Early Surgery Versus Conventional Treatment for Asymptomatic Severe Mitral Regurgitation

Risks factors of adverse clinical outcomes in asymptomatic mitral regurgitation patients with preserved ejection fraction: a systematic review and meta-analysis

INTRODUCTION AND OBJECTIVE

Indication for mitral valve (MV) surgery in asymptomatic mitral regurgitation (MR) patients with preserved ejection fraction (EF) remains unclear. This study aims to identify risk factors of adverse clinical outcomes in asymptomatic MR patients with preserved EF for early indication of MV surgery.

METHODS

3 databases were systematically searched to include studies with asymptomatic MR patients with preserved EF. Risk factors of adverse clinical outcomes (composite outcome of MACE and MV surgery indication), mortality, and left ventricular dysfunction (LVD) are pooled with a meta-analysis of random effect model.

RESULTS

A total of 39 observational studies with 9135 asymptomatic moderate to severe MR patients are included. We identified 21 statistically significant risk factors for adverse outcomes. Increased natriuretic peptide, presence of atrial fibrillation, LV GLS > 20%, LVEDD > 35 mm, LVESD > 22 mm, and LAVI > 55 ml/mm2, ERO > 55mm2, and regurgitation volume > 60 ml (HR 2.21, 2.07, 4.23, 2.98, 4.05, 1.84, 4.02, 3.30, respectively; p-value < 0.05; I2 0-87%) are associated with greater risk of adverse clinical outcome. Risk factors associated with postoperative LVD are the increase of LVEDD, LVESD, and RVSP. Risk factors associated with mortality are increasing STS score and LV GLS.

CONCLUSION

Several clinical parameters and risk factors can be used to stratify asymptomatic MR patients with preserved ejection fraction who could benefit from early indication for MV surgery.

The Role of Global Longitudinal Strain in the Follow-Up of Asymptomatic Patients with Chronic Primary Mitral Regurgitation

Background/Objectives: In patients with chronic primary mitral regurgitation (MR), postoperative persistent left ventricular (LV) dysfunction underlines the lack of a sensitive parameter that can identify subclinical LV dysfunction and optimize the timing of intervention. Left ventricular global longitudinal strain (LV-GLS) is a measure of the longitudinal left ventricular systolic function, with prognostic significance. Its role in the follow-up of asymptomatic patients with MR is, however, poorly defined. The aim of this study was to assess the relative changes in LV-GLS in a cohort of MR patients and to correlate these changes with the need for intervention during a follow-up period. Methods: We conducted a prospective study on a cohort of 218 patients, divided into three subgroups according to MR severity (mild, moderate, severe). LV-GLS was measured at baseline and every six months during a median follow-up period of 30 months. The composite endpoint was the occurrence of heart failure symptoms, hospitalization for heart failure, LVEF < 60%, LVEDD > 45 mm, new onset atrial fibrillation, or cardiovascular death. Results: Patients with moderate and severe MR had a significantly lower GLS at baseline than those with mild MR (19.5% and 19.1% versus 22.3%, p < 0.01) despite a normal LVEF in all subgroups. The relative decrease in LV-GLS occurred earlier (at 12 months vs. 24 months) and was more evident in patients with moderate and severe MR (13.6% and 14.5%, respectively) versus patients with mild MR (6.72%). The baseline LV-GLS being under 18% and a relative decrease of over 10% in GLS were independent predictors of a composite outcome (HR = 1.59, CI 95% 1.17-2.86; HR = 1.74, CI 95% 1.2-2.91, p < 0.01). Conclusions: LV-GLS is a valuable monitoring tool for asymptomatic MR patients, a relative decrease > 10% in GLS may be predictive for the need for valve intervention.

Pulmonary arterial compliance as a measure of right ventricular loading in mitral regurgitation

Pulmonary hypertension (PH) is a common and prognostically important complication of mitral regurgitation (MR). Mean pulmonary arterial pressure (mPAP) and pulmonary vascular resistance (PVR) are traditionally used to diagnose PH, however these indices measure static rather than pulsatile load, leading to an incomplete representation of pulmonary vascular load on the right ventricle (RV). Pulmonary arterial compliance (PAC) is one method for quantifying pulsatile load, and is both a stronger predictor of prognosis in left heart failure, as well as a more sensitive measure of early pulmonary vascular dysfunction than PVR. With the expansion of transcatheter mitral and tricuspid valve therapies, there is renewed interest to more accurately define the load imposed by the pulmonary vasculature on the RV, especially in the early phase, prior to the onset of chronic PH. This review discusses the pathophysiology of pH in left heart failure and MR, the utility of PAC as a measure of RV afterload, and its calculation for clinical use and interpretation, underlining the utility of PAC as an adjunct for assessing pulmonary vascular haemodynamics.

Prevalence of asymptomatic valvular heart disease in the elderly population: a community-based echocardiographic study

AIMS

With an ageing population, the presence of asymptomatic valvular heart disease (VHD) in the community remains unknown. The aim of this study is to determine the prevalence and associated factors of asymptomatic VHD in individuals ≥60 years old and to evaluate the feasibility of echocardiographic screening for VHD in this population.

METHODS AND RESULTS

This was a prospective cohort study conducted between 2007 and 2016 in the UK. Asymptomatic patients with no prior indication for echocardiography were invited to participate and evaluated with a health questionnaire, clinical examination, and transthoracic echocardiography. A total of 10,000 individuals were invited through their general practices. A total of 5429 volunteered to participate, of whom 4237 were eligible for inclusion. VHD was diagnosed in more than a quarter of patients (28.2%). The most common types of VHD were regurgitation of the tricuspid (13.8%), mitral (12.8%), and aortic (8.3%) valves (trivial regurgitation was not included). The rate of prevalence of clinically significant VHD was 2.4% (2.2% moderate and 0.2% severe), with mitral and aortic regurgitation being the most common. The only parameter associated with significant VHD was age (odds ratio 1.07 per 1 year increment, 95% confidence interval 1.05-1.09, P < 0.001). The number needed to scan to diagnose one clinically significant case of VHD is 42 for individuals ≥60 and 15 for those ≥75 years old.

CONCLUSION

Asymptomatic VHD is present in a significant proportion of otherwise healthy individuals without known VHD over 60 years old. Age is strongly associated with an increased incidence of significant VHD.

Degenerative mitral regurgitation due to flail leaflet: sex-related differences in presentation, management, and outcomes

BACKGROUND AND AIMS

Presentation, outcome, and management of females with degenerative mitral regurgitation (DMR) are undefined. We analysed sex-specific baseline clinical and echocardiographic characteristics at referral for DMR due to flail leaflets and subsequent management and outcomes.

METHODS

In the Mitral Regurgitation International Database (MIDA) international registry, females were compared with males regarding presentation at referral, management, and outcome (survival/heart failure), under medical treatment, post-operatively, and encompassing all follow-up.

RESULTS

At referral, females (n = 650) vs. males (n = 1660) were older with more severe symptoms and higher MIDA score. Smaller cavity diameters belied higher cardiac dimension indexed to body surface area. Under conservative management, excess mortality vs. expected was observed in males [standardized mortality ratio (SMR) 1.45 (1.27-1.65), P < .001] but was higher in females [SMR 2.00 (1.67-2.38), P < .001]. Female sex was independently associated with mortality [adjusted hazard ratio (HR) 1.29 (1.04-1.61), P = .02], cardiovascular mortality [adjusted HR 1.58 (1.14-2.18), P = .007], and heart failure [adjusted HR 1.36 (1.02-1.81), P = .04] under medical management. Females vs. males were less offered surgical correction (72% vs. 80%, P < .001); however, surgical outcome, adjusted for more severe presentation in females, was similar (P ≥ .09). Ultimately, overall outcome throughout follow-up was worse in females who displayed persistent excess mortality vs. expected [SMR 1.31 (1.16-1.47), P < .001], whereas males enjoyed normal life expectancy restoration [SMR 0.92 (0.85-0.99), P = .036].

CONCLUSIONS

Females with severe DMR were referred to tertiary centers at a more advanced stage, incurred higher mortality and morbidity under conservative management, and were offered surgery less and later after referral. Ultimately, these sex-related differences yielded persistent excess mortality despite surgery in females with DMR, while males enjoyed restoration of life expectancy, warranting imperative re-evaluation of sex-specific DMR management.

2023 Korean Society of Echocardiography position paper for the diagnosis and management of valvular heart disease, part II: mitral and tricuspid valve disease

This manuscript represents the official position of the Korean Society of Echocardiography on valvular heart diseases. This position paper focuses on the diagnosis and management of valvular heart diseases with referring to the guidelines recently published by the American College of Cardiology/American Heart Association and the European Society of Cardiology. The committee sought to reflect national data on the topic of valvular heart diseases published to date through a systematic literature search based on validity and relevance. In the part II of this article, we intend to present recommendations for diagnosis and treatment of mitral valve disease and tricuspid valve disease.

Comparison of maternal and fetal outcomes in mothers with non-congenital mitral valve stenosis and healthy control

Background

Physiological changes during pregnancy cause complications in mothers with mitral stenosis and their infants. This study was designed to assess maternal and fetal pregnancy outcomes in women with rheumatic mitral valve stenosis and compare them with the control group.

Materials and methods

This study is a case-control study on 153 pregnant women, including 51 with mitral stenosis (MS) and 102 without MS as the control group, between 2007-2022. For each studied patient, two control participants were selected and matched in residence, age, and year of pregnancy. SPSS version 22 was used for data analysis.

Results

The mean age was 31.7 ± 4.6 years in cases and 31.6 ± 4.7 in the healthy controls. Demographic variables were not significantly different between the case and control groups. The rate of stillbirth (5.9% vs. 0.0%), %), NICU admission (13.7% vs. 2.0%), and IUGR (5.9% vs. 0.0%) were higher in the fetal case group compared with the control group. On the other hand, maternal outcomes, including pulmonary edema (13.7% vs. 0.0%), ICU admission (23.5% vs. 0.0%), limb edema (15.7% vs. 0.0%), dyspnea (37.3% vs. 0.0%), pulmonary hypertension (9.8% vs. 0.0%), palpitations (21.1% vs. 0.0%) and hospital admission during pregnancy (37.2% vs. 4.9%) were statistically more common in the case groups.

Conclusions

Pregnancy is associated with significant fetomaternal morbidities in women with mitral valve heart disease. So they need a multidisciplinary approach in preconception and antenatal care.

Degenerative Mitral Regurgitation Outcomes in Asian Compared With European-American Institutions

Background

Clinical outcome and interventional thresholds for degenerative mitral regurgitation (DMR) were developed in studies of patients at European and American institutions (EAIs), but little is known about patients at Asian institutions (AsIs).

Objectives

This study sought to contrast DMR presentation/management/outcomes of AsI patients vs EAI patients.

Methods

Patients with DMR due to flail leaflet from Hong Kong and Singapore (AsI cohort, n = 737) were compared with EAI patients (n = 682) enrolled in the MIDA (Mitral regurgitation International Database) registry with similar eligibility criteria.

Results

AsI patients presented similar DMR lesion/consequences vs EAI patients, but they were younger, with fewer symptoms (74% vs 44% Class I), more sinus rhythm (83% vs 69%), and lower EuroSCORE II (European System for Cardiac Operative Risk Evaluation II) (0.9 ± 0.5 vs 1.4 ± 1.5; all P < 0.0001). Imaging showed smaller absolute left atrial/ventricular dimensions in AsI patients, belying cardiac dilatation with larger body surface area-indexed diameters (all P < 0.01). Surgical/interventional mitral repair was similarly predominant (90% vs 91%; P = 0.47), and early repair was similarly beneficial (for AsI patients, adjusted HR: 0.28; 95% CI: 0.16-0.49; for EAI patients, HR: 0.32; 95% CI: 0.20-0.49; both P < 0.0001). However, AsI patients underwent fewer interventions (55% ± 2% vs 77% ± 2% at 1 year; P < 0.0001) and incurred excess mortality (adjusted HR: 1.60 [95% CI: 1.13-2.27] vs EAI patients; P = 0.008) at long-term postdiagnosis. Propensity score matching (434 patient pairs), which balanced all clinical characteristics, confirmed that there was undertreatment and excess mortality in the long term in AsI patients with DMR (P < 0.0001).

Conclusions

Imaging may underestimate volume overload in AsI patients due to smaller cardiac cavities related to smaller body size compared with EAI patients with similar mitral lesions and DMR severity. AsI patients enjoy similar mitral repair predominance and early intervention benefits but undergo fewer mitral interventions than EAI patients and incur subsequent excess mortality, suggesting the need to account for imaging and cultural specificity to improve DMR outcomes worldwide.

Degenerative mitral regurgitation

Degenerative mitral regurgitation is a major threat to public health and affects at least 24 million people worldwide, with an estimated 0.88 million disability-adjusted life years and 34,000 deaths in 2019. Improving access to diagnostic testing and to timely curative therapies such as surgical mitral valve repair will improve the outcomes of many individuals. Imaging such as echocardiography and cardiac magnetic resonance allow accurate diagnosis and have provided new insights for a better definition of the most appropriate timing for intervention. Advances in surgical techniques allow minimally invasive treatment with durable results that last for ≥20 years. Transcatheter therapies can provide good results in select patients who are considered high risk for surgery and have a suitable anatomy; the durability of such repairs is up to 5 years. Translational science has provided new knowledge on the pathophysiology of degenerative mitral regurgitation and may pave the road to the development of medical therapies that could be used to halt the progression of the disease.

Mitral Repair vs Replacement for Degenerative Mitral Regurgitation in Patients Aged ≥65 Years

BACKGROUND

The benefits of mitral valve repair vs replacement are well documented. However, survival benefits in the elderly population are more controversial. In this novel lifetime analysis, we hypothesize that survival benefits for valve repair vs replacement in the elderly are sustained throughout the patient's lifetime.

METHODS

From January 1985 through December 2005, 663 patients, aged ≥65 years with myxomatous degenerative mitral valve disease underwent primary isolated mitral valve repair (n = 434) or replacement (n = 229). Propensity score matching was used to balance variables potentially related to outcome.

RESULTS

Follow-up was complete in 99.1% of mitral repair and 99.6% of mitral replacement patients. In matched patients, perioperative mortality was 3.9% (9 of 229) for repair and 10.9% (25 of 229) for replacement (P = .004). Survival estimates (95% confidence limits) from 29-year follow-up for matched patients were 54.6% (48.0%, 61.1%) and 11.0% (6.8%, 15.2%) at 10 years and 20 years for repair patients, and 34.2% (27.7%, 40.7%) and 3.7% (1%, 6.4%) for replacement patients, respectively. Median survival (95% confidence limits) was 11.3 years (9.6, 12.2 years) for repair patients compared with 6.9 years (6.3, 8.0 years) for replacement patients (P < .001).

CONCLUSIONS

This study demonstrates that although the elderly population is prone to multiple comorbidities, survival benefits of isolated mitral valve repair vs replacement are sustained throughout the patient's lifetime.

Predictability and durability of mitral valve repair in patients with severe degenerative mitral regurgitation in medium sized centres

INTRODUCTION

Mitral valve repair (MVr) is now the treatment of choice to correct severe degenerative mitral regurgitation (MR). Repair rates vary greatly from centre to centre, and the concept of heart valve centres of excellence has been established.

OBJECTIVE

The purpose of this study was to see whether large international centre repair rates, and outcomes, are transferrable to medium-sized centres with an interest in mitral repair.

METHODS

Between 2011 and 2018, a total of 346 patients underwent mitral valve surgery by a single surgeon. Of these, 238 consecutive patients had repairs, or attempted repairs for degenerative MR, and are included in this study.

RESULTS

The study sample consisted of 71% male patients and had a mean age of 64.4 ± 12.3 years; 66% of the study population had concomitant procedures. The overall repair rate in this cohort is 99%. Mean follow up was 3.7 ± 1.9 years. At 5 years, the freedom from MR ≥ 3+ was 95.9 ± 1.9% and at 7 years 91.1 ± 3.8%. Freedom from reoperation at 5 years was 92.9 ± 3.7%, while the 5 years actuarial survival was 89.1 ± 3.7%. On a multivariate analysis, predischarge echo grade was associated with higher risk of future reoperation (odds ratio (OR) = 21.82, p = 0.05). Only age (OR = 1.3, p = 0.03) was predictive of long-term survival.

CONCLUSIONS

In specialised medium-sized heart centres, where the surgical team have undergone specialist mitral training, favourable short- and long-term outcomes are achievable with mitral repair rates similar to those from large international centres of excellence. In these heart centres, early surgery should be considered for all patients with severe degenerative MR.

Clinical significance of myocardial contraction fraction in significant primary mitral regurgitation

BACKGROUND

The optimal timing for mitral valve (MV) surgery in asymptomatic patients with primary mitral regurgitation (MR) remains a matter of debate. Myocardial contraction fraction (MCF) - the ratio of the left ventricular (LV) stroke volume to that of the myocardial volume - is a volumetric measure of LV myocardial shortening independent of size or geometry.

AIM

To assess the relationship between MCF and outcome in patients with significant chronic primary MR due to prolapse managed in contemporary practice.

METHODS

Clinical, Doppler-echocardiographic and outcome data prospectively collected in 174 patients (mean age 62 years, 27% women) with significant primary MR and no or mild symptoms were analysed. The impact of MCF< or ≥30% on cardiac events (cardiovascular death, acute heart failure or MV surgery) was studied.

RESULTS

During an estimated median follow-up of 49 (22-77) months, cardiac events occurred in 115 (66%) patients. The 4-year estimates of survival free from cardiac events were 21±5% for patients with MCF <30% and 40±6% for those with ≥30% (P<0.001). MCF <30% was associated with a considerable increased risk of cardiac events after adjustment for established clinical risk factors, MR severity and current recommended class I triggers for MV surgery (adjusted hazard ratio: 2.33, 95% confidence interval: 1.51-3.58; P<0.001). Moreover, MCF<30% improved the predictive performance of models, with better global fit, reclassification and discrimination.

CONCLUSIONS

MCF<30% is strongly associated with occurrence of cardiac events in patients with significant primary MR due to prolapse. Further studies are needed to assess the direct impact of MCF on patient management and outcomes.

Prognostic value of forward flow indices in primary mitral regurgitation due to mitral valve prolapse

Background

Degenerative mitral regurgitation (DMR) due to mitral valve prolapse (MVP) is a common valve disease associated with significant morbidity and mortality. Timing for surgery is debated for asymptomatic patients without Class I indication, prompting the search for novel parameters of early left ventricular (LV) systolic dysfunction.

Aims

To evaluate the prognostic impact of preoperative forward flow indices on the occurrence of post-operative LV systolic dysfunction.

Methods

We retrospectively included all consecutive patients with severe DMR due to MVP who underwent mitral valve repair between 2014 and 2019. LVOTTVI, forward stroke volume index, and forward LVEF were assessed as potential risk factors for LVEF <50% at 6 months post-operatively.

Results

A total of 198 patients were included: 154 patients (78%) were asymptomatic, and 46 patients (23%) had hypertension. The mean preoperative LVEF was 69 ± 9%. 35 patients (18%) had LVEF ≤ 60%, and 61 patients (31%) had LVESD ≥40 mm. The mean post-operative LVEF was 59 ± 9%, and 21 patients (11%) had post-operative LVEF<50%. Based on multivariable analysis, LVOTTVI was the strongest independent predictor of post-operative LV dysfunction after adjustment for age, sex, symptoms, LVEF, LV end systolic diameter, atrial fibrillation and left atrial volume index (0.75 [0.62-0.91], p < 0.01). The best sensitivity (81%) and specificity (63%) was obtained with LVOTTVI ≤15 cm based on ROC curve analysis.

Conclusion

LVOTTVI represents an independent marker of myocardial performance impairment in the presence of severe DMR. LVOTTVI could be an earlier marker than traditional echo parameters and aids in the optimization of the timing of surgery.

Research Opportunities in the Treatment of Mitral Valve Prolapse: JACC Expert Panel

In light of the adverse prognosis related to severe mitral regurgitation, heart failure, or sudden cardiac death in a subset of patients with mitral valve prolapse (MVP), identifying those at higher risk is key. For the first time in decades, researchers have the means to rapidly advance discovery in the field of MVP thanks to state-of-the-art imaging techniques, novel omics methodologies, and the potential for large-scale collaborations using web-based platforms. The National Heart, Lung, and Blood Institute recently initiated a webinar-based workshop to identify contemporary research opportunities in the treatment of MVP. This report summarizes 3 specific areas in the treatment of MVP that were the focus of the workshop: 1) improving management of degenerative mitral regurgitation and associated left ventricular systolic dysfunction; 2) preventing sudden cardiac death in MVP; and 3) understanding the mechanisms and progression of MVP through genetic studies and small and large animal models, with the potential of developing medical therapies.

Significance of Left Ventricular Ejection Time in Primary Mitral Regurgitation

The optimal timing for mitral valve (MV) surgery in asymptomatic patients with primary mitral regurgitation (MR) remains controversial. We aimed at evaluating the relation between left ventricular ejection time (LVET) and outcome in patients with moderate or severe chronic primary MR because of prolapse. Clinical, Doppler echocardiographic, and outcome data prospectively collected from 302 patients (median age 61 [54 to 74] years, 34% women) with moderate or severe primary MR were analyzed. Patients were retrospectively stratified by quartiles of LVET. The primary end point of the study was the composite of need for MV surgery or all-cause mortality. During a median follow-up time of 66 (25th to 75th percentile, 33 to 95) months, 178 patients reached the primary end point. Patients in the lowest quartile of LVET (<260 ms) were at high risk for adverse events compared with those in the other quartiles of LVET (global p = 0.005), whereas the rate of events was similar for the other quartiles (p = NS for all). After adjustment for clinical predictors of outcome, including age, gender, history of atrial fibrillation, MR severity, and current recommended triggers for MV surgery in asymptomatic primary MR, LVET <260 ms was associated with an increased risk of events (adjusted hazard ratio 1.49, 95% confidence interval 1.03 to 2.16, p = 0.033). In conclusion, we observed that shorter LVET is associated with increased risk of adverse events in patients with moderate or severe primary MR because of prolapse. Further studies are required to investigate whether shorter LVET has a direct effect on outcomes or is solely a risk marker in primary MR.

Cardiac Damage Staging Classification in Asymptomatic Moderate or Severe Primary Mitral Regurgitation

Background

Optimal timing for intervention remains uncertain in asymptomatic patients with primary mitral regurgitation (MR). We aimed to assess the prognostic value of a new cardiac damage staging classification in patients with asymptomatic moderate or severe primary MR.

Methods

Clinical, Doppler-echocardiographic, and outcome data prospectively collected in 338 asymptomatic patients (64 ± 15 years, 68% men) with at least moderate primary MR were retrospectively analyzed. Patients were hierarchically classified as per the following staging classification: no cardiac damage (stage 0), mild left ventricular or left atrial damage (stage 1), moderate or severe left ventricular or left atrial damage (stage 2), pulmonary vasculature or tricuspid valve damage (stage 3), or right ventricular damage (stage 4).

Results

There was a stepwise increase in 10-year mortality rates as per cardiac damage stage: 20.0% in stage 0, 25.6% in stage 1, 31.5% in stage 2, and 61.3% in stage 3-4 (p < 0.001). The staging classification was significantly associated with increased risk of mortality (hazard ratio = 1.41 per one-stage increase, 95% confidence interval: 1.07-1.85, p = 0.015) and the composite of cardiovascular mortality or hospitalization (hazard ratio = 1.51 per one-stage increase, 95% confidence interval: 1.07-2.15, p = 0.020) in multivariable analysis adjusted for EuroSCORE II, mitral valve intervention as a time-dependent variable, and other risk factors. The proposed scheme showed incremental value over several clinical variables (net reclassification index = 0.40, p = 0.03).

Conclusions

The new staging classification provides independent and incremental prognostic value in patients with asymptomatic moderate or severe MR.

Relation of Guideline Adherence to Outcomes in Patients With Asymptomatic Severe Primary Mitral Regurgitation

Current guidelines empirically recommend serial clinical evaluations for asymptomatic patients with severe mitral regurgitation (MR). However, there is a paucity of data on the effectiveness of such monitoring. This study sought to examine the potential benefit of guideline adherence among asymptomatic patients with severe primary MR. Asymptomatic patients with severe primary MR who had been evaluated in the Allina Health system between January 1, 2012 and May 30, 2018 were examined. The medical records were manually reviewed for demographics, comorbidities, echocardiographic data, subsequent interventions, and clinical outcomes. Patients were grouped according to occurrence of guideline adherence, which was defined as a serial clinical evaluation with echocardiography every 12 ± 1 month until mitral valve surgery, or death. Over the study period, 246 patients (67.3 ± 15.5 years, 61.4% men) with severe, asymptomatic primary MR were identified, including 154 patients (62.6%) with and 92 patients (37.4%) without guideline adherence. Overall, there were no differences in demographics, morbidities, MR severity, or left ventricular function between patient adherence groups. During follow-up (40.9; 21.2, 58.3 months), patients with adherence more frequently had surgery or transcatheter therapy performed (64.3% vs 18.5%; p <0.001) and the time to intervention was earlier (13.6 [3.9-22.7] vs 44.2[25.6-57.3] months; p <0.001). Compared to non-adherent patients, those with guideline adherence had a significantly higher five-year survival free from all-cause mortality (92.0% vs 74.3%, p = 0.002), and freedom from death or hospitalization for heart failure (90.1% vs 69.3%, p = 0.001). Adherent patients also had a significantly better survival free from combined endpoint of death, re-hospitalization for heart failure, myocardial infarction, and stroke (84.5% vs 63.2%, p = 0.002). In patients with asymptomatic severe primary MR, guideline adherence with serial evaluations every 12 months or less is associated with earlier therapy and improved long-term outcomes. These data support educational efforts to promote guideline adherence.

Mitral valve repair in chronic severe mitral regurgitation: short-term results and analysis of mortality predictors

Introduction

Mitral valve repair is the accepted treatment for mitral regurgitation (MR) but lack of resources and socioeconomic concerns delay surgical referral and intervention in developing countries. We evaluated immediate and short-term results of mitral valve repair for non-ischemic MR at our centre and aimed to identify the predictors of in-hospital and follow-up mortality.

Materials and methods

The study was conducted at a tertiary-level hospital in South India. All patients >18 years with severe non-ischemic MR who underwent mitral valve repair over a period of 6 years were included. Perioperative data was collected from hospital records and follow-up data was obtained by prospective methods.

Results

There were 244 patients (170 males). Most of the patients were in the age group 31-60 years (76.6%). Aetiology of MR was degenerative (n = 159; 65.2%), rheumatic (n = 34; 13.9%), structural (n = 42; 17.2%), or miscellaneous (n = 9; 3.7%). All patients underwent ring annuloplasty with various valve repair techniques. One hundred patients (44.7%) underwent additional cardiac procedures. At discharge, MR was moderate in 4 patients; the rest had no or mild MR. The mean hospital stay of survivors was 7.1 days (SD 2.52, range 5-25 days). There were 9 in-hospital deaths (3.68%) and 10 deaths during follow-up (4.2%). The mean follow-up period was 1.39 years, complete for 87.6%. Pre-operative left ventricle ejection fraction (LVEF) <60% (p = 0.04) was found to be significantly associated with immediate mortality. Logistic regression analysis detected age (p = 0.019), female sex (p = 0.015), and left ventricular (LV) dysfunction at discharge (p = 0.025) to be significantly associated with follow-up mortality.

Conclusion

Pre-operative LV dysfunction was identified as a significant risk factor for in-hospital mortality. Female sex, age greater than 45 years, and LV dysfunction at discharge were found to be significantly associated with follow-up mortality. Hence, it is important to perform mitral valve repair in severe regurgitation patients before significant LV dysfunction sets in for a better outcome.

Surgical and percutaneous management of Aboriginal Australians with rheumatic heart disease: Timeliness and concordance between practice and guidelines

BACKGROUND

Rheumatic heart disease (RHD) affects over 40 million people globally who are predominantly young and from impoverished communities. The barriers to valvular intervention are complex and contribute to the high morbidity and mortality associated with RHD. The rates of guideline indicated intervention in patients with significant RHD have not yet been reported.

METHODS

From 2007 to 2017, we used the Australian Northern Territory Cardiac Database to identify patients with RHD who fulfilled at least one ESC/EACTS guideline indication for mitral valve intervention. Baseline clinical status, comorbidities, echocardiographic parameters, indication for intervention, referral and any interventions were recorded.

RESULTS

154 patients (mean age 38.5 ± 14.6, 66.1% female) were identified as having a class I or IIa indication for invasive management. Symptoms, atrial fibrillation and pulmonary hypertension were the most common indications for surgery (74.5%, 48.1%, 40.9%). From the onset of a guideline indication the actuarial rates of accepted referral and intervention within two-years were 66.0% ± 4.0% and 53.1% ± 4.4% respectively. Of those who were referred and accepted for intervention, 86% received it within 2 years. The rates of accepted referral for patients with class I indications were 72.5% ± 4.2% while class IIa indications were 42.5% ± 9.0% (p<0.001).

CONCLUSIONS

Approximately half of Aboriginal patients with significant rheumatic mitral valve disease who met ESC/EACTS guideline indications for intervention received surgery or valvuloplasty within two-years. A significant difference in referral rates was found between Class I and Class IIa indications for valvular intervention.

Clinical Outcomes after Mitral Valve Repair with the Physio II Annuloplasty Ring

BACKGROUND

 Mitral valve (MV) repair with annuloplasty is the standard of care in patients with primary degenerative mitral regurgitation (DMR). Newer generations of annuloplasty rings have been developed with the goals of closer reproduction of native annular geometry and easier implantation. This study investigates the short-term and 5-year clinical outcomes of MV repair with the Carpentier-Edwards (CE) Physio II annuloplasty ring.

METHODS

 This is an observational study including a total of 486 patients who underwent MV repair for DMR using the CE Physio II annuloplasty ring between 2011 and 2016.

RESULTS

 Mean age was 54.8 ± 12.1 years, 364 patients (74.9%) were males, and 84 patients (17.3%) presented with atrial fibrillation. Mean left ventricular ejection fraction was 62.3 ± 7.3%. Mean logistic EuroSCORE was 2.7 ± 2.4%. New York Heart Association functional class III-IV symptoms were present in 134 (27.6%) patients preoperatively. Isolated MV repair was performed via a right-sided mini-thoracotomy in 479 patients (98.6%). Concomitant procedures included ablation for atrial fibrillation in 83 patients (17.1%) and closure of atrial septum defect in 88 patients (18.1%). Median size of implanted annuloplasty rings was 34 mm (interquartile range: 34-38 mm). Mean cardiopulmonary bypass time was 116 ± 34 minutes and mean cross-clamp time was 74 ± 25 minutes. Thirty-day mortality was 0.4%. The Kaplan-Meier 4-year survival was 98.5%. Freedom from MV reoperation was 96.2 and 94.0% at 1 and 4 years.

CONCLUSION

 MV repair with the CE Physio II annuloplasty ring is associated with excellent midterm clinical outcome.

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

This executive summary of the valvular heart disease guideline provides recommendations for clinicians to diagnose and manage valvular heart disease as well as supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from January 1, 2010, to March 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected database relevant to this guideline. Structure: Many recommendations from the earlier valvular heart disease guidelines have been updated with new evidence and provides newer options for diagnosis and treatment of valvular heart disease. This summary includes only the recommendations from the full guideline which focus on diagnostic work-up, the timing and choice of surgical and catheter interventions, and recommendations for medical therapy. The reader is referred to the full guideline for graphical flow charts, text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in developing these guidelines.

Tricuspid regurgitation after transcatheter mitral valve repair: Clinical course and impact on outcome

Objectives

The aim of this study was to determine the course of tricuspid regurgitation (TR) after transcatheter mitral valve repair (TMVR), identify predictors for severe TR after TMVR and determine the association of severe TR after TMVR with outcome.

Background

TR is often present in patients with symptomatic mitral regurgitation (MR) and is associated with increased morbidity and mortality. The clinical course of TR after TMVR has not been clearly determined.

Methods

Patients that underwent TMVR between 2009 and 2017 were included. Clinical data were compared between patients with and without severe TR at 6 months after TMVR. Multivariate logistic regression analysis was performed to identify predictors for severe TR after TMVR. Survival analysis was done for both groups, using the Kaplan–Meier method.

Results

A total of 146 patients were included (mean age 76 years, 51% male, 79% New York Heart Association class ≥3 and 29% severe TR at baseline).

Advanced age, atrial fibrillation (AF), right ventricular (RV) dysfunction, and limited procedural MR reduction were revealed as independent predictors for severe TR after TMVR. Survival of patients with severe TR after TMVR was 58% after 2 years compared to 82% for those with non, mild or moderate TR.

Conclusions

Severe TR after TMVR is common in patients at advanced age, those with AF, RV dysfunction and limited MR reduction during TMVR and is associated with impaired survival. As the associated parameters are indicators of longstanding MR, research investigating the benefits of earlier intervention in MR should be initiated.

Asymptomatic degenerative mitral regurgitation repair: Validating guidelines for early intervention

INTRODUCTION

Mitral repair for asymptomatic (New York Heart Association [NYHA] class I) degenerative mitral regurgitation (MR) is supported by the guidelines, but is not performed often. We sought to determine outcomes for asymptomatic patients when compared with those with symptoms.

METHODS

Between 2004 and 2018, 1027 patients underwent mitral replacement (22) or repair with or without other cardiac surgery (1005), the latter being grouped by NYHA class: I (n = 470; 47%), II (n = 408; 40%), or III/IV (n = 127; 13%). Statistical analyses included propensity score matching and weighting, and multistate models.

RESULTS

The proportion of patients designated as NYHA class I undergoing surgery increased steadily during this period (P < .001). Overall, 30-day mortality was 0.4%, and zero for patients designated NYHA class I. Unadjusted 10-year survival was significantly greater in patients designated NYHA class I compared with II and III/IV (P < .001). Freedom from reoperation at 10 years was 99.8% overall, and 100% for patients designated NYHA class I. In patients designated as NYHA class I, predischarge and 10-year moderate MR were 0.7% and 20.1%, whereas more than moderate was zero and 0.6%. Preoperative ejection fraction less than 60% was associated with late mortality (P = .025). After covariate-adjustments, freedom from MR and tricuspid regurgitation were not statistically significantly different by NYHA class. However, overall survival was significantly worse in patients with NYHA class III/IV, compared with class II.

CONCLUSIONS

Mitral repair in asymptomatic patients is safe and durable. Careful monitoring until class II symptoms is appropriate. However, repair before ejection fraction decreases below 60% is important for late overall survival.

Global Longitudinal Strain Predicts Survival and Left Ventricular Function After Mitral Valve Surgery: A Meta-analysis

The timing for surgical treatment in patients with primary organic severe mitral valve regurgitation and preserved left ventricular ejection fraction (LVEF) systolic is a challenge since it depends upon LV end systolic dimension and LVEF which may be late markers of LV dysfunction. Echocardiography is the most important tool in the diagnosis of mechanisms, etiology, severity, and hemodynamic consequences of mitral regurgitation. The global longitudinal strain (GLS), a new and sensitive method for the detection of LV dysfunction, might be a useful method for the evaluation of preclinical systolic dysfunction. Nevertheless, its role for predicting postoperative outcomes is not well established. A meta-analysis was performed to address the role of GLS in patients with severe mitral regurgitation and preserved LVEF who underwent mitral surgery. We included studies that compared outcomes according to preoperative GLS in regard to survival and postoperative LV function. We included 2358 patients enrolled in 8 studies. Patients with reduced GLS% had worse long term survival after mitral valve surgery (hazard ratio = 1.13, 95% confidence interval [CI]: 1.02-1.26). Patients with preoperatively reduced GLS% had lower LVEF after surgery (mean difference [MD] = -5.06%, 95% CI: -8.97-1.16%) and additionally, patients who presented postoperative LVEF dysfunction had worse preoperative GLS (MD = 4.33, 95% CI: 3.89-4.76). In patients with primary mitral regurgitation, preoperative GLS is a predictor for long term survival and postoperative LVEF. It is a useful parameter to be included when considering early surgery in patients with severe mitral regurgitation and normal LVEF.

Global longitudinal strain to predict left ventricular dysfunction in asymptomatic patients with severe mitral valve regurgitation: literature review

The optimal treatment strategy for asymptomatic patients with severe mitral valve regurgitation (MR) and preserved left ventricular (LV) function is challenging. This manuscript reviews the available literature on the value of left ventricular global longitudinal strain (LV-GLS) in predicting LV dysfunction after mitral valve surgery in these patients and discusses its current place in the treatment strategy. Studies were identified from Cochrane Library, SCOPUS, PubMed and Web of Science up to February 2018. The domain used was MR. The determinant was LV-GLS; other methods of deformation imaging were excluded. The examined outcome was LV dysfunction after surgery. A total of 144 articles were retrieved, of which 11 publications met the inclusion criteria, including a total of 2415 patients. Ten studies showed a significant correlation between preoperative LV-GLS and LV dysfunction postoperatively; one study reported a negative correlation. These studies suggest that LV-GLS is a predictor of LV dysfunction after surgery in asymptomatic patients with chronic MR. Hence, incorporation of LV-GLS for clinical decision-making in these patients might be of additional value. Further research is needed to confirm the role of LV-GLS in postoperative patients, and additionally in asymptomatic MR patients during a 'watchful waiting' strategy.

Preoperative left atrial volume index is associated with postoperative outcomes in mitral valve repair for chronic mitral regurgitation

OBJECTIVE

To assess determinants of left atrial reverse remodeling after mitral valve repair and to evaluate the impact of preoperative left atrial volume on postoperative outcomes.

METHODS

We reviewed the records of 720 patients who underwent mitral valve repair from September 2008 to July 2015 and had preoperative measurement of left atrial volume index. We analyzed the association of preoperative left atrial volume index on early and late outcomes, and determined which baseline characteristics are associated with left atrial reverse remodeling, as measured by changes in left atrial volume index in 512 patients who had at least 1 postoperative measurement.

RESULTS

The median (interquartile range) preoperative left atrial volume index was 54.0 (44.0-66.0) mL/m². Preoperative left atrial volume index, age, body mass index, and atrial fibrillation were independently associated with the degree of left atrial reverse remodeling over the follow-up period. Reverse remodeling was greatest in patients with higher baseline left atrial volume index (P < .001), but less reverse remodeling was observed in patients with advanced age (P < .001), preoperative atrial fibrillation (P < .001), and extreme values of body mass index (P = .004), although these effects were moderately attenuated when limiting the analysis to 6-month follow-up. Secondary analysis demonstrated marginally significant effects of preoperative left atrial volume index on risks of early postoperative atrial fibrillation (P = .030) and late mortality (P = .077) after adjusting for age and sex.

CONCLUSIONS

In patients with degenerative mitral valve regurgitation who had mitral valve repair, preoperative left atrial volume index was associated with extent of left atrial reverse remodeling, risk of early postoperative atrial fibrillation, and late mortality. The majority of reverse remodeling occurs within the first month after operation and is greatest in younger patients.

Left ventricular remodelling in chronic primary mitral regurgitation: implications for medical therapy

Surgical repair or replacement of the mitral valve is currently the only recommended therapy for severe primary mitral regurgitation. The chronic elevation of wall stress caused by the resulting volume overload leads to structural remodelling of the muscular, vascular and extracellular matrix components of the myocardium. These changes are initially compensatory but in the long term have detrimental effects, which ultimately result in heart failure. Understanding the changes that occur in the myocardium due to volume overload at the molecular and cellular level may lead to medical interventions, which potentially could delay or prevent the adverse left ventricular remodelling associated with primary mitral regurgitation. The pathophysiological changes involved in left ventricular remodelling in response to chronic primary mitral regurgitation and the evidence for potential medical therapy, in particular beta-adrenergic blockers, are the focus of this review.

Surgical Techniques for Mitral Valve Repair: A Pathoanatomic Grading System

Mitral valve surgery has evolved over 4 decades from one based on the principles of prosthetic replacement to a subspecialty with a foundation based on the principles of repair. This review will attempt to enumerate the contemporary techniques of mitral valve repair and a pathoanatomically directed approach with which to apply them by focusing on degenerative disease and associated complexities.

Long-Term Results Following Repair for Degenerative Mitral Regurgitation - Analysis of Factors Influencing Durability

BACKGROUND

The majority of patients with degenerative mitral regurgitation (DMR) are amenable to reconstructive procedures. There is debate regarding factors that influence long-term durability with respect to repair technique, valve remodelling and progressive myxomatous change.

METHODS

A total of 685 patients with DMR underwent mitral valve repair by a single surgeon between 1991 and 2011 with follow-up completed at 31 December 2016. Repair rate for patients undergoing surgery for DMR was over 90%. Mean age was 64 years (18-89) with 66.2% male, 47% NYHA class III-IV, and 20% had permanent atrial fibrillation (PAF). Major associated procedures were performed in 28% of patients (189); including coronary artery bypass graft (CABG) (127), aortic valve replacement (15), aortic root surgery (3) and tricuspid valve annuloplasty (61).

RESULTS

Operative mortality (≤30 days) occurred in four patients (0.58%). At 20 years, survival was 58%, freedom from reoperation was 90% and freedom from reoperation and non-operated recurrent MR >2+ (relapse) was 78%. Factors influencing survival were advancing age, left ventricular (LV) dysfunction (ejection fraction <60% or end systolic dimension >40mm), New York Heart Association (NYHA) III-IV and PAF. Predictors of relapse were the degree of residual intraoperative mitral regurgitation (p<0.001), anterior leaflet prolapse (p<0.001) and the addition of a sliding annuloplasty in isolated posterior leaflet repair (p=0.023). The majority of reoperations were for technical issues related to the original repair. A competent valve at 6 months to 3 years postoperatively predicted an excellent long-term result.

CONCLUSION

The great majority of degenerative mitral valves are repairable regardless of age with excellent long-term results achievable following surgery. Survival is reduced by significant symptoms, LV dysfunction and preoperative PAF. Repair is best performed before these features develop. Durability is largely dependent on the technical performance of the repair and degree of residual MR on the post-pump transoesophageal echocardiogram. We recommend surgery should be performed by surgeons specialising and skilled in mitral valve repair.

Stress echocardiography in valvular heart disease

INTRODUCTION

The management of patients with heart valve disease can be complex. Patients may have symptoms disproportionate to the severity or the severity may be unclear. In addition, the optimal timing of intervention in patients with severe disease may be controversial. Areas covered: This article examines the role of stress echocardiography for assessment of patients with low-flow, low-gradient aortic stenosis, asymptomatic severe valve disease and patients where symptoms are discordant to the resting severity of valve disease. Expert commentary: Stress echocardiography helps clinicians determine the true severity of valve disease and may identify the cause of symptoms in patients with only mild/moderate disease. The data provided by stress echocardiography will help determine the appropriate management strategy and the correct timing of intervention.

Long-term results of mitral valve repair for severe mitral regurgitation in asymptomatic patients

BACKGROUND

In asymptomatic patients with severe degenerative mitral valve regurgitation (MR), early surgery is often performed in experienced centers. The patient- and valve-related results and the quality of life after surgery in these patients remain insufficiently explored.

METHODS

Between 1/2000 and 12/2015, 83 asymptomatic patients (mean age 56.6±12.6 years, 21 female) without any complications related to long-lasting MR underwent early surgery. Follow-up clinical and echocardiographic data and health-related quality of life assessment (SF-36) were studied and matched to the general population.

RESULTS

Repair rate was 100% and early mortality was 0%. Residual MR (≥grade 2+) was seen in 1 (1%) patient who underwent a successful re-repair while 4 (5%) patients needed permanent pacemaker implantation. At a median follow-up of 7.6 (IQR 4.1-11.9) years, 6 late deaths occurred. The 10-year overall survival rate was 91.5% (95% CI 84.2-98.8%) and was comparable to the general population. The health-related quality of life (84% complete) did not differ from the general population. One patient underwent late reintervention. Median echocardiography follow-up was 5.2 years (IQR 2.4-10.4; 98% complete). The 10-year freedom from recurrent MR rate (≥grade 2+) was 86.7% (95% CI 76.1-97.3%). The 10-year freedom from any atrial tachycardia rate was 68.7% (95% CI 55.2-82.2%) while 7 (8%) patients underwent late pacemaker implantation.

CONCLUSIONS

Early surgical intervention in asymptomatic patients with severe MR can be performed safely and restores normal life expectancy and quality of life. However, the frequency of late arrhythmias and pacemaker implantation is high and needs further evaluation.

Early Surgery in Valvular Heart Disease

The burden of valvular heart disease (VHD) is increasing with age, and the elderly patients with moderate or severe VHD are notably common. When to operate in asymptomatic patients with VHD remains controversial. The controversy is whether early surgical intervention should be preferred, or a watchful waiting approach should be followed. The beneficial effects of early surgery should be balanced against operative mortality and long-term results. Indications of early surgery in each of the VHD will be discussed in this review on the basis of the latest American and European guidelines.

Forward Left Ventricular Ejection Fraction: A Simple Risk Marker in Patients With Primary Mitral Regurgitation

Background

The timing of mitral valve surgery in asymptomatic patients with primary mitral regurgitation (MR) is controversial. We hypothesized that the forward left ventricular (LV) ejection fraction (LVEF; ie, LV outflow tract stroke volume divided by LV end‐diastolic volume) is superior to the total LVEF to predict outcomes in MR. The objective of this study was to examine the association between echocardiographic parameters of MR severity and LV function and outcomes in patients with MR.

Methods and Results

The clinical and Doppler‐echocardiographic data of 278 patients with ≥mild MR and no class I indication of mitral valve surgery at baseline were retrospectively analyzed. The primary study end point was the composite of mitral valve surgery or death. During a mean follow‐up of 5.4±3.2 years, there were 147 (53%) events: 96 (35%) MV surgeries and 66 (24%) deaths. Total LVEF and global longitudinal strain were not associated with the occurrence of events, whereas forward LVEF (P<0.0001) and LV end‐systolic diameter (P=0.0003) were. After adjustment for age, sex, MR severity, Charlson probability, coronary artery disease, and atrial fibrillation, forward LVEF remained independently associated with the occurrence of events (adjusted hazard ratio: 1.09, [95% confidence interval]: 1.02–1.17 per 5% decrease; P=0.01), whereas LV end‐systolic diameter was not (P=0.48).

Conclusions

The results of this study suggest that the forward LVEF may be superior to the total LVEF and LV end‐systolic diameter to predict outcomes in patients with primary MR. This simple and easily measurable parameter may be useful to improve risk stratification and select the best timing for intervention in patients with primary MR.

Initial surgery versus conservative management of symptomatic severe mitral regurgitation in the elderly

OBJECTIVE

In elderly patients, the benefit of surgical correction of severe mitral regurgitation (MR) may not be greater than the operative risk. This study sought to compare the long-term clinical outcomes between initial surgery and conservative management in elderly patients (≥70 years of age) with severe MR.

METHODS

We prospectively evaluated 157 consecutive patients (75 men, 74±4 years of age) with severe degenerative MR and mild symptoms. Mitral valve surgery was performed on 79 (initial surgery group), whereas the conservative strategy was chosen for 78 patients (conservative management group). We compared the overall and cardiac mortality and cardiac event between strategies in the overall and propensity-matched cohort (46 pairs).

RESULTS

During the median follow-up of 5.4 years, overall death occurred less in the initial surgery group (16 vs 37 patients). This group showed reduced cardiac mortality (HR 0.31; 95% CI 0.13 to 0.73; p=0.007), overall mortality (HR 0.39; 95% CI 0.21 to 0.74; p=0.004) and cardiac event (HR 0.26; 95% CI 0.13 to 0.53; p<0.001). A significant reduction in cardiac mortality (HR 0.18; 95% CI 0.05 to 0.63; p=0.007), overall mortality (HR 0.36; 95% CI 0.15 to 0.86; p=0.022) and cardiac event (HR 0.20; 95% CI 0.07 to 0.52; p=0.001) in the initial surgery group was also observed in the propensity-matched cohort.

CONCLUSIONS

In elderly patients with severe degenerative MR and mild symptoms, initial surgical strategy was associated with significant long-term reductions in cardiac and overall mortality compared with conservative management.

Implication of pulmonary hypertension in patients undergoing MitraClip therapy: results from the German transcatheter mitral valve interventions (TRAMI) registry

AIMS

We sought to evaluate the impact of pulmonary hypertension on outcomes following MitraClip therapy.

METHODS AND RESULTS

The 643 patients in the TRAnscatheter Mitral valve Interventions (TRAMI) registry were divided into three groups according to echocardiographically graded systolic pulmonary artery pressure (sPAP) (Group 1: patients with sPAP of ≤36 mmHg; Group 2: patients with sPAP of 37-50 mmHg; Group 3: patients with sPAP of >50 mmHg) and followed for 1 year. Recent cardiac decompensation, aortic valve disease and tricuspid valve insufficiency were observed more frequently in patients with higher sPAP. Furthermore, logEuroSCORE, Society of Thoracic Surgeons score and age were higher with rising sPAP values. No differences were observed in mitral regurgitation (MR) severity, co-morbidities or clinical findings (New York Heart Association class, 6-min walking distance). Reduction to MR of grade 1 or lower was achieved more often in patients with lower sPAP levels (P = 0.01). In Groups 2 and 3, sPAP was reduced significantly. Major adverse cardiac or cardiovascular events (MACCEs) occurring in hospital (death, myocardial infarction, stroke; <4% in each group), as well as 30-day rates of MACCEs (6.1% in Group 1, 11.9% in Group 2, 12.4% in Group 3) and rehospitalization (18.9% in Group 1, 24.8% in Group 2, 24.8% in Group 3) did not differ significantly. At 1 year, differences in rates of mortality and MACCEs (20.3% in Group 1, 33.1% in Group 2, 34.7% in Group 3; P < 0.01) were significant. Both Groups 2 [hazard ratio (HR) 1.81, P = 0.0122] and 3 (HR 1.85, P = 0.0092) were independently predictive of death. Rehospitalization rates did not differ during follow-up.

CONCLUSIONS

Despite higher mortality in patients with elevated sPAP, these data suggest the safety, feasibility and benefit of MitraClip therapy even in advanced stages of disease. An early approach might prevent the progress of pulmonary hypertension and improve outcomes.