Percutaneous Coronary Sinus-Based Mitral Valve Repair Differentially Modulates Coronary Sinus to Mitral Valve Annulus Geometry and Topography

Objectives: Coronary sinus (CS) based mitral annuloplasty using the Carillon device is a therapeutic option for the treatment of functional mitral valve regurgitation (FMR).Background: Little is known about the change of CS and mitral valve annulus (MVA) planes following Carillon implantation and how they are modulated by the tension applied on the device.Methods: In a retrospective single-center analysis, 10 patients underwent Carillon device implantation and received CT-angiography (CTA) prior and post CS based percutaneous mitral valve repair. Patients were assigned to responders or non-responders according to the 3-month transthoracic echocardiographic follow-up. A prototype software was used to assess distance and angulation of both CS (pre) or Carillon-device (post) and mitral annulus planes.Results: Comparison of the distance and angulation of the CS plane or Carillon device plane and the MVA plane prior and post intervention showed significant reduction of distance and unchanged angulation in responders while angulation was increased and distance reduced in non-responders without statistical significance. Furthermore, in FMR responders MVA perimeter, anterior-posterior diameter, intercommisural diameter and MVA area were decreased following successful indirect mitral valve annuloplasty, while in FMR non-responders Carillon device implantation had no effect on MVA geometry.Conclusions: Insufficient reduction of FMR following indirect mitral valve annuloplasty is associated with device malposition in relation to the mitral valve annulus. Patient selection using CTA-derived distance and angulation of CS to MVA planes is one option to increase effectiveness of indirect mitral valve annuloplasty.

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

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.