Immediate and 12-Month Outcomes of Ischemic Versus Nonischemic Functional Mitral Regurgitation in Patients Treated With MitraClip (from the 2011 to 2012 Pilot Sentinel Registry of Percutaneous Edge-To-Edge Mitral Valve Repair of the European Society of Cardiology)

Impact of heart failure hospitalizations on clinical outcomes after mitral transcatheter edge-to-edge repair: Results from the EXPAND study

AIM

This analysis aimed to compare the clinical outcomes associated with heart failure (HF) readmissions and to identify associations with HF hospitalizations (HFH) in patients treated with the MitraClip™ NTR/XTR System in the EXPAND study.

METHODS AND RESULTS

The global, real-world EXPAND study enrolled 1041 patients with primary or secondary mitral regurgitation (MR) treated with the MitraClip NTR/XTR System. Echocardiograms were analysed by an independent echocardiographic core laboratory. The study population was stratified into HFH and No-HFH groups based on the occurrence of HFH 1 year post-index procedure. Clinical outcomes including MR severity, New York Heart Association (NYHA) functional class, Kansas City Cardiomyopathy Questionnaire (KCCQ) score, and all-cause mortality were compared (HFH: n = 181; No-HFH: n = 860). Both groups achieved consistent 1-year MR reduction to ≤1+ (HFH vs. No-HFH: 87.3% vs. 89.5%, p = 0.6) and significant 1-year improvement in KCCQ scores (+16.5 vs. +22.3, p = 0.09) and NYHA functional class. However, more patients in the No-HFH group had 1-year NYHA class ≤II (HFH vs. No-HFH: 67.9% vs. 81.9%, p < 0.01). All-cause mortality at 1 year was 36.8% in the HFH group versus 10.4% in the No-HFH group (p < 0.001). The HFH rate decreased by 63% at 1 year post-M-TEER versus 1 year pre-treatment (relative risk 0.4, p < 0.001). Independent HFH associations were MR ≥2+ at discharge, HFH 1 year prior to treatment, baseline NYHA class ≥III, baseline tricuspid regurgitation ≥2+, and baseline left ventricular ejection fraction ≤40%.

CONCLUSIONS

This study reports the impact of HFH on clinical outcomes post-treatment in the EXPAND study. Results demonstrate that the occurrence of HFH was associated with worse 1-year survival, and treatment with the MitraClip system substantially reduced HFH and improved patient symptoms and quality of life.

Changes in exercise stress echocardiographic parameters before and after transcatheter mitral valve edge-to-edge repair

The safety and feasibility are still not well known for exercise-induced mitral regurgitation (MR). This study is aimed to assess and compare the hemodynamic and symptomatic changes in patients with significant secondary MR during exercise stress echocardiography (ESE) before and after transcatheter edge-to-edge repair (TEER). The study included a total of 15 patients with secondary MR who underwent ESE before and after TEER using the MitraClip system (Abbott, Abbott Park, IL, USA). Echocardiographic data of ESE were collected both before the procedure and during the follow-up visit at 3 months. During the one-year postoperative observation period, the rate of readmission due to heart failure was 13% (n = 2), with no recorded fatalities. Although no significant differences of ESE data were observed in exercise-induced pulmonary hypertension or cardiac output before and after the repair, the severity of MR was significantly improved after the procedure, both at rest (2 [2-3] vs. 1 [1-2], p = 0.0125) and during ESE (3 [3-3] vs. 1 [1-1], p < 0.0001). Furthermore, the New York Heart Association Functional Classification was improved (3 [3-3] vs. 1 [1-1], p < 0.0001) after treatment. For a supplemental analysis, MR during ESE was significantly improved not only in cases with atrial secondary MR but also in ventricular secondary MR. Transcatheter edge-to-edge repair for exercise-induced MR resulted in a significant improvement in postoperative MR severity and subjective symptoms. These results are novel, as they have not been extensively reported previously, particularly among Japanese patients.

Impact of coronary artery disease on outcome after transcatheter edge-to-edge mitral valve repair with the MitraClip system

BACKGROUND

The clinical impact of coronary artery disease (CAD) on the prognosis of patients undergoing MitraClip implantation is still unclear.

METHODS

One thousand nine hundred fifty-three patients undergoing MitraClip implantation included in the multicenter GIOTTO Registry were stratified according to CAD. Endpoints were all-cause death, cardiac death, and re-hospitalization for heart failure at follow-up (median 15.8 months).

RESULTS

Although younger, CAD patients were more symptomatic, had worse cardiovascular risk profile, higher burden of comorbidities, more frequently affected by functional MR, with higher left ventricle (LV) diameters and lower ejection fraction (EF). At follow-up, CAD patients showed higher rates of all-cause death (25.4% vs. 19.6%; P=0.002), cardiovascular death (14.0% vs. 10.1%; P=0.007) and re-hospitalization for heart failure (13.9% vs. 10.2%; P=0.011). Dividing the population according to mitral regurgitation (MR) etiology (functional vs. non-functional MR), no differences were observed between CAD and no-CAD patients. At multivariate logistic regression, NYHA III/IV class, prior heart failure hospitalization, severe chronic kidney disease, atrial fibrillation, LV end-diastolic diameter and LVEF<30% but not CAD resulted independent predictors of all-cause death. The same finding was confirmed even after propensity score adjustment.

CONCLUSIONS

CAD did not show a relevant impact on mid-term prognosis per se, but seemed to identify a more complex and diseased cohort of patients with worse clinical and functional status.

Percutaneous Mitral-Valve Intervention for Secondary Mitral Regurgitation: Data From Real-Life

Many questions were raised due to the divergent results between cardiovascular outcomes assessment of the MitraClip percutaneous therapy for heart failure patients with functional mitral regurgitation (COAPT) and multicenter study of percutaneous mitral valve Repair MitraClip device in patients with severe secondary mitral regurgitation (MITRA-FR) trials on the use of percutaneous mitral valve repair for secondary mitral regurgitation. This paper examined pooled patients' characteristics and outcomes from real-life experience compared with those in the 2 landmark trials. A comprehensive search identified eligible studies published in 2020 and 2021. Mean difference and odds ratio (OR) were used to compare continuous and categorical data. Thirty-three studies included more than 9200 patients. Patients in landmark trials were younger than in real-life, less likely to present with severe heart failure symptoms ([COAPT: OR 0.25; 95% CI: 0.21, 0.31]; [MITRA-FR: OR 0.32; 95% CI: 0.23, 0.45]) or severe mitral regurgitation grade (COAPT only: OR 0.57; 95% CI: 0.45, 0.71) with larger left ventricular end diastolic volume. Procedure success (OR 1.94; 95% CI: 1.10, 3.40) was more frequent with lower all-cause mortality (OR 0.73; 95% CI: 0.54, 0.99) in COAPT. Real-life patients experienced more favorable procedural and clinical outcomes compared with MITRA-FR patients. Real-life data on percutaneous mitral valve repair in secondary mitral regurgitation showed important variations in patient selection and procedural outcomes. Rates of death and heart failure hospitalization in observational studies were lower than MITRA-FR but higher than COAPT trial.

Edge-to-edge percutaneous mitral repair for functional ischaemic and non-ischaemic mitral regurgitation: a systematic review and meta-analysis

AIM

Randomized controlled trials comparing the use of the MitraClip device in addition to guideline directed medical therapy (GDMT) to GDMT alone in patients with secondary mitral regurgitation (MR) have shown conflicting results. However, if these differences could be due to the underlying MR aetiology is still unknown. Therefore, we aimed to evaluate if the effects of percutaneous edge-to-edge repair with MitraClip implantation could differ in patients with ischaemic (I-MR) and non-ischaemic mitral regurgitation (NI-MR).

METHODS AND RESULTS

PubMed, Embase, BioMed Central, and the Cochrane Central Register of Controlled Trials were searched for all studies including patients with secondary MR treated with the MitraClip device. Data were pooled using a random-effects model. Primary endpoint was the composite of all-cause death and heart failure-related hospitalization. Secondary endpoints were the single components of the primary endpoint, New York Heart Association functional Classes III and IV, and mitral valve re-intervention. Seven studies enrolling 2501 patients were included. Patients with I-MR compared with patients with NI-MR had a similar risk of the primary endpoint (odds ratio: 1.17; 95% confidence interval: 0.93 to 1.46; I² : 0%). The risk of all-cause death was increased in patients with I-MR (odds ratio: 1.31; 95% confidence interval: 1.07 to 1.62; I² : 0%), while no differences were observed between the two groups in terms of the other secondary endpoints.

CONCLUSIONS

The risk of mortality after MitraClip implantation is lower in patients with NI-MR than in those with I-MR. No absolute differences in the risk of heart failure related hospitalization were observed between groups.

Fourteen-Year Temporal Trends in Patients Hospitalized for Mitral Regurgitation: The Increasing Burden of Mitral Valve Prolapse in Men

Mitral regurgitation (MR) is the second most common valvular heart disease in Europe. The aging of the population and the increase in post-infarction survival could increase the prevalence of MR. To estimate the burden of patients hospitalized for MR in France in 2019 and temporal trends by etiology and sex from 2006 to 2020, we selected all patients hospitalized for MR using the national hospital database. In 2019, 49.2% of such patients had mitral valve prolapse (MVP), 17.1% had ischemic MR, 9.9% had rheumatic MR and 4.4% had MR with cardiomyopathy. The mean age of MVP patients was 67.8 years, and 34% were women. Among 89% of MVP inpatients who had received mitral valve repair or replacement, 55% received surgical repair, 13% received percutaneous repair and 25% received replacement. The all-cause mortality of one year after a mitral procedure of MVP was 5.4%. Among ischemic MR inpatients, 29% have had a mitral valve replacement, 16% a surgical repair and 19% a percutaneous repair. Between 2006 and 2019, the age-standardized rates of patients hospitalized for MVP have increased by 60%, especially in men (+80%) with 5.3/100,000 Person-Years (PY). The age-standardized rates of patients hospitalized for ischemic MR have increased by 25% with 1.8/100,000 PY; that of rheumatic MR has decreased by 36%. The study found that the burden of MVP in hospitals has increased substantially, especially among men. These results emphasize the need to monitor these temporal trends and anticipate care needs in the coming years.

Postdischarge-to-30-Day Mortality Among Patients Receiving MitraClip: A Systematic Review and Meta-Analysis

Background

MitraClip (MC) implantation is the recommended treatment for severe symptomatic mitral regurgitation in patients not responding to medical therapy and at prohibitive surgical risk. It is important to quantify immediate mortality during postdischarge-to-30-day period so as to improve the procedural outcomes. Hence, we aim to identify the incidence of postdischarge-to-30-day mortality and its associated predictors using the technique of meta-analysis.

Methods

We searched Medline, Embase, and Cochrane CENTRAL databases from inception until July 3, 2019 for studies reporting mortality prior to discharge, at 30 days and 1 year after MC implantation. The primary outcome was postdischarge-to-30-day all-cause mortality.

Results

Of 2394 references, 15 studies enrolling 7498 patients were included. Random effects analysis showed that all-cause cumulative inpatient, 30-day, and 1-year mortality was 2.40% (2.08, 2.77; I² = 0%), 4.31% (3.64, 5.09, I² = 41.9%), and 20.71% (18.32; 23.33, I² = 81.5%), respectively. The postdischarge-to-30-day mortality was 1.70% (95% confidence interval: 1.0, 2.70; I² = 84%). A total of 71.50% of deaths (95% confidence interval: 36.80-91.50, I² = 63%) in the postdischarge-to-30-day period were due to cardiac etiology. On meta-regression, pre-MC left ventricular ejection fraction (p = 0.003), Log.Euroscore (p = 0.047), Society of Thoracic Surgeons Predicted Risk of Mortality (p < 0.001), and prolonged ventilation >48 ​hours (p < 0.001) were found to be its significant predictors.

Conclusions

Our meta-analysis reports an additional mortality of ∼2% immediately after MC implantation during the postdischarge-to-30-day period. Majority of deaths occurred due to cardiac causes. Pre-MC left ventricular ejection fraction, Log.Euroscore, Society of Thoracic Surgeons Predicted Risk of Mortality score, and prolonged ventilation were found to be its significant predictors. Further studies are needed to better understand the causes of this early mortality to maximize benefits of this important therapy.

Safety and Feasibility of MitraClip Implantation in Patients with Acute Mitral Regurgitation after Recent Myocardial Infarction and Severe Left Ventricle Dysfunction

Patients with severe mitral regurgitation (MR) after myocardial infarction (MI) have an increased risk of mortality. Transcatheter mitral valve repair may therefore be a suitable therapy. However, data on clinical outcomes of patients in an acute setting are scarce, especially those with reduced left ventricle (LV) dysfunction. We conducted a multinational, collaborative data analysis from 21 centers for patients who were, within 90 days of acute MI, treated with MitraClip due to severe MR. The cohort was divided according to median left ventricle ejection fraction (LVEF)-35%. Included in the study were 105 patients. The mean age was 71 ± 10 years. Patients in the LVEF < 35% group were younger but with comparable Euroscore II, multivessel coronary artery disease, prior MI and coronary artery bypass graft surgery. Procedure time was comparable and acute success rate was high in both groups (94% vs. 90%, p = 0.728). MR grade was significantly reduced in both groups along with an immediate reduction in left atrial V-wave, pulmonary artery pressure and improvement in New York Heart Association (NYHA) class. In-hospital and 1-year mortality rates were not significantly different between the two groups (11% vs. 7%, p = 0.51 and 19% vs. 12%, p = 0.49) and neither was the 3-month re-hospitalization rate. In conclusion, MitraClip intervention in patients with acute severe functional mitral regurgitation (FMR) due to a recent MI in an acute setting is safe and feasible. Even patients with severe LV dysfunction may benefit from transcatheter mitral valve intervention and should not be excluded.

Predictors of functional mitral regurgitation recurrence after percutaneous mitral valve repair

We aimed to identify predictors of mitral regurgitation recurrence (MR) after percutaneous mitral valve repair (PMVR) in patients with functional mitral regurgitation (FMR). Patients with FMR were enrolled who underwent PMVR using the MitraClip^® device. Procedural success was defined as reduction of MR of at least one grade to MR grade ≤ 2 + assessed at discharge. Recurrence of MR was defined as MR grade 3 + or worse at one year after initially successful PMVR. A total of 306 patients with FMR underwent PMVR procedure. In 279 out of 306 patients (91.2%), PMVR was successfully performed with MR grade ≤ 2 + at discharge. In 11.4% of these patients, MR recurrence of initial successful PMVR after 1 year was observed. Recurrence of MR was associated with a higher rate of heart failure rehospitalization during the 12 months follow-up (52.0% vs. 30.3%; p = 0.029), and less improvement in New York Heart Association (NYHA) functional class [68% vs. 19% of the patients presenting with NYHA functional class III or IV one year after PMVR when compared to patients without recurrence (p = 0.001)]. Patients with MR recurrence were characterized by a higher left ventricular sphericity index {0.69 [Interquartile range (IQR) 0.64, 0.74] vs. 0.65 (IQR 0.58, 0.70), p = 0.003}, a larger left atrium volume [118 (IQR 96, 143) ml vs. 102 (IQR 84, 123) ml, p = 0.019], a larger tenting height 10 (IQR 9, 13) mm vs. 8 (IQR 7, 11) mm (p = 0.047), and a larger mitral valve annulus [41 (IQR 38, 43) mm vs. 39 (IQR 36, 40) mm, p = 0.015] when compared to patients with durable optimal long-term results. In a multivariate regression model, the left ventricular sphericity index [Odds Ratio (OR) 1.120, 95% Confidence Interval (CI) 1.039–1.413, p = 0.003)], tenting height (OR 1.207, 95% CI 1.031–1.413, p = 0.019), and left atrium enlargement (OR 1.018, 95% CI 1.000–1.038, p = 0.047) were predictors for MR recurrence after 1 year. In patients with FMR, baseline parameters of advanced heart failure such as spherical ventricle, tenting height and a large left atrium might indicate risk of recurrent MR one year after PMVR.

Impact of transcatheter mitral valve repair on ventricular arrhythmias

AIMS

Patients with heart failure and severe mitral regurgitation (MR) have a poor prognosis and carry an increased risk for ventricular arrhythmias. The present study evaluates the impact of transcatheter mitral valve repair using the MitraClip on the potential reduction of ventricular arrhythmias.

METHODS AND RESULTS

Patients undergoing MitraClip implantation were prospectively enrolled into the present study and received 24 h Holter ECG assessment prior to and 6 months after the procedure. In addition, left ventricular dimensions and function were assessed at baseline and follow-up. A total of 50 patients with mainly functional MR (82%) were included. Non-sustained or sustained ventricular tachycardia (nsVT and/or sVT) occurred in 32% of patients and was reduced to 14% at follow-up (P = 0.01). Also, premature ventricular complex (PVC) burden ≥5% decreased from 16% to 4% (P = 0.04). Patients with persistent (n = 6) or new (n = 1) nsVT and/or sVT at follow-up showed a significant decrease in left ventricular ejection fraction from 38% (interquartile range 26-45%) to 33% (interquartile range 22-44%; P = 0.03).

CONCLUSIONS

In this prospective study, transcatheter mitral valve repair using MitraClip was associated with a reduced prevalence of ventricular arrhythmias. The subset of patients with persistent or new ventricular arrhythmias after MitraClip implantation showed progression of left ventricular dysfunction.

Chest radiography of contemporary trans-catheter cardiovascular devices: a pictorial essay

There is a plethora of cardiovascular devices used for therapy and monitoring, and newer devices are being introduced constantly. As a result of advancement of medical technology and rapid development of such technology to address unmet needs across cardiovascular care, multiple conditions which were previously treated surgically or with medications now benefit from trans-catheter device-based evaluation and management. Moreover, innovation to existing technology has transformed the structural design of many traditional cardiovascular devices, making them safer and enabling easier deployment within the chest (catheter-based versus surgical). A post-procedure chest radiography (CXR) is often the first routine imaging test ordered in these patients. A CXR is a relatively inexpensive and noninvasive imaging tool, which can be obtained at the patient's bedside if needed. Commonly implanted cardiovascular devices can be quite easily checked for appropriate positioning on routine CXRs. Potential complications associated with mal-positioning of such devices may be life-threatening. Such complications often manifest early on CXRs and may not be readily apparent on clinical examination. Prompt recognition of such abnormal radiographic appearances is critical for timely diagnosis and effective management. Clinicians need to be familiar with new devices in order to assess proper placement and identify complications related to mal-positioning. This pictorial essay aims to describe the radiologic appearances of contemporary cardiovascular devices, review indications for their usage and potential complications, and discuss magnetic resonance imaging (MRI) compatibility.

Sex-Based Differences in Coronary and Structural Percutaneous Interventions

In the current state of interventional cardiology, the ability to offer advanced therapies to patients who historically were not surgical candidates has grown exponentially in the last few decades. As therapies have expanded in complex coronary and structural interventions, the nuances of treating certain populations have emerged. In particular, the role of sex-based anatomic and outcome differences has been increasingly recognized. As guidelines for cardiovascular prevention and treatment for certain conditions may vary by sex, therapeutic interventions in the structural and percutaneous coronary areas may also vary. In this review, we aim to discuss these differences, the current literature available on these topics, and areas of focus for the future.

The Use of MitraClip in Secondary Mitral Regurgitation and Heart Failure

Secondary (also known as functional) mitral regurgitation (MR) has increased substantially over the last several decades due to an increase in the prevalence of dilated cardiomyopathy (ischemic and non-ischemic). Mortality and morbidity in patients with dilated cardiomyopathy is much greater when associated with MR as compared to without MR. MR will result in further left ventricular (LV) volume overload, LV dilation, and pupillary muscle displacement resulting in deterioration of the severity of MR leading to a vicious cycle. Optimization of heart failure medical therapy, and cardiac resynchronization therapy for those that qualify, can improve severity of MR; however, significant MR will persist in certain patients. Transcatheter mitral valve repair to treat significant MR using the MitraClip (Abbott, Menlo Park, California), which grasps and coapts the posterior and anterior mitral valve leaflets, in appropriately selected patients with dilated cardiomyopathy and secondary MR has been shown to improve quality of life and prolong survival.

Predictors of functional improvement in the short term after MitraClip implantation in patients with secondary mitral regurgitation

Background and objectives

MitraClip implantation is an established therapy for secondary mitral regurgitation (MR) in high-risk patients and has shown to improve several important outcome parameters such as functional capacity. Patient selection is both challenging and crucial for achieving therapeutic success. This study investigated baseline predictors of functional improvement as it was quantified by the six-minute walk distance (6MWD) after transcatheter mitral valve repair.

Methods and results

We retrospectively analyzed 79 patients with secondary MR treated with MitraClip implantation at an academic tertiary care center. Before and four weeks after the procedure, all patients underwent comprehensive clinical assessment, six-minute walk tests and echocardiography. 6MWD significantly improved after MitraClip therapy (295 m vs. 265 m, p < 0.001). A linear regression model including seven clinical baseline variables significantly predicted the change in 6MWD (p = 0.002, R² = 0.387). Female gender, diabetes mellitus and arterial hypertension were found to be significant negative predictors of 6MWD improvement. At baseline, female patients had significant higher left ventricular ejection fraction (49% vs. 42%, p = 0.019) and lower 6MWD (240 m vs. 288 m, p = 0.034) than male patients.

Conclusion

MitraClip implantation in secondary MR significantly improves functional capacity in high-risk patients even in the short term of four weeks after the procedure. Female gender, diabetes mellitus and arterial hypertension are baseline predictors of a less favourable functional outcome. While further validation in a larger cohort is recommended, these parameters may improve patient selection for MitraClip therapy.

Left ventricular function after correction of mitral regurgitation: Impact of the clipping approach

AIMS

Functional mitral regurgitation (FMR) is associated with poor outcome in systolic heart failure (HF) patients. Percutaneous edge-to-edge mitral valve repair (PMVR) in Mitra-Fr study failed to prove any beneficial effect over optimal medical treatment (OMT) but win in COAPT study. Nevertheless, little is known about the effect of PMVR on LV performance and mechanics in HF patients with severe secondary MR.

METHOD AND RESULTS

Thirty-seven patients with severe FMR undergoing PMVR were included and compared (according to indices of LV myocardial function and the relationship between LV-size and the degree of regurgitation) to nineteen patients with FMR treated by OMT. Both groups were clinically comparable. At 6-month follow-up, cardiac index such as LV global constructive work (GCW) improved significantly in both groups (1.86 vs 2.13 L/min/m² , P = .02, 1.73 vs 2.28 L/min/m² P = .002 and 977 vs 1101 mm Hg.%, P = .003, 967 vs 1110 mm Hg.%, P = .002 for PMVR and OMT groups, respectively) whereas left ventricular (LV) end-systolic volume index, LV ejection fraction, and global longitudinal strain were not different. Receiver operating characteristics in PMVR with LVEF ≤ 35% subgroup analysis demonstrated that global work index (GWI) had the best ability to identify patients with worse evolution (AUC = 0.882; P = .009), confirmed by univariable logistic regression, particularly for patients with GWI < 482 mm Hg.%.

CONCLUSION

Echocardiographic characteristics at 6-month follow-up are not different when compare PMVR and OMT for HF patients with severe FMR. A low global work index might be a tool for discouraging the implantation of clips for this indication.

Five-year clinical outcomes after percutaneous edge-to-edge mitral valve repair: Insights from the multicenter GRASP-IT registry

Limited evidence is available on 5-year clinical outcomes after percutaneous edge-to-edge mitral valve repair.

METHODS

The Getting Reduction of mitrAl inSufficiency by Percutaneous clip implantation in ITaly (GRASP-IT) is a multicenter registry including 304 consecutive patients undergoing Mitraclip between October 2008 and October 2013 at 4 Italian centers. Primary end point (all-cause mortality) and secondary end point (all-cause mortality or heart failure [HF] hospitalization) were evaluated up to 5 years and between 1 and 5 years.

RESULTS

Cumulative incidence of the primary and secondary end points at 1, 2, 3, 4, and 5 years were 15.1%, 26.4%, 35.5%, 42.1%, and 47.3% and 29.1%, 41.7%, 49.8%, 56%, and 62.3%, respectively. Landmark analysis between 1 and 5 years showed an incidence of primary and secondary end point of 37.9% and 46.8%, respectively. Five-year event rates were significantly higher in patients with functional ischemic mitral regurgitation (MR) compared to other etiologies. MR recurrence and left ventricular ejection fraction <30% were associated with an increased risk of both primary and secondary end points. EuroSCORE II >5% was associated with an increased risk of 5-year mortality. Ischemic etiology of MR, baseline serum creatinine >1.5 mg/dL, chronic obstructive pulmonary disease, and previous HF hospitalizations were independent predictors of 5-year secondary end point.

CONCLUSIONS

At 5-year follow-up after Mitraclip, nearly half of patients died and almost two thirds died or were admitted for HF. MR recurrence, ischemic etiology, high comorbidity burden (ie, EuroSCORE II >5%, chronic obstructive pulmonary disease), and advanced cardiomyopathy (ie, left ventricular ejection fraction <30%, prior HF admission, creatinine >1.5 mg/dL) significantly increase the relative risk of 5-year clinical events.

Predictive impact of previous coronary artery bypass grafting on mortality after MitraClip implantation for ischemic functional mitral regurgitation

BACKGROUND

Many candidates with ischaemic functional mitral regurgitation (FMR) have previously undergone coronary artery bypass grafting (CABG), in which transcatheter mitral valve repair can be reasonable for ameliorating the deteriorated hemodynamic and heart failure symptoms. We sought to elucidate the outcomes of MitraClip (MC) implantation in patients with symptomatic ischaemic FMR after CABG.

METHODS

We investigated clinical characteristics, outcomes and predictive impact of previous CABG on mortality in ischaemic FMR patients who underwent MC implantation from two high-volume centres in Germany.

RESULTS

We enrolled 159 patients who previously underwent CABG. Compared with a reference group that did not previously undergo CABG (n = 182), the cohort consisted of more elderly patients (75.0, standard deviation [SD] 7.7 versus 72.9, SD 9.6 years, p = 0.028), more men (84% vs. 69%, p < 0.001), and reduced tricuspid annular plane systolic excursion (14.0, SD 4.0, vs. 16.6, SD 4.6 mm, p < 0.0001). The CABG group showed similar outcomes regarding procedural success (91% vs. 94%, p = 0.24) and 30-day mortality (5.0% vs. 6.0%, p = 0.68), but worse survival after MC implantation (log-rank p = 0.019, hazard ratio 1.56 [95% confidence interval (CI) 1.08-2.26]). After propensity score matching (n = 224), the hazard ratio was 1.18 [95%CI 0.76-1.84] without statistical significance (p = 0.46).

CONCLUSIONS

Transcatheter mitral valve repair using the MC is a viable treatment option for patients with symptomatic ischaemic FMR after CABG. Although the baseline characteristics seemed to point to sick patients, CABG itself had only a modest impact on survival.

Secondary mitral regurgitation: percutaneous edge-to-edge repair on the cutting edge?

PURPOSE OF REVIEW

Secondary mitral regurgitation commonly complicates heart failure. Although the evidence for its management is most robust for treating the underlying cardiomyopathy, treatment aimed at additionally reducing the severity of mitral regurgitation with a percutaneous edge-to-edge device, MitraClip, has recently emerged.

RECENT FINDINGS

Despite the use of contemporary evidence-based heart failure therapies, patients with secondary mitral regurgitation and heart failure continue to remain at high risk for adverse clinical events; in both the MITRA-FR and COAPT trials, an extremely high event rate was evident in the medically managed arms over the respective 12-24-month follow-up. Data supporting the use of MitraClip to mitigate adverse outcomes in secondary mitral regurgitation is, however, conflicting. In MITRA-FR no difference was noted between MitraClip compared with the medically managed arm for the composite of all-cause death or heart failure hospitalization at 12 months. However, in COAPT, a significant reduction in the rate of heart failure re-hospitalization over 2 years was evident with MitraClip compared with medical therapy alone.

SUMMARY

Recommendations exist for the use of MitraClip in patients with primary mitral regurgitation and prohibitive surgical risk. However, with the divergent results of two recent high-quality randomized trials, its role in patients with secondary mitral regurgitation remains controversial.

A meta-analysis of MitraClip combined with medical therapy vs. medical therapy alone for treatment of mitral regurgitation in heart failure patients

AIMS

Survival benefit of percutaneous mitral valve repair with the MitraClip over conservative treatment of functional mitral regurgitation (MR) remains unclear. The purpose of this meta-analysis is to compare survival outcomes of MitraClip with those of medical therapy in patients with functional MR.

METHODS AND RESULTS

A comprehensive literature search of PubMed, MEDLINE, and Google Scholar was conducted including studies evaluating MitraClip vs. medical therapy with multivariate adjustment and with >80% of patients with functional MR. Death from any cause was the primary endpoint, while freedom from readmission was the secondary one, evaluated with random effects. These analyses were performed at study level and at patient level including only functional MR when available, evaluating the effect of MitraClip in different subgroups according to age, ischaemic aetiology, presence of implantable cardioverter defibrillator/cardiac resynchronization therapy, and left ventricular ejection fraction and volumes. We identified six eligible observational studies including 2121 participants who were treated with MitraClip (n = 833) or conservative therapy (n = 1288). Clinical follow-up was documented at a median of 400 days. At study-level analysis, MitraClip, when compared with medical therapy (P = 0.005), was associated with significant reduction of death (P = 0.002) and of readmission due to cardiac disease. At patient-level analysis, including 344 patients, MitraClip confirmed robust survival benefit over medical therapy for all patients with functional MR and among the most important subgroups.

CONCLUSIONS

Compared with conservative treatment, MitraClip is associated with a significant survival benefit. Importantly, this superiority is particularly pronounced among patients with functional MR and across all the main subgroups.

Left ventricular restoration devices post myocardial infarction

Even in the era of percutaneous reperfusion therapy, left ventricular (LV) remodeling after myocardial infarction (MI) leading to heart failure remains a major health concern. Contractile dysfunction of the infarcted myocardium results in an increased pressure load, leading to maladaptive reshaping of the LV. Several percutaneous transcatheter procedures have been developed to deliver devices that restore LV shape and function. The purposes of this review are to discuss the spectrum of transcatheter devices that are available or in development for attenuation of adverse LV remodeling and to critically examine the available evidence for improvement of functional status and cardiovascular outcomes.

Transcatheter Mitral Valve Therapy: Defining the Patient Who Will Benefit

PURPOSE OF REVIEW

This report aims to define the clinical and anatomic variables key in determining patient suitability for transcatheter mitral valve therapies.

RECENT FINDINGS

Candidacy for transcatheter mitral valve repair requires weighing the clinical variables that may impact the ability to improve patient symptoms and prolong survival that include left ventricular ejection fraction, symptom severity, pulmonary hypertension, and magnitude of residual regurgitation or stenosis. Individualized selection of transcatheter repair or replacement based on patho-anatomy is being explored. The primary goal is achieving significant reduction in mitral regurgitation. Transcatheter mitral valve replacement requires rigorous anatomic screening using computed tomography and candidates should be able to take oral anticoagulation. Selection of patients for transcatheter mitral valve repair is complex and requires intimate knowledge of clinical variables and specific device limitations.

Invasive hemodynamics and cardiac biomarkers to predict outcomes after percutaneous edge-to-edge mitral valve repair in patients with severe heart failure

BACKGROUND

Percutaneous mitral valve repair (PMVR) via MitraClip implantation is a therapeutic option for high-risk or non-surgical candidates with severe mitral regurgitation (MR) and advanced stages of heart failure (HF). However, these patients have a high mortality despite PMVR, and predictors for outcomes are not well established. Here, we evaluated invasive hemodynamics, echocardiography parameters, and biomarkers to predict outcomes after PMVR in severe HF patients.

METHODS

Patients with reduced ejection fraction (EF) and severe and moderate-to-severe MR undergoing PMVR at our centre between September 2009 and January 2016 were analysed retrospectively. Inclusion criteria were: left ventricular EF < 45%, preoperative right heart catheterization, successful MitraClip deployment ("technical success"), and follow-up for at least 1 year after the procedure. Data from preoperative right heart catheterization, echocardiography, and biomarkers were assessed. Primary endpoint was all-cause mortality at 1 year after PMVR. We performed univariate and multivariate Cox regression analyses and generated a risk score to predict outcomes.

RESULTS

Of 174 patients with PMVR and severe HF, 79.9% had functional MR. Mean EF was 25% (17.2; 30.7) and advanced New York Heart Association functional class was prevalent (class II: 13%; class III: 70%; and class IV: 17%). The cumulative incidences of all-cause death were 6.9% and 17.8% at 30 days and 1 year, respectively. In the Cox multivariate model, high-sensitive troponin T [hsTnT; hazard ratio (HR) 1.01; confidence interval (CI) 1.01-1.02; p < 0.0001] and mixed venous O₂-saturation (HR 0.92; CI 0.89-0.96; p < 0.0001) were found to significantly and independently predict outcomes. A simple risk score including these two parameters was sufficient to discriminate between low- and high-risk patients (HR 7.22; CI 3.4-15.5; p < 0.001).

CONCLUSION

In a cohort of patients with severe HF undergoing PMVR, patients with elevated hsTnT and reduced mixed venous O₂-saturation carried the worst prognosis. A simple risk score including these two parameters may improve patient selection and outcomes after PMVR.

Predictors of mortality in ischaemic versus non-ischaemic functional mitral regurgitation after successful transcatheter mitral valve repair using MitraClip: results from two high-volume centres

INTRODUCTION

Transcatheter edge-to-edge mitral valve repair using the MitraClip has been widely performed in surgical high-risk patients with reduced left ventricular systolic function and severe functional mitral regurgitation (FMR). Ischaemic heart disease is the leading aetiology of heart disease worldwide. We aimed to assess the clinical implications of ischaemic aetiology in patients with severe FMR who underwent MitraClip implantation.

METHODS AND RESULTS

From two high-volume centres in Germany, we retrospectively compared the clinical outcomes and clinical predictors of all-cause mortality after MitraClip implantation in patients with ischaemic (I-FMR) and non-ischaemic FMR (NI-FMR). In the overall FMR cohort (n = 575), there were 336 (58%) patients with I-FMR and 239 (42%) with NI-FMR. There was no significant difference in survival between the two groups (log-rank p = 0.78). In a multivariable Cox regression analysis of all-cause mortality, different predictors were observed for either group. In I-FMR patients, decreasing tricuspid annular systolic excursion [adjusted hazard ratio (HR_adj) 1.06, 95% confidence interval (95% CI) 1.01-1.14 /1 mm, p = 0.028] and increasing logistic EuroSCORE (HR_adj 1.02, 95% CI 1.00-1.03, p = 0.037) were independent predictors, whereas in NI-FMR patients, NT-pro BNP (HR_adj 1.05, 95% CI 1.02-1.08, p = 0.001) and age (HR_adj 1.06, 95% CI 1.01-1.11, p = 0.013) were independently predictive of mortality.

CONCLUSIONS

Despite the similar survival between ischaemic and non-ischaemic FMR, different predictors of all-cause mortality were demonstrated. Further clinical studies are mandated to focus on each FMR subgroup with stratification by ischaemic origin.

Radiographic Review of Current Therapeutic and Monitoring Devices in the Chest

Chest radiographs are obtained as a standard part of clinical care. Rapid advancements in medical technology have resulted in a myriad of new medical devices, and familiarity with their imaging appearance is a critical yet increasingly difficult endeavor. Many modern thoracic medical devices are new renditions of old designs and are often smaller than older versions. In addition, multiple device designs serving the same purpose may have varying morphologies and positions within the chest. The radiologist must be able to recognize and correctly identify the proper positioning of state-of-the-art medical devices and identify any potential complications that could impact patient care and management. To familiarize radiologists with the arsenal of newer thoracic medical devices, this review describes the indications, radiologic appearance, complications, and magnetic resonance imaging safety of each device. ^©RSNA, 2018.

Transcatheter Mitral Valve Repair Using the Edge-to-Edge Clip

Percutaneous intervention for mitral valve (MV) disease has been established as an alternative to open surgical MV repair in patients with prohibitive surgical risk. Multiple percutaneous approaches have been described and are in various stages of development. Edge-to-edge leaflet plication with the MitraClip (Abbott, Menlo Park, CA) is currently the only Food and Drug Administration-approved device specifically for primary or degenerative lesions. Use of the edge-to-edge clip for secondary mitral regurgitation is currently under investigation and may result in expanded indications. Echocardiography has significantly increased our understanding of the anatomy of the MV and provided us with the ability to classify and quantify the associated mitral regurgitation. For percutaneous interventions of the MV, transesophageal echocardiography imaging is used for patient screening, intraprocedural guidance, and confirmation of the result. Optimal outcomes require the echocardiographer and the proceduralist to have a thorough understanding of intra-atrial septal and MV anatomy, as well as an appreciation for the key points and potential pitfalls of each of the procedural steps. With increasing experience, more complex valvular pathology can be successfully percutaneously treated. In addition to two-dimensional echocardiography, advances in three-dimensional echocardiography and fusion imaging will continue to support the refinement of current technologies, the expansion of clinical applications, and the development of novel devices.

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

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.

3D vena contracta area after MitraClip© procedure: precise quantification of residual mitral regurgitation and identification of prognostic information

BACKGROUND

Percutaneous mitral valve repair (PMVR) is increasingly performed in patients with severe mitral regurgitation (MR). Post-procedural MR grading is challenging and an unsettled issue. We hypothesised that the direct planimetry of vena contracta area (VCA) by 3D-transoesophageal echocardiography allows quantifying post-procedural MR and implies further prognostic relevance missed by the usual ordinal scale (grade I-IV).

METHODS

Based on a single-centre PMVR registry containing 102 patients, the association of VCA reduction and patients' functional capacity measured as six-minute walk distance (6 MW) was evaluated. 3D-colour-Doppler datasets were available before, during and 4 weeks after PMVR.

RESULTS

Twenty nine patients (age 77.0 ± 5.8 years) with advanced heart failure (75.9% NYHA III/IV) and severe degenerative (34%) or functional (66%) MR were eligible. VCA was reduced in all patients by PMVR (0.99 ± 0.46 cm² vs. 0.22 ± 0.15 cm², p < 0.0001). It remained stable after median time of 33 days (p = 0.999). 6 MW improved after the procedure (257.5 ± 82.5 m vs. 295.7 ± 96.3 m, p < 0.01). Patients with a decrease in VCA less than the median VCA reduction showed a more distinct improvement in 6 MW than patients with better technical result (p < 0.05). This paradoxical finding was driven by inferior results in very large functional MR.

CONCLUSIONS

VCA improves the evaluation of small residual MR. Its post-procedural values remain stable during a short-term follow-up and imply prognostic information for the patients' physical improvement. VCA might contribute to a more substantiated estimation of treatment success in the heterogeneous functional MR group.

Role of Echocardiography in Transcatheter Valvular Heart Disease Interventions

PURPOSE OF REVIEW

Transcatheter valvular interventions have increased in importance and utility for surgical valve repair and replacement. Cardiac imaging is the most crucial aspect of procedural planning and guidance. Echocardiography is a widely used, portable, and dynamic imaging modality used for many of these interventions. This review will summarize the role echocardiography in structural heart valvular interventions.

RECENT FINDINGS

Intraprocedural echocardiographic guidance has been a mainstay of structural heart interventions. Over the years, the use of 3-dimensional echocardiography has increased, and studies have shown utility in paravalvular leak prediction in the setting of transcatheter aortic valve replacement, procedural guidance in MitraClip repair, and in mitral and tricuspid valve therapies. Intraprocedural echocardiography is of paramount important for procedural success during all structural heart valvular interventions. Continued use of 2 and 3-dimensional echocardiography will be a major factor in driving the innovative field of structural heart interventions forward.