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Nunes MCP, Levine RA, Braulio R, Pascoal-Xavier MA, Elmariah S, Gomes NFA, Soares JR, Esteves WAM, Zeng X, Dal-Bianco JP, Passos LSA, Passaglia LG, Ribeiro VT, Gelape CL, Costa PHN, Lodi-Junqueira L, Dutra W, Tan TC, Aikawa E, Hung J. Mitral Regurgitation After Percutaneous Mitral Valvuloplasty: Insights Into Mechanisms and Impact on Clinical Outcomes. JACC Cardiovasc Imaging 2020; 13:2513-2526. [PMID: 32950446 DOI: 10.1016/j.jcmg.2020.07.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 07/13/2020] [Accepted: 07/23/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES The aim of this study was to assess the incidence, mechanisms, and outcomes of mitral regurgitation (MR) after percutaneous mitral valvuloplasty (PMV). BACKGROUND Significant MR continues to be a major complication of PMV, with a wide range in clinical presentation and prognosis. METHODS Consecutive patients with mitral stenosis undergoing PMV were prospectively enrolled. MR severity was evaluated by using quantitative echocardiographic criteria, and its mechanism was characterized by 3-dimensional transesophageal echocardiography, divided broadly into 4 categories based on the features contributing to the valve damage. B-type natriuretic peptide levels were obtained before and 24 h after the procedure. Endpoints estimated cardiovascular death or mitral valve (MV) replacement due to predominant MR. RESULTS A total of 344 patients, ages 45.1 ± 12.1 years, of whom 293 (85%) were women, were enrolled. Significant MR after PMV was found in 64 patients (18.6%). The most frequent mechanism of MR was commissural, which occurred in 22 (34.4%) patients, followed by commissural with posterior leaflet in 16 (25.0%), leaflets at central scallop or subvalvular damage in 15 (23.4%), and central MR in 11 (17.2%). During the mean follow-up period of 3 years (range 1 day to 10.6 years), 60 patients reached the endpoint. The event-free survival rates were similar among patients with mild or commissural MR, whereas patients with damaged central leaflet scallop or subvalvular apparatus had the worst outcome, with an event-free survival rate at 1 year of only 7%. Long-term outcome was predicted by net atrioventricular compliance (Cn) at baseline and post-procedural variables, including valve area, mean gradient, and magnitude of decrease in B-type natriuretic peptide levels, adjusted for the mechanism of MR. CONCLUSIONS Significant MR following PMV is a frequent event, mainly related to commissural splitting, with favorable clinical outcome. Parameters that express the relief of valve obstruction and the mechanism by which MR develops were predictors of long-term outcomes.
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Affiliation(s)
- Maria Carmo P Nunes
- Hospital das Clinicas, School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
| | - Robert A Levine
- Cardiac Ultrasound Lab, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Renato Braulio
- Hospital das Clinicas, School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Marcelo A Pascoal-Xavier
- Laboratory of Molecular Pathology, Department of Pathological Anatomy and Legal Medicine, School of Medicine of the Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Sammy Elmariah
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nayana F A Gomes
- Hospital das Clinicas, School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil; Laboratory of Molecular Pathology, Department of Pathological Anatomy and Legal Medicine, School of Medicine of the Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Juliana R Soares
- Hospital das Clinicas, School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - William A M Esteves
- Hospital das Clinicas, School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Xin Zeng
- Cardiac Ultrasound Lab, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jacob P Dal-Bianco
- Cardiac Ultrasound Lab, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Livia S A Passos
- Department of Morphology, Institute of Biological Sciences, Federal University of Minas Gerais, and National Institutes for Science and Technology, Belo Horizonte, Minas Gerais, Brazil; The Center for Excellence in Vascular Biology, Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Luiz G Passaglia
- Hospital das Clinicas, School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Victor T Ribeiro
- Hospital das Clinicas, School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Cláudio L Gelape
- Hospital das Clinicas, School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Paulo H N Costa
- Hospital das Clinicas, School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Lucas Lodi-Junqueira
- Hospital das Clinicas, School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Walderez Dutra
- Department of Morphology, Institute of Biological Sciences, Federal University of Minas Gerais, and National Institutes for Science and Technology, Belo Horizonte, Minas Gerais, Brazil
| | - Timothy C Tan
- Department of Cardiology, Blacktown Hospital, University of Western Sydney, New South Wales, Australia
| | - Elena Aikawa
- The Center for Excellence in Vascular Biology, Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Judy Hung
- Cardiac Ultrasound Lab, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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