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Prasad P, Chandrashekar P, Golwala H, Macon CJ, Steiner J. Functional Mitral Regurgitation: Patient Selection and Optimization. Interv Cardiol Clin 2024; 13:167-182. [PMID: 38432760 DOI: 10.1016/j.iccl.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Functional mitral regurgitation appears commonly among all heart failure phenotypes and can affect symptom burden and degree of maladaptive remodeling. Transcatheter mitral valve edge-to-edge repair therapies recently became an important part of the routine heart failure armamentarium for carefully selected and medically optimized candidates. Patient selection is considering heart failure staging, relevant comorbidities, as well as anatomic criteria. Indications and device platforms are currently expanding.
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Affiliation(s)
- Pooja Prasad
- Division of Cardiology, University of California-San Francisco, 505 Parnassus Avenue, Suite M1182, Box 0124, San Francisco, CA 94143, USA
| | - Pranav Chandrashekar
- Knight Cardiovascular Institute, Oregon Health & Science University, 3161 SW Pavilion Loop, Portland, OR 97239, USA
| | - Harsh Golwala
- Knight Cardiovascular Institute, Oregon Health & Science University, 3161 SW Pavilion Loop, Portland, OR 97239, USA
| | - Conrad J Macon
- Knight Cardiovascular Institute, Oregon Health & Science University, 3161 SW Pavilion Loop, Portland, OR 97239, USA
| | - Johannes Steiner
- Knight Cardiovascular Institute, Oregon Health & Science University, 3161 SW Pavilion Loop, Portland, OR 97239, USA.
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2
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Camaj A, Thourani VH, Gillam LD, Stone GW. Heart Failure and Secondary Mitral Regurgitation: A Contemporary Review. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:101195. [PMID: 39131058 PMCID: PMC11308134 DOI: 10.1016/j.jscai.2023.101195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 09/15/2023] [Accepted: 09/26/2023] [Indexed: 08/13/2024]
Abstract
Secondary mitral regurgitation (SMR) in patients with heart failure (HF) is associated with significant morbidity and mortality. In recent decades, SMR has received increasing scientific attention. Advances in echocardiography, computed tomography and cardiac magnetic resonance imaging have refined our ability to diagnose, quantify and characterize SMR. Concurrently, the treatment options for this high-risk patient population have continued to evolve. Guideline-directed medical therapies including beta-blockers, angiotensin receptor-neprilysin inhibitors, mineralocorticoid receptor antagonists and sodium-glucose cotransporter-2 inhibitors target the underlying cardiomyopathy, and along with diuretics to treat pulmonary congestion, remain the cornerstone of therapy. Cardiac resynchronization therapy also reduces MR, alleviates symptoms and prolongs life in selected HF patients with SMR. While data supporting surgical mitral valve repair or replacement for SMR are limited, transcatheter edge-to-edge repair (TEER) has been demonstrated to improve survival, reduce the rate of hospitalization for heart failure, and improve functional capacity and quality-of-life in select patients with SMR who remain symptomatic despite medical therapy. Emerging transcatheter mitral valve repair and replacement technologies are undergoing investigation in TEER-eligible and TEER-ineligible patients. The optimal management of HF patients with SMR requires a multidisciplinary team of cardiologists, cardiac surgeons, imaging experts, and other organ specialists to select the best treatment approaches to improve the prognosis of these high-risk patients.
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Affiliation(s)
- Anton Camaj
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Vinod H. Thourani
- Department of Cardiovascular Surgery, Marcus Valve Center, Piedmont Heart Institute, Atlanta, Georgia
| | - Linda D. Gillam
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey
| | - Gregg W. Stone
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
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3
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Pienta MJ, Romano MA. Secondary Mitral Regurgitation and Transcatheter Mitral Valve Therapies: Do They Have a Role in Advanced Heart Failure with Reduced Ejection Fraction? Cardiol Clin 2023; 41:575-582. [PMID: 37743079 DOI: 10.1016/j.ccl.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
Transcatheter mitral valve repair should be considered for patients with severe secondary mitral regurgitation with symptomatic heart failure with reduced ejection fraction for symptom improvement and survival benefit. Patients with a higher severity of secondary mitral regurgitation relative to the degree of left ventricular dilation are more likely to benefit from transcatheter mitral valve repair. A multidisciplinary Heart Team should participate in patient selection for transcatheter mitral valve therapy.
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Affiliation(s)
- Michael J Pienta
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Matthew A Romano
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
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4
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Lander MM, Brener MI, Goel K, Tang PC, Verlinden NJ, Zalawadiya S, Lindenfeld J, Kanwar MK. Mitral Interventions in Heart Failure. JACC. HEART FAILURE 2023; 11:1055-1069. [PMID: 37611988 DOI: 10.1016/j.jchf.2023.07.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/10/2023] [Accepted: 07/19/2023] [Indexed: 08/25/2023]
Abstract
Patients with heart failure with reduced ejection fraction who have secondary mitral regurgitation (SMR) have poorer outcomes and quality of life than those without SMR. Guideline-directed medical therapy is the cornerstone of SMR treatment. Careful evaluation of landmark trials using mitral transcatheter edge-to-edge repair in SMR has led to an improved understanding of who will benefit from percutaneous interventions with emphasis on a multidisciplinary approach. The success with mitral transcatheter edge-to-edge repair in SMR has also spurred the evaluation of its role in populations that were not initially studied, such as end-stage heart failure and cardiogenic shock. A spectrum of transcatheter devices in development and clinical trials promise to further provide a growing array of management options for heart failure with reduced ejection fraction patients with symptomatic SMR.
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Affiliation(s)
- Matthew M Lander
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Michael I Brener
- Division of Cardiology at Columbia University Irving Medical Center, New York, New York, USA
| | - Kashish Goel
- Vanderbilt Heart and Vascular Institute, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Paul C Tang
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Nathan J Verlinden
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Sandip Zalawadiya
- Vanderbilt Heart and Vascular Institute, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - JoAnn Lindenfeld
- Vanderbilt Heart and Vascular Institute, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Manreet K Kanwar
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, Pennsylvania, USA.
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5
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Kumar M, Thompson PD, Chen K. New Perspective on Pathophysiology and Management of Functional Mitral Regurgitation. Trends Cardiovasc Med 2023; 33:386-392. [PMID: 35259483 DOI: 10.1016/j.tcm.2022.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/15/2022] [Accepted: 03/01/2022] [Indexed: 12/31/2022]
Abstract
Functional mitral regurgitation (FMR) occurs as a result of global or segmental left ventricular (LV) dysfunction or left atrial dilatation, leading to mitral annular dilatation, papillary muscle displacement, mitral valve (MV) leaflet tethering, and leaflet remodeling. The prevalence of FMR continues to rise in the United States. Even mild FMR is associated with adverse clinical outcomes. Echocardiography is the primary imaging modality used to assess the type and severity of mitral regurgitation. FMR treatment depends on the etiology. Evidence-based pharmacologic and cardiac resynchronization therapies for underlying LV dysfunction remain the mainstay of treatment. Patients who remain symptomatic despite optimal medical therapy can be considered for surgical or percutaneous MV intervention. This article reviews the pathophysiology, imaging evaluation, and therapeutic options of FMR, highlighting the most recent developments in a rapidly evolving field.
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Affiliation(s)
- Manish Kumar
- Pat and Jim Calhoun Cardiology Center, Department of Internal Medicine, University of Connecticut Health Center, Farmington, CT, 06030, United States.
| | - Paul D Thompson
- Department of Cardiology, Hartford Hospital, Hartford, 06106, United States
| | - Kai Chen
- Pat and Jim Calhoun Cardiology Center, Department of Internal Medicine, University of Connecticut Health Center, Farmington, CT, 06030, United States.
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Ocher R, May M, Labin J, Shah J, Horwich T, Watson KE, Yang EH, Calfon Press MA. Mitral Regurgitation in Female Patients: Sex Differences and Disparities. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:101032. [PMID: 39131652 PMCID: PMC11308238 DOI: 10.1016/j.jscai.2023.101032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/18/2023] [Accepted: 04/23/2023] [Indexed: 08/13/2024]
Abstract
Mitral regurgitation is the most common valvular disease, particularly in older adults. Recent literature has consistently supported that there are significant differences in mitral regurgitation outcomes between male and female patients and that this is likely multifactorial. Numerous sex differences in anatomy and pathophysiology may play a role in delayed diagnoses, referrals, and treatments for female patients. Despite the recognition of these discrepancies in the literature, many guidelines that steer clinical care do not incorporate these factors into society recommendations. Identifying and validating sex-specific diagnostic parameters and increasing the representation of female patients in trials of new mitral regurgitation treatment modalities are key factors in improving outcomes for female patients.
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Affiliation(s)
- Rebecca Ocher
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Megan May
- Division of Cardiology, Department of Medicine, MedStar Health, Washington, DC
| | - Jonathan Labin
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Janki Shah
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Tamara Horwich
- Barbra Streisand Women’s Heart Health Program, Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Karol E. Watson
- Barbra Streisand Women’s Heart Health Program, Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Eric H. Yang
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Marcella A. Calfon Press
- Barbra Streisand Women’s Heart Health Program, Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
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Milwidsky A, Mathai SV, Topilsky Y, Jorde UP. Medical Therapy for Functional Mitral Regurgitation. Circ Heart Fail 2022; 15:e009689. [PMID: 35862021 DOI: 10.1161/circheartfailure.122.009689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Functional mitral regurgitation (FMR) can be broadly categorized into 2 main groups: ventricular and atrial, which often coexist. The former is secondary to left ventricular remodeling usually in the setting of heart failure with reduced ejection fraction or less frequently due to ischemic papillary muscle remodeling. Atrial FMR develops due to atrial and annular dilatation related to atrial fibrillation/flutter or from increased atrial pressures in the setting of heart failure with preserved ejection fraction. Guideline-directed medical therapy is the first step and prevails as the mainstay in the treatment of FMR. In this review, we address the medical therapeutic options for FMR management and highlight a targeted approach for each FMR category. We further address important clinical and echocardiographic characteristics to aid in determining when medical therapy is expected to have a low yield and an appropriate window for effective interventional approaches exists.
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Affiliation(s)
- Assi Milwidsky
- Department of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (A.M., U.P.J.).,Department of Cardiology, Tel-Aviv Sourasky Medical Center (affiliated with the Sackler School of Medicine), Tel-Aviv University, Israel (A.M., Y.T.)
| | - Sheetal Vasundara Mathai
- Department of Medicine, Jacobi Medical Center and Albert Einstein College of Medicine, Bronx, NY (S.V.M.)
| | - Yan Topilsky
- Department of Cardiology, Tel-Aviv Sourasky Medical Center (affiliated with the Sackler School of Medicine), Tel-Aviv University, Israel (A.M., Y.T.)
| | - Ulrich P Jorde
- Department of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (A.M., U.P.J.)
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Vajapey R, Kwon D. Guide to functional mitral regurgitation: a contemporary review. Cardiovasc Diagn Ther 2021; 11:781-792. [PMID: 34295705 PMCID: PMC8261742 DOI: 10.21037/cdt-20-277] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 11/16/2020] [Indexed: 11/06/2022]
Abstract
Functional mitral regurgitation (FMR) occurs in the absence of organic mitral valve (MV) disease and is a result of LV dysfunction due to ischemic vs. non ischemic etiologies. The prevalence of FMR is increasing, as 2.0-2.5 million people in the USA were diagnosed with FMR in 2000-and this number is expected to double to 4 million by 2030. FMR tends to develop in a significant number of patients after myocardial infarction (MI) and many develop heart failure (HF) subsequently with mortality rates ranging from 15-40% at 1 year. Therefore, there has been much interest and effort to develop optimized methods for quantifying and classifying the severity of FMR, as well as developing effective therapeutic interventions to improve outcomes in patients with significant FMR. Echocardiogram is typically the primary diagnostic method of assessment, however, there have been various technological advances including cardiac CT and cardiac MRI that can better guide quantification and management of this disease. Management of this disease is mostly aimed at optimizing left ventricular (LV) remodeling with surgical and transcatheter management gaining more popularity with recent times. The purpose of this paper is to provide a comprehensive review of the current evaluation methods and interventional strategies for FMR.
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Affiliation(s)
- Ramya Vajapey
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Deborah Kwon
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Martin N, Manoharan K, Davies C, Lumbers RT. Beta-blockers and inhibitors of the renin-angiotensin aldosterone system for chronic heart failure with preserved ejection fraction. Cochrane Database Syst Rev 2021; 5:CD012721. [PMID: 34022072 PMCID: PMC8140651 DOI: 10.1002/14651858.cd012721.pub3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Beta-blockers and inhibitors of the renin-angiotensin-aldosterone system improve survival and reduce morbidity in people with heart failure with reduced left ventricular ejection fraction (LVEF); a review of the evidence is required to determine whether these treatments are beneficial for people with heart failure with preserved ejection fraction (HFpEF). OBJECTIVES To assess the effects of beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor neprilysin inhibitors, and mineralocorticoid receptor antagonists in people with HFpEF. SEARCH METHODS We updated searches of CENTRAL, MEDLINE, Embase, and one clinical trial register on 14 May 2020 to identify eligible studies, with no language or date restrictions. We checked references from trial reports and review articles for additional studies. SELECTION CRITERIA: We included randomised controlled trials with a parallel group design, enrolling adults with HFpEF, defined by LVEF greater than 40%. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included 41 randomised controlled trials (231 reports), totalling 23,492 participants across all comparisons. The risk of bias was frequently unclear and only five studies had a low risk of bias in all domains. Beta-blockers (BBs) We included 10 studies (3087 participants) investigating BBs. Five studies used a placebo comparator and in five the comparator was usual care. The mean age of participants ranged from 30 years to 81 years. A possible reduction in cardiovascular mortality was observed (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.62 to 0.99; number needed to treat for an additional benefit (NNTB) 25; 1046 participants; three studies), however, the certainty of evidence was low. There may be little to no effect on all-cause mortality (RR 0.82, 95% CI 0.67 to 1.00; 1105 participants; four studies; low-certainty evidence). The effects on heart failure hospitalisation, hyperkalaemia, and quality of life remain uncertain. Mineralocorticoid receptor antagonists (MRAs) We included 13 studies (4459 participants) investigating MRA. Eight studies used a placebo comparator and in five the comparator was usual care. The mean age of participants ranged from 54.5 to 80 years. Pooled analysis indicated that MRA treatment probably reduces heart failure hospitalisation (RR 0.82, 95% CI 0.69 to 0.98; NNTB = 41; 3714 participants; three studies; moderate-certainty evidence). However, MRA treatment probably has little or no effect on all-cause mortality (RR 0.91, 95% CI 0.78 to 1.06; 4207 participants; five studies; moderate-certainty evidence) and cardiovascular mortality (RR 0.90, 95% CI 0.74 to 1.11; 4070 participants; three studies; moderate-certainty evidence). MRA treatment may have little or no effect on quality of life measures (mean difference (MD) 0.84, 95% CI -2.30 to 3.98; 511 participants; three studies; low-certainty evidence). MRA treatment was associated with a higher risk of hyperkalaemia (RR 2.11, 95% CI 1.77 to 2.51; number needed to treat for an additional harmful outcome (NNTH) = 11; 4291 participants; six studies; high-certainty evidence). Angiotensin-converting enzyme inhibitors (ACEIs) We included eight studies (2061 participants) investigating ACEIs. Three studies used a placebo comparator and in five the comparator was usual care. The mean age of participants ranged from 70 to 82 years. Pooled analyses with moderate-certainty evidence suggest that ACEI treatment likely has little or no effect on cardiovascular mortality (RR 0.93, 95% CI 0.61 to 1.42; 945 participants; two studies), all-cause mortality (RR 1.04, 95% CI 0.75 to 1.45; 1187 participants; five studies) and heart failure hospitalisation (RR 0.86, 95% CI 0.64 to 1.15; 1019 participants; three studies), and may result in little or no effect on the quality of life (MD -0.09, 95% CI -3.66 to 3.48; 154 participants; two studies; low-certainty evidence). The effects on hyperkalaemia remain uncertain. Angiotensin receptor blockers (ARBs) Eight studies (8755 participants) investigating ARBs were included. Five studies used a placebo comparator and in three the comparator was usual care. The mean age of participants ranged from 61 to 75 years. Pooled analyses with high certainty of evidence suggest that ARB treatment has little or no effect on cardiovascular mortality (RR 1.02, 95% 0.90 to 1.14; 7254 participants; three studies), all-cause mortality (RR 1.01, 95% CI 0.92 to 1.11; 7964 participants; four studies), heart failure hospitalisation (RR 0.92, 95% CI 0.83 to 1.02; 7254 participants; three studies), and quality of life (MD 0.41, 95% CI -0.86 to 1.67; 3117 participants; three studies). ARB was associated with a higher risk of hyperkalaemia (RR 1.88, 95% CI 1.07 to 3.33; 7148 participants; two studies; high-certainty evidence). Angiotensin receptor neprilysin inhibitors (ARNIs) Three studies (7702 participants) investigating ARNIs were included. Two studies used ARBs as the comparator and one used standardised medical therapy, based on participants' established treatments at enrolment. The mean age of participants ranged from 71 to 73 years. Results suggest that ARNIs may have little or no effect on cardiovascular mortality (RR 0.96, 95% CI 0.79 to 1.15; 4796 participants; one study; moderate-certainty evidence), all-cause mortality (RR 0.97, 95% CI 0.84 to 1.11; 7663 participants; three studies; high-certainty evidence), or quality of life (high-certainty evidence). However, ARNI treatment may result in a slight reduction in heart failure hospitalisation, compared to usual care (RR 0.89, 95% CI 0.80 to 1.00; 7362 participants; two studies; moderate-certainty evidence). ARNI treatment was associated with a reduced risk of hyperkalaemia compared with valsartan (RR 0.88, 95% CI 0.77 to 1.01; 5054 participants; two studies; moderate-certainty evidence). AUTHORS' CONCLUSIONS There is evidence that MRA and ARNI treatment in HFpEF probably reduces heart failure hospitalisation but probably has little or no effect on cardiovascular mortality and quality of life. BB treatment may reduce the risk of cardiovascular mortality, however, further trials are needed. The current evidence for BBs, ACEIs, and ARBs is limited and does not support their use in HFpEF in the absence of an alternative indication. Although MRAs and ARNIs are probably effective at reducing the risk of heart failure hospitalisation, the treatment effect sizes are modest. There is a need for improved approaches to patient stratification to identify the subgroup of patients who are most likely to benefit from MRAs and ARNIs, as well as for an improved understanding of disease biology, and for new therapeutic approaches.
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Affiliation(s)
- Nicole Martin
- Institute of Health Informatics Research, University College London, London, UK
| | | | - Ceri Davies
- Department of Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - R Thomas Lumbers
- Institute of Health Informatics, University College London, London, UK
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Kaneko H, Kiriyama H, Kamon T, Itoh H, Kodera S, Fujiu K, Daimon M, Morita H, Hatano M, Komuro I. Percutaneous Mitral Valve Intervention Using MitraClip for Functional Mitral Regurgitation and Heart Failure. Int Heart J 2021; 62:4-8. [PMID: 33518664 DOI: 10.1536/ihj.20-712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Functional mitral regurgitation (FMR) frequently coexists with left ventricular systolic dysfunction and advanced heart failure, and typically has poor clinical outcomes. Although various therapeutic options including cardiac resynchronization therapy and surgical mitral intervention, have been proposed, an optimal treatment strategy for functional mitral regurgitation has not yet been established. Over the last decade, transcatheter mitral valve repair using MitraClip has emerged as a novel alternative therapeutic option for functional mitral regurgitation. In 2018, the COAPT trial demonstrated that MitraClip treatment reduced rehospitalization due to heart failure and all-cause death in patients with functional mitral regurgitation and heart failure. As a consequence, the MitraClip has become a very promising potential treatment for functional mitral regurgitation. In this review, we discuss and summarize the current status and future perspectives of the treatment for functional mitral regurgitation and heart failure.
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Affiliation(s)
- Hidehiro Kaneko
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo.,Department of Advanced Cardiology, Graduate School of Medicine, The University of Tokyo
| | - Hiroyuki Kiriyama
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
| | - Tatsuya Kamon
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
| | - Hidetaka Itoh
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
| | - Satoshi Kodera
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
| | - Katsuhito Fujiu
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo.,Department of Advanced Cardiology, Graduate School of Medicine, The University of Tokyo
| | - Masao Daimon
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo.,Department of Clinical Laboratory, The University of Tokyo Hospital
| | - Hiroyuki Morita
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
| | - Masaru Hatano
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo.,Department of Therapeutic Strategy for Heart Failure, Graduate School of Medicine, The University of Tokyo
| | - Issei Komuro
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
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11
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Gill H, Chehab O, Allen C, Patterson T, Redwood S, Rajani R, Prendergast B. The advantages, pitfalls and limitations of guideline-directed medical therapy in patients with valvular heart disease. Eur J Heart Fail 2021; 23:1325-1333. [PMID: 33421239 DOI: 10.1002/ejhf.2097] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 12/15/2020] [Accepted: 01/01/2021] [Indexed: 11/05/2022] Open
Abstract
Heart failure is an inevitable end-stage consequence of significant valvular heart disease (VHD) that is left untreated and increasingly encountered in an ageing society. Recent advances in transcatheter procedures and improved outcomes after valve surgery mean that intervention can (and should) be considered in all patients - even the elderly and those with multiple comorbidities - at earlier stages of the natural history of primary VHD, before the onset of irreversible left ventricular dysfunction (and frequently before the onset of symptoms). All patients with known VHD should be monitored carefully in the setting of a heart valve clinic and those who meet guideline criteria for surgical or transcatheter intervention referred for intervention without delay. High quality evidence for the use of medical therapy in VHD is limited and achieving target doses in an elderly and comorbid population frequently challenging. Furthermore, determining whether the valve or ventricle is the principal disease driver is crucial (although the distinction is not always binary, and often unclear). Guideline-directed medical therapy remains the mainstay of treatment for secondary mitral regurgitation - although up to 50% of patients may fail to respond and should be considered for cardiac resynchronization, transcatheter or surgical valve intervention. Early and definitive management strategies are essential and should be overseen by a specialist Heart Team that includes a Heart Failure specialist. In this article, we provide an evidence-based summary of approaches to the medical treatment of VHD and clinical guidance for the best management of patients in situations where high quality evidence is lacking.
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Affiliation(s)
- Harminder Gill
- School of Bioengineering and Imaging Sciences, King's College London, London, UK
| | - Omar Chehab
- Cardiovascular Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Christopher Allen
- Cardiovascular Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Tiffany Patterson
- Cardiovascular Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Simon Redwood
- Cardiovascular Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Ronak Rajani
- School of Bioengineering and Imaging Sciences, King's College London, London, UK.,Cardiovascular Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Bernard Prendergast
- Cardiovascular Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
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12
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Treatment options for ischemic mitral regurgitation: A meta-analysis. J Thorac Cardiovasc Surg 2020; 163:607-622.e14. [PMID: 32713629 DOI: 10.1016/j.jtcvs.2020.05.041] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 05/12/2020] [Accepted: 05/15/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Treatment of ischemic mitral regurgitation (IMR) is in evolution, as percutaneous procedures and complex surgical repair have been recently investigated in randomized clinical trials and matched studies. This study aims to review and compare the current treatment options for IMR. METHODS A comprehensive literature search was conducted using electronic databases. The primary outcome was all-cause long-term mortality. The secondary outcomes were perioperative mortality, unplanned rehospitalization, reoperation, and composite end points as defined in the original articles. RESULTS A total of 12 articles met the inclusion criteria and were included in the final meta-analysis. The MitraClip procedure did not confer a significant benefit in mortality and repeated hospitalization compared with medical therapy alone. In patients with moderate IMR, the adjunct of mitral procedure over coronary artery bypass graft is not associated with clinical improvements. When evaluating mitral valve (MV) replacement versus repair, hospital mortality was greater among patients undergoing replacement (odds ratio [OR], 1.91; P = .009), but both reoperation and readmission rates were lower (OR, 0.60, P = .05; and OR, 0.45, P < .02, respectively). Comparing restrictive annuloplasty alone with adjunctive subvalvular repair, subvalvular procedures resulted in fewer readmissions (OR, 0.50; P = .06) and adverse composite end points (P = .009). CONCLUSIONS MitraClip procedure is not associated with improved outcomes compared with medical therapy. MV replacement is associated with increased early mortality but reduced reoperation rate and readmission rate compared with MV repair using annuloplasty in moderate-to-severe IMR. Despite no significant benefit in isolated outcomes comparing annular and adjunct subvalvular procedures, the adjunct of subvalvular procedures reduces the risk of major postoperative adverse events.
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Nappi F, Nenna A, Sing SSA, Timofeeva I, Mihos C, Gentile F, Chello M. Mitral regurgitation: lessons learned from COAPT and MITRA-Fr. J Thorac Dis 2020; 12:2936-2944. [PMID: 32642206 PMCID: PMC7330366 DOI: 10.21037/jtd.2020.01.67] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Recent studies about percutaneous treatment of secondary mitral regurgitation (MR) underlined the importance of left ventricular geometry and features of mitral valve as determinants of procedural and long-term success. Guideline-directed medical therapy (GDMT), transcatheter mitral valve treatment (TMVT) and surgical procedures (mitral valve replacement, mitral valve repair at level of the annulus or subvalvular apparatus) have been extensively evaluated but not adequately compared in current clinical studies. A detailed analysis of the results of the study about transcatheter mitral valve repair would allow to evaluate the safety and effectiveness of such procedure and would provide potential indications for improving the quality of percutaneous and surgical repair in patients with moderate-to-severe secondary MR. Patients with proportionate MR (i.e., MR severity is proportional to the amount of left ventricular dilatation) are prone to respond to the optimization of medical therapy, while patients with disproportionate MR (i.e., MR severity is disproportionately higher than predicted by left ventricular dilatation, with high EROA and small left ventricle) are likely to benefit from additional repair. The identification of specific subpopulation of "high responders", based on the anatomic characteristics of the mitral valve and the relative dimensions of the annulus, the regurgitation and the left ventricle, can also apply to medical therapy. However, some pivotal component of MR (such as the symmetry of tethering and the differences in biomechanical features of leaflets) are not adequately investigated in current studies and warrant further evaluation.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France
| | - Antonio Nenna
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Sanjeet Singh Avvtar Sing
- Department of Cardiac Surgery, Golden Jubilee National Hospital. Glasgow, UK.,Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Irina Timofeeva
- Department of Imaging, Centre Cardiologique du Nord de Saint-Denis, Paris, France
| | - Christos Mihos
- Echocardiography Lab, Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami, USA
| | | | - Massimo Chello
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
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Functional Mitral Valve Regurgitation. CURRENT CARDIOVASCULAR RISK REPORTS 2019. [DOI: 10.1007/s12170-019-0624-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Contrasting Effects of Pharmacological, Procedural, and Surgical Interventions on Proportionate and Disproportionate Functional Mitral Regurgitation in Chronic Heart Failure. Circulation 2019; 140:779-789. [DOI: 10.1161/circulationaha.119.039612] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Two distinct pathways can lead to functional mitral regurgitation (MR) in patients with chronic heart failure and a reduced ejection fraction. When remodeling and enlargement of the left ventricle (LV) cause annular dilatation and tethering of the mitral valve leaflets, there is a linear relationship between LV end-diastolic volume and the effective regurgitant orifice area of the mitral valve. These patients, designated as having proportionate MR, respond favorably to treatments that lead to reversal of LV remodeling and a decrease in LV volumes (eg, neurohormonal antagonists and LV assist devices), but they may not benefit from interventions that are directed only at the mitral valve leaflets (eg, transcatheter mitral valve repair). In contrast, when ventricular dyssynchrony causes functional MR attributable to unequal contraction of the papillary muscles, the magnitude of regurgitation is greater than that predicted by LV volumes. These patients, designated as having severe but disproportionate MR, respond favorably to treatments that are directed to the mitral valve leaflets or their supporting structures (eg, cardiac resynchronization or transcatheter mitral valve repair), but they may derive little benefit from interventions that act only to reduce LV cavity size (eg, pharmacological treatments). This novel conceptual framework reflects the important interplay between LV geometry and mitral valve function in determining the clinical presentation of patients, and it allows characterization of the determinants of functional MR to guide the most appropriate therapy in the clinical setting.
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Nappi F, Avtaar Singh SS, Padala M, Attias D, Nejjari M, Mihos CG, Benedetto U, Michler R. The Choice of Treatment in Ischemic Mitral Regurgitation With Reduced Left Ventricular Function. Ann Thorac Surg 2019; 108:1901-1912. [PMID: 31445916 DOI: 10.1016/j.athoracsur.2019.06.039] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 05/15/2019] [Accepted: 06/10/2019] [Indexed: 01/26/2023]
Abstract
BACKGROUND Ischemic mitral regurgitation is a condition characterized by mitral insufficiency secondary to an ischemic left ventricle. Primarily, the pathology is the result of perturbation of normal regional left ventricular geometry combined with adverse remodeling. We present a comprehensive review of contemporary surgical, medical, and percutaneous treatment options for ischemic mitral regurgitation, rigorously examined by current guidelines and literature. METHODS We conducted a literature search of the PubMed database, Embase, and the Cochrane Library (through November 2018) for studies reporting perioperative or late mortality and echocardiographic outcomes after surgical and nonsurgical intervention for ischemic mitral regurgitation. RESULTS Treatment of this condition is challenging and often requires a multimodality approach. These patients usually have multiple comorbidities that may preclude surgery as a viable option. A multidisciplinary team discussion is crucial in optimizing outcomes. There are several options for treatment and management of ischemic mitral regurgitation with differing benefits and risks. Guideline-directed medical therapy for heart failure is the treatment choice for moderate and severe ischemic mitral regurgitation, with consideration of coronary revascularization, mitral valve surgery, cardiac resynchronization therapy, or a combination of these, in appropriate candidates. The use of transcatheter mitral valve therapy is considered appropriate in high-risk patients with severe ischemic mitral regurgitation, heart failure, and reduced left ventricular ejection fraction, especially in those with hemodynamic instability. CONCLUSIONS The role of mitral valve surgery and transcatheter mitral valve therapy continues to evolve.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France.
| | | | - Muralidhar Padala
- Structural Heart Research & Innovation, Laboratory, Carlyle Fraser Heart Center, Division of Cardiothoracic Surgery, Emory University, Atlanta, Georgia
| | - David Attias
- Department of Cardiology, Centre Cardiologique du Nord, Saint-Denis, France
| | - Mohammed Nejjari
- Department of Cardiology, Interventional Cardiology Centre Cardiologique du Nord, Saint-Denis, France
| | - Christos G Mihos
- Echocardiography Laboratory, Division of Cardiology, Columbia University, Mount Sinai Heart Institute, Miami Beach, Florida
| | - Umberto Benedetto
- Department of Cardiothoracic Surgery, Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Robert Michler
- Department of Surgery and Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York
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de Groot-de Laat LE, Huizer J, Lenzen M, Spitzer E, Ren B, Geleijnse ML, Caliskan K. Evolution of mitral regurgitation in patients with heart failure referred to a tertiary heart failure clinic. ESC Heart Fail 2019; 6:936-943. [PMID: 31390167 PMCID: PMC6816234 DOI: 10.1002/ehf2.12478] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 04/27/2019] [Accepted: 05/21/2019] [Indexed: 12/11/2022] Open
Affiliation(s)
- Lotte E de Groot-de Laat
- Department of Cardiology, The Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jessy Huizer
- Department of Cardiology, The Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Mattie Lenzen
- Department of Cardiology, The Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ernest Spitzer
- Department of Cardiology, The Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ben Ren
- Department of Cardiology, The Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marcel L Geleijnse
- Department of Cardiology, The Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Kadir Caliskan
- Department of Cardiology, The Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
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Ischemic Mitral Regurgitation: Current Understanding and Surgical Options. Indian J Thorac Cardiovasc Surg 2019; 36:27-33. [PMID: 32733119 DOI: 10.1007/s12055-019-00811-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Secondary, or functional, mitral regurgitation (MR) occurs with impaired coaptation of structurally normal valve leaflets due to abnormal structure and/or function of the left ventricle (LV). A leading cause of functional mitral regurgitation is ischemic cardiomyopathy, resulting in left ventricular dysfunction and subsequent congestive heart failure (CHF) and ischemic mitral regurgitation (IMR). The value of surgical or transcatheter correction of IMR remains controversial, since the underlying pathology of IMR is attributed to a dysfunctional left ventricle. However, even mild IMR has been shown to be harmful to CHF patients, as IMR is both a surrogate of advanced CHF and an independent contributor to CHF morbidity and mortality. While observational and randomized studies have examined surgical treatment of IMR with conflicting outcomes, additional well-designed randomized controlled trials should be performed to further clarify the optimal treatment for IMR. Additionally, close attention should be paid to the quality of interventions performed, as durable reduction in IMR provides the best hope of a positive clinical outcome. This review focuses on the pathophysiology of IMR, current evidence regarding surgical and transcatheter interventions, and future directions in management of IMR.
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Secondary mitral regurgitation: percutaneous edge-to-edge repair on the cutting edge? Curr Opin Cardiol 2018; 34:185-193. [PMID: 30575648 DOI: 10.1097/hco.0000000000000593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Martin N, Manoharan K, Thomas J, Davies C, Lumbers RT. Beta-blockers and inhibitors of the renin-angiotensin aldosterone system for chronic heart failure with preserved ejection fraction. Cochrane Database Syst Rev 2018; 6:CD012721. [PMID: 29952095 PMCID: PMC6513293 DOI: 10.1002/14651858.cd012721.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Beta-blockers and inhibitors of the renin-angiotensin aldosterone system improve survival and reduce morbidity in people with heart failure with reduced left ventricular ejection fraction. There is uncertainty whether these treatments are beneficial for people with heart failure with preserved ejection fraction and a comprehensive review of the evidence is required. OBJECTIVES To assess the effects of beta-blockers, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor neprilysin inhibitors, and mineralocorticoid receptor antagonists in people with heart failure with preserved ejection fraction. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and two clinical trial registries on 25 July 2017 to identify eligible studies. Reference lists from primary studies and review articles were checked for additional studies. There were no language or date restrictions. SELECTION CRITERIA We included randomised controlled trials with a parallel group design enrolling adult participants with heart failure with preserved ejection fraction, defined by a left ventricular ejection fraction of greater than 40 percent. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion and extracted data. The outcomes assessed included cardiovascular mortality, heart failure hospitalisation, hyperkalaemia, all-cause mortality and quality of life. Risk ratios (RR) and, where possible, hazard ratios (HR) were calculated for dichotomous outcomes. For continuous data, mean difference (MD) or standardised mean difference (SMD) were calculated. We contacted trialists where neccessary to obtain missing data. MAIN RESULTS 37 randomised controlled trials (207 reports) were included across all comparisons with a total of 18,311 participants.Ten studies (3087 participants) investigating beta-blockers (BB) were included. A pooled analysis indicated a reduction in cardiovascular mortality (15% of participants in the intervention arm versus 19% in the control arm; RR 0.78; 95% confidence interval (CI) 0.62 to 0.99; number needed to treat to benefit (NNTB) 25; 1046 participants; 3 studies). However, the quality of evidence was low and no effect on cardiovascular mortality was observed when the analysis was limited to studies with a low risk of bias (RR 0.81; 95% CI 0.50 to 1.29; 643 participants; 1 study). There was no effect on all-cause mortality, heart failure hospitalisation or quality of life measures, however there is uncertainty about these effects given the limited evidence available.12 studies (4408 participants) investigating mineralocorticoid receptor antagonists (MRA) were included with the quality of evidence assessed as moderate. MRA treatment reduced heart failure hospitalisation (11% of participants in the intervention arm versus 14% in the control arm; RR 0.82; 95% CI 0.69 to 0.98; NNTB 41; 3714 participants; 3 studies; moderate-quality evidence) however, little or no effect on all-cause and cardiovascular mortality and quality of life measures was observed. MRA treatment was associated with a greater risk of hyperkalaemia (16% of participants in the intervention group versus 8% in the control group; RR 2.11; 95% CI 1.77 to 2.51; 4291 participants; 6 studies; high-quality evidence).Eight studies (2061 participants) investigating angiotensin converting enzyme inhibitors (ACEI) were included with the overall quality of evidence assessed as moderate. The evidence suggested that ACEI treatment likely has little or no effect on cardiovascular mortality, all-cause mortality, heart failure hospitalisation, or quality of life. Data for the effect of ACEI on hyperkalaemia were only available from one of the included studies.Eight studies (8755 participants) investigating angiotensin receptor blockers (ARB) were included with the overall quality of evidence assessed as high. The evidence suggested that treatment with ARB has little or no effect on cardiovascular mortality, all-cause mortality, heart failure hospitalisation, or quality of life. ARB was associated with an increased risk of hyperkalaemia (0.9% of participants in the intervention group versus 0.5% in the control group; RR 1.88; 95% CI 1.07 to 3.33; 7148 participants; 2 studies; high-quality evidence).We identified a single ongoing placebo-controlled study investigating the effect of angiotensin receptor neprilysin inhibitors (ARNI) in people with heart failure with preserved ejection fraction. AUTHORS' CONCLUSIONS There is evidence that MRA treatment reduces heart failure hospitalisation in heart failure with preserverd ejection fraction, however the effects on mortality related outcomes and quality of life remain unclear. The available evidence for beta-blockers, ACEI, ARB and ARNI is limited and it remains uncertain whether these treatments have a role in the treatment of HFpEF in the absence of an alternative indication for their use. This comprehensive review highlights a persistent gap in the evidence that is currently being addressed through several large ongoing clinical trials.
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Affiliation(s)
- Nicole Martin
- University College LondonFarr Institute of Health Informatics Research222 Euston RoadLondonUKNW1 2DA
| | - Karthick Manoharan
- John Radcliffe HospitalEmergency Department3 Sherwood AvenueLondonMiddlesexUKUb6 0pg
| | - James Thomas
- University College LondonEPPI‐Centre, Social Science Research Unit, UCL Institute of EducationLondonUK
| | - Ceri Davies
- Barts Heart Centre, St Bartholomew's HospitalDepartment of CardiologyWest SmithfieldLondonUKEC1A 7BE
| | - R Thomas Lumbers
- University College LondonInstitute of Health InformaticsLondonUK
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Abstract
Functional mitral regurgitation (FMR) is common in patients with heart failure and portends a poor prognosis. The etiology is secondary to nonischemic or ischemic (postmyocardial infarction) adverse remodeling. Treatment includes guideline-directed medical therapy, cardiac resynchronization therapy, and in some cases, surgical repair or replacement. Transcatheter mitral valve (MV) repair with the MitraClip device is approved in patients with degenerative MR and is currently under investigation for use in FMR, as are several transcatheter MV replacement devices. This review discusses the basis of FMR pathophysiology, classification, and prognosis; provides an overview of current therapeutic approaches; examines the available literature on the use of MitraClip in patients with FMR; and provides insight into ongoing clinical trials and new investigational devices for the treatment of FMR.
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23
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Kron IL, LaPar DJ, Acker MA, Adams DH, Ailawadi G, Bolling SF, Hung JW, Lim DS, Mack MJ, O'Gara PT, Parides MK, Puskas JD. 2016 update to The American Association for Thoracic Surgery (AATS) consensus guidelines: Ischemic mitral valve regurgitation. J Thorac Cardiovasc Surg 2017; 153:e97-e114. [DOI: 10.1016/j.jtcvs.2017.01.031] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 01/31/2017] [Indexed: 01/06/2023]
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Kron IL, Acker MA, Adams DH, Ailawadi G, Bolling SF, Hung JW, Lim DS, LaPar DJ, Mack MJ, O'Gara PT, Parides MK, Puskas JD. 2015 The American Association for Thoracic Surgery Consensus Guidelines: Ischemic mitral valve regurgitation. J Thorac Cardiovasc Surg 2016; 151:940-56. [DOI: 10.1016/j.jtcvs.2015.08.127] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 08/03/2015] [Accepted: 08/19/2015] [Indexed: 12/01/2022]
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Gonzalez FM, Finch AP, Armeni P, Boscolo PR, Tarricone R. Comparative effectiveness of Mitraclip plus medical therapy versus medical therapy alone in high-risk surgical patients: a comprehensive review. Expert Rev Med Devices 2015; 12:471-85. [PMID: 26051009 DOI: 10.1586/17434440.2015.1054807] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In recent years, Mitraclip has become available as a treatment option for mitral regurgitation in high-risk surgical patients. Focusing on the incremental effectiveness of Mitraclip versus the current standard of care, this article provides a comparative review of the evidence on Mitraclip and standard medical therapy (MT) in high-risk mitral regurgitation patients. Evidence was retrieved from seven major databases. Results suggest that Mitraclip presents a high safety profile and a good middle-term effectiveness performance. Evidence on long-term effectiveness is limited both for Mitraclip and MT. Few studies allow a comparison with MT and comparative results on different endpoints are mixed. Therefore, the available evidence does not conclusively inform whether or under which circumstances Mitraclip should be preferred over MT in the treatment of high-risk patients. Head-to-head real-world studies would be needed, as they would provide great and timely insights to support policy decisions when medical devices are at stake.
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Affiliation(s)
- Fernando Matias Gonzalez
- Centre for Research on Health and Social Care Management (CERGAS), Università Bocconi, Milan, Italy
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Secondary Mitral Regurgitation in Heart Failure. J Am Coll Cardiol 2015; 65:1231-1248. [DOI: 10.1016/j.jacc.2015.02.009] [Citation(s) in RCA: 303] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Revised: 01/16/2015] [Accepted: 02/03/2015] [Indexed: 12/23/2022]
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Grayburn PA, Carabello B, Hung J, Gillam LD, Liang D, Mack MJ, McCarthy PM, Miller DC, Trento A, Siegel RJ. Defining “Severe” Secondary Mitral Regurgitation. J Am Coll Cardiol 2014; 64:2792-801. [DOI: 10.1016/j.jacc.2014.10.016] [Citation(s) in RCA: 158] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Revised: 10/06/2014] [Accepted: 10/08/2014] [Indexed: 11/15/2022]
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Benjamin MM, Smith RL, Grayburn PA. Ischemic and Functional Mitral Regurgitation in Heart Failure: Natural History and Treatment. Curr Cardiol Rep 2014; 16:517. [DOI: 10.1007/s11886-014-0517-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Evidence of Atrial Functional Mitral Regurgitation Due to Atrial Fibrillation. J Am Coll Cardiol 2011; 58:1474-81. [PMID: 21939832 DOI: 10.1016/j.jacc.2011.06.032] [Citation(s) in RCA: 301] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Revised: 06/06/2011] [Accepted: 06/14/2011] [Indexed: 11/22/2022]
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Abstract
Mitral regurgitation affects more than 2 million people in the USA. The main causes are classified as degenerative (with valve prolapse) and ischaemic (ie, due to consequences of coronary disease) in developed countries, or rheumatic (in developing countries). This disorder generally progresses insidiously, because the heart compensates for increasing regurgitant volume by left-atrial enlargement, causes left-ventricular overload and dysfunction, and yields poor outcome when it becomes severe. Doppler-echocardiographic methods can be used to quantify the severity of mitral regurgitation. Yearly mortality rates with medical treatment in patients aged 50 years or older are about 3% for moderate organic regurgitation and about 6% for severe organic regurgitation. Surgery is the only treatment proven to improve symptoms and prevent heart failure. Valve repair improves outcome compared with valve replacement and reduces mortality of patient with severe organic mitral regurgitation by about 70%. The best short-term and long-term results are obtained in asymptomatic patients operated on in advanced repair centres with low operative mortality (<1%) and high repair rates (>/=80-90%). These results emphasise the importance of early detection and assessment of mitral regurgitation.
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Comin-Colet J, Marti-Almor J, Viles D, Bruguera J. Clinical predictors of outcome in patients with heart failure and neurohormonal blockade: referral for transplantation from heart failure units without heart transplantation programs. Transplant Proc 2002; 34:3227-9. [PMID: 12493428 DOI: 10.1016/s0041-1345(02)03704-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- J Comin-Colet
- Heart Failure Unit, Department of Cardiology: Hospital del Mar (IMAS), Barcelona, Spain.
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