of Mitral Regurgitation after Direct Intramyocardial Injection of Angiogenic Cell Precursor

2009 ◽  
Vol 4 (5) ◽  
pp. 291-293
Author(s):  
Kitipan V. Arom ◽  
Permyos Ruengsakulrach ◽  
Lertlak Chaothawee
Keyword(s):  
Mitral Regurgitation ◽  
Dilated Cardiomyopathy ◽  
Myocardial Fibrosis ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Severe Mitral Regurgitation ◽  
Class Iii ◽  
Intramyocardial Injection ◽  
Ventricular Ejection Fraction ◽  
Cell Implantation

We reported a case of dilated cardiomyopathy and moderate-severe mitral regurgitation (MR) who we treated by surgical direct intramyocardial angiogenic cell precursors injection. The patient was a New York Heart Association functional class III-IV, 56 year old man, who presented with end-stage congestive heart failure, moderate/severe mitral regurgitation, and myocardial fibrosis with the left ventricular ejection fraction of 13%. After he underwent direct surgical intramyocardial cell implantation, the myocardial fibrosis was resolved at 3 months follow-up. The severity of MR reduced to moderate and mild at 3 and 9 months, respectively. The left ventricular function gradually improved up to 53% at 19 months. To our knowledge, this is one of the only reports of successful direct surgical intramyocardial peripheral blood stem cell implantation to treat MR in dilated cardiomyopathy patient.

Mitigating cardiac dysfunction by TOE-guided cardioplegia and mitral valve repair

2020 ◽  
Vol 28 (7) ◽  
pp. 427-430
Author(s):  
Xu Yu Jin ◽  
Rana Sayeed ◽  
John Pepper ◽  
Mario Petrou
Keyword(s):  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Ejection Fraction ◽  
Transesophageal Echocardiography ◽  
Mitral Valve Repair ◽  
Surgical Repair ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Valve Repair ◽  
Ventricular Ejection Fraction

Based on current guidelines, 15% to 20% of patients undergoing mitral valve repair for regurgitation develop left ventricular dysfunction (ejection fraction < 50%–55%) despite a normal baseline. Two schools of thought have been debated: preexisting myocardial disease or suboptimal intraoperative myocardial protection. In our view, they could be reconciled. It is well recognized that left ventricular ejection fraction with a standard cut off at 50%–55% has limited sensitivity in detecting early systolic impairment in mitral regurgitation patients. Mitral regurgitation also leads to mitochondrial oxidative stress, thus rendering the myocardium more susceptible to ischemia-reperfusion injury and precipitating postoperative cardiac dysfunction. The fall in left ventricular ejection fraction early after mitral valve repair was shown to be caused by the reduction in both myocardial contractility and left ventricular stroke volume. To mitigate the risk to myocardial reperfusion injury, appropriate cardioplegia volume and distribution and well-defined surgical repair processes are equally important. We use transesophageal echocardiography-guided cardioplegia delivery, imaging the intramyocardial flow and ensuring adequate protection of the subendocardium during mitral valve repair. Mild aortic regurgitation on a beating heart often leads to left ventricular dilatation with diminished cardioplegia flow in the myocardium, thus requiring direct ostia cardioplegia. Systematic transesophageal echocardiography assessment before surgery is essential for establishing the mitral regurgitation mechanisms and translating them into precise surgical repair strategies. The benefits of transesophageal echocardiography-guided cardioplegia delivery warrant further clinical trials in order to evolve into part of a high surgical standard.

Abstract 13691: Right Ventricular Remodeling Post MitraClip Insertion for Severe Mitral Regurgitation - Single Centre Echocardiographic Study

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Kalilur Anvardeen ◽  
Eric Yamen ◽  
Jurgen Passage ◽  
Chris Finn ◽  
Brendan McQuillan
Keyword(s):  
Mitral Regurgitation ◽  
Pulmonary Artery ◽  
Right Ventricular ◽  
Left Ventricular ◽  
Right Atrial ◽  
Left Ventricular Ejection ◽  
Pulmonary Vasculature ◽  
Severe Mitral Regurgitation ◽  
Ventricular Ejection Fraction ◽  
The Impact

Introduction: Percutaneous mitral valve repair (Mitraclip) has expanded treatment options for high risk surgical patients with severe mitral regurgitation (MR). Hypothesis: The impact of amelioration of MR by Mitraclip on right ventricular (RV) remodeling and the pulmonary vasculature has received limited investigation. Methods: We undertook a prospective evaluation of consecutive patients who underwent Mitraclip insertion at our centre. Transthoracic echocardiograms were performed pre Mitraclip, 1 day, 1 month, 6 months and 12 months post Mitraclip procedure. We assessed right ventricular (RV) size, fractional area change (FAC), Myocardial performance index (MPI), right atrial (RA) area, left ventricular ejection fraction (LVEF), and estimated pulmonary artery systolic pressure (PASP) from the tricuspid regurgitant spectral Doppler signal according to published ASE guidelines. Results: Twenty-nine patients underwent Mitraclip procedure from March 2011 to June 2013. Six patients were excluded from 12 month analysis because of incomplete data (2 patients), insertion of a LV assist device (1), and mortality (3), Among the 23 study patients, mean age was 73 y (range 52 to 85). The following table shows the mean values and standard errors with significant differences indicated in * (p<0.05), ** (p<0.01) Linear mixed effects models were used to compare pre treatment measurements with post treatment measurements. Conclusion: Right ventricular function by FAC and MPI improved post Mitraclip. Pulmonary artery pressures also improved although the benefit appeared limited to 6 months post procedure. We observed no clear change in other parameters of right heart function or chamber size. Larger long term studies are required to evaluate these results.

scholarly journals Changes in Left Ventricular Ejection Fraction after Mitral Valve Repair for Primary Mitral Regurgitation

2021 ◽  
Vol 10 (13) ◽  
pp. 2830
Author(s):  
Kyoung-Woon Joung ◽  
Seon-Ok Kim ◽  
Jae-Sik Nam ◽  
Young-Jin Moon ◽  
Hyeun-Joon Bae ◽  
...  
Keyword(s):  
Left Ventricular Ejection Fraction ◽  
Mitral Regurgitation ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Valve Repair ◽  
Ventricular Ejection Fraction ◽  
Long Term Changes ◽  
Short And Long Term ◽  
Primary Mitral Regurgitation

This study sought to identify the short- and long-term changes in left ventricular ejection fraction (LVEF) after mitral valve repair (MVr) in patients with chronic primary mitral regurgitation according to preoperative LVEF (pre-LVEF) and preoperative left ventricular end-systolic diameter (pre-LVESD). This study evaluated 461 patients. Restricted cubic spline regression models were constructed to demonstrate the long-term changes in postoperative LVEF (post-LVEF). The patients were divided into four groups according to pre-LVEF (<50%, 50–60%, 60–70%, and ≥70%). The higher the pre-LVEF was, the greater was the decrease in LVEF immediately after MVr. In the same pre-LVEF range, immediate post-LVEF was lower in patients with pre-LVESD ≥ 40 mm than in those with pre-LVESD < 40 mm. The patterns of long-term changes in post-LVEF differed according to pre-LVEF (p for interaction < 0.001). The long-term post-LVEF reached a plateau of approximately 60% when the pre-LVEF was ≥50%, but it seemed to show a downward trend after reaching a peak at approximately 3–4 years after MVr when the pre-LVEF was ≥70%. The patterns of short- and long-term changes in post-LVEF differed according to pre-LVEF and pre-LVESD values in patients with chronic primary mitral regurgitation after MVr.

scholarly journals P299 Acute effects of Levosimendan on myocardial function in patients with severe mitral regurgitation and left ventricular dysfunction undergoing MitraClip repair

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
V Cammalleri ◽  
A Tavernese ◽  
P De Vico ◽  
M Macrini ◽  
A Gismondi ◽  
...  
Keyword(s):  
Mitral Regurgitation ◽  
Myocardial Contractility ◽  
Therapeutic Option ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Severe Mitral Regurgitation ◽  
Ventricular Ejection Fraction ◽  
Significant Difference ◽  
Severe Reduction ◽  
Procedural Success

Abstract Background MitraClip system has developed as a valid therapeutic option in patients affected by moderate to severe and severe mitral regurgitation, low left ventricular ejection fraction (LVEF) and high surgical risk. Often, after the procedure occurs afterload mismatch, an acute and transient worsening of LVEF. Inotropic drugs can improve hemodynamic values at the prize of severe side effects. Levosimendan increases myocardial contractility without an elevation of intracellular calcium concentration, tachyarrhythmia and cardiomyocytes necrosis. Purpose Aim of our study was to assess the acute Levosimendan effects on LVEF of patients who underwent MitraClip procedure Methods Among 160 patients who underwent MitraClip procedure in our institute, 99 patients, with LVEF ≤35%, were included in the study. Transthoracic echocardiogram was performed in all patients, at moment of hospital admission and at discharge; transesophageal echocardiogram was performed during the procedure. We recorded the LVEF by modified Simpson’s rule. Periprocedural hemodynamic parameters were also recorded. 59 patients received Levosimendan during and early after the procedure (L-group) and 40 patients did not (no-L-group). Levosimendan perfusion was started at 0.01 μg/kg/min 1 h before the procedure without a loading dose, and maintained for 12h, according to hemodynamics. Results In the overall population, patients suffered from a severe reduction of LVEF (29.5 ± 5.3%) and high systolic pulmonary arterial pressure (sPAP) (51 ± 14.2 mmHg), without significant difference between the two groups. Acute procedural success was achieved in 98% of the study population, with 2 procedural failures in no-L-group (p = 0.16). During the procedure we observed a significant improvement of LVEF compared to baseline values only in L-group (from 29.6 ± 5.7% to 32.1 ± 7.6%, p = 0.046); in no-L-group the LVEF improved from 29.4 ± 5% to 30.2 ± 4.9% (p = 0.47); at discharge the LVEF was 31.3 ± 4.9% and 30.8 ± 5.7%, in L-group and no-L-group, respectively (p = ns compared to baseline and procedure). At discharge the sPAP significantly reduced in the overall population to 46.3 ± 12.7 mmHg (p 0.015): from 50.8 ± 12.3 mmHg vs 48.7 ± 11.9 in L-group (p = 0.35); from 51.2 ± 16 to 44.3 ± 13.2 mmHg (p = 0.04) in no-L-group. In-hospital mortality was 1.7% in L-group (1 patient die) and 0% in no-L-group. No relevant arrhythmias were reported in any patient during the hospital recovery. Conclusion In MitraClip patients with severe reduction of LVEF, Levosimendan has proven to improve hemodynamic outcome, increasing myocardial contractility during and early after procedure.

scholarly journals P337 Edge-to-edge mitral valve repair in patients with secondary mitral regurgitation: impact of tethering pattern on clinical, echocardiographic and procedure-related characteristics

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
M J Oneto Fernandez ◽  
M Ruiz Ortiz ◽  
M Delgado Ortega ◽  
A M Rodriguez Almodovar ◽  
R Gonzalez Manzanares ◽  
...  
Keyword(s):  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Mitral Valve Repair ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Valve Repair ◽  
Mitral Valve Leaflet ◽  
Ventricular Ejection Fraction ◽  
Secondary Mitral Regurgitation ◽  
The Impact

Abstract Edge-to-edge mitral valve repair (E2E-MVR) has emerged as a therapeutical option in patients with secondary mitral regurgitation (SMR). Two tethering patterns (TP) have been described in SMR: symmetric and asymmetric. However, information on the implications of these TP on E2E-MVR is limited. Our aim was to assess the impact of mitral valve TP on clinical, echocardiographic and procedure-related characteristics in patients undergoing E2E-MVR. We consecutively recruited 62 patients with at least moderate SMR who underwent E2E-MVR in our center between 2011 and 2019 and analysed clinical, echocardiographic and procedure-related characteristics according to TP, which we classified into symmetric and asymmetric considering jet direction and mitral valve leaflet position during systole by means of two-dimensional transesophageal echocardiography (Figure 1). In our series, 43 patients (69.3%) had symmetric TP and 19 (30.7%) had asymmetric TP. Asymmetric TP was associated with ischemic aetiology (52.6% vs 23.3%, p = 0.02) and a non-significant trend to higher frequency of male sex (89.5% vs 67.4%, p = 0.07), diabetes mellitus (52.6% vs 27.9%, p = 0.06), massive regurgitation (78.9% vs 58.1%, p = 0.11) and higher values of left ventricular ejection fraction (LVEF) (34 ± 9% vs 28 ± 11%, p = 0.06). There were no differences in procedure-related characteristic between groups, in particular in number of devices (1.63 [IQR 1-2] vs 1.52 [IQR 1-2], p = 0.27), number of graspings (3.21 [IQR 2-4] vs 2.78 [IQR 2-3], p = 0.16) and time of procedure (95 ± 38min vs 107 ± 43min, p = 0.29). Procedural success (defined as SMR severity reduction≥2) was high in both groups (89.5% vs 74.4%, p = 0.18). At discharge, there was a significant reduction in effective regurgitant orifice area (EROA) in (0.36 ± 0.16cm² vs 0.15 ± 0.10cm², p &lt; 0.001) and pulmonary artery systolic pressure (PASP) (46 ± 12mmHg vs 40 ± 12mmHg, p = 0.004). LVEF was impaired in patients with asymmetric TP but not in patients with symmetric TP (difference in LVEF after procedure: -5 ± 9% vs -0 ± 8%, p = 0.03). In our study, asymmetric TP was related to the ischemic aetiology of left ventricular dysfunction. Procedural characteristics, and EROA and PASP reductions at discharge were similar regardless of TP. However, patients with asymmetric TP had a significantly impairment in LVEF, probably because of afterload mismatch phenomenon. Abstract P337 Figure 1: example of tethering patterns

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