Overview of mitral regurgitation in Europe: results from the European Registry of mitral regurgitation (EuMiClip)

Ring only repair of bileaflet mitral valve prolapse with mitral regurgitation: Insights from computational modeling

This study evaluates the efficacy of annuloplasty repair as a standalone procedure for treating bileaflet mitral valve prolapse with mitral regurgitation (MR). Various flexible ring bands for MR of different severities were compared to assess their biomechanical impact and treatment outcomes. Computational beating heart models, based on the Living Heart Human Model, were utilized to simulate annuloplasty repairs. Repairs using bands of varying lengths were modeled on moderate and severe MR cases, considering bileaflet mitral valve prolapse. Key parameters, including regurgitant orifice area (ROA), prolapse severity, coaptation length, leaflet position, and deformation, were computed to compare conditions before and after implantation. Annuloplasty repairs effectively reduced the ROA in both moderate and severe MR cases, achieving complete sealing in selective instances. Additionally, annuloplasty repair corrected bileaflet prolapse, with prolapse severity decreasing as the annular size increased. Successful coaptation was indicated by the expansion of each leaflet's contact area distribution and percentage in contact with the opposing leaflet. The risk of systolic anterior motion, that may obstruct the left ventricular outflow tract, was minimized, as the anterior leaflet was directed towards the posterior position. In conclusion, annuloplasty repair alone can effectively treat MR when an appropriate band length is selected. It facilitates a significant reduction in ROA, correction of bileaflet prolapse, and improvement in leaflet coaptation. These findings have important clinical implications, potentially offering a less complex surgical treatment avenue and reducing complications in the management of MR.

Overcoming the Disparity in Mitral Valve Repair: A Sex-Based Analysis of Long-Term Outcomes

BACKGROUND

Sex disparities remain pervasive across most cardiovascular diseases and continue to demonstrate notably worse early and late outcomes for women, especially after surgical repair. This study aims to investigate outcomes of mitral valve (MV) repair by sex and identify opportunities for improvement.

METHODS

A single center retrospective analysis of consecutive patients undergoing MV repair from May 2008 to February 2023 was conducted. In-hospital and long-term outcomes, including survival and symptomatic disease recurrence were examined by sex. Adjusted outcome analysis was performed using inverse-probability treatment weighting.

RESULTS

In total, 490 patients underwent MV repair (median age, 65 years; interquartile range [IQR], 57-73 years; sternotomy n = 128 [26%], minimally invasive n = 362 [74%]), including 343 male and 147 female patients. Median follow-up time was 5.4 years (IQR, 3.1-8.4 years). inverse-probability treatment weighting-adjusted 30-day outcomes for female vs male, including death (1.4% vs 0.6%, P = .59) and major adverse cardiovascular events (8.2% vs 7.6%, P = .81), were not significantly different. Survival for female vs male after mitral valve repair was 94.9% vs 98.0% at 2 years, 91.4% vs 97.8% at 4 years, and 87.2% vs 88.7% at 8 years (hazard ratio, 0.52; IQR, 0.19-1.44). Both unadjusted and inverse-probability treatment weighting-adjusted Cox-regression hazard ratios for survival and freedom from symptomatic disease recurrence demonstrated no significant difference between sexes at long-term follow-up.

CONCLUSIONS

These contemporary results are encouraging and suggest that a critical "bridging of the gap" between sexes is possible with comprehensive efforts including earlier detection and awareness and improved surgical techniques, though other factors may be important to explore further.

Outcomes of Mitral Valve Regurgitation Management after Expert Multidisciplinary Valve Team Evaluation

Background/Objectives: Mitral regurgitation (MR) affects millions worldwide, necessitating timely intervention. There are significant clinical challenges in the conservative management of MR, leaving a knowledge gap regarding the impact of multidisciplinary decision-making on treatment outcomes. This study aimed to provide insights into the impact of multidisciplinary decision-making on the survival outcomes of MR patients, focusing on conservative approaches. Methods: This study retrospectively analyzes 1365 patients evaluated by an expert multidisciplinary heart team (MDT) in a single center from 2015 to 2022. Treatments included surgery, catheter-based interventions, and conservative management. Propensity matching was utilized to compare surgery and conservative approaches. Results: Surgical intervention was associated with superior long-term survival outcomes compared to conservative and catheter-based treatments, particularly for degenerative MR (DMR). Survival rates of patients deemed by the MDT to have non-severe DMR were comparable to surgical patients (HR 1.07, 95% CI: 0.37-3.12, p = 0.90). However, non-severe functional MR (FMR) patients trended towards elevated mortality risk (HR 1.77, 95% CI: 0.94-3.31, p = 0.07). Pharmacological treatment for DMR was associated with significantly higher mortality compared to surgery (HR 8.0, 95% CI: 1.78-36.03, p = 0.001). Functional MR patients treated pharmacologically exhibited a non-significantly higher mortality risk compared to surgical intervention (HR 1.93, 95% CI: 0.77-4.77, p = 0.20). Conclusions: Survival analysis revealed significant benefits for surgical intervention, contrasting with elevated mortality risks associated with conservative management. "Watchful waiting" may be appropriate for non-severe DMR, while FMR may require closer monitoring. Further research is needed to assess the impact of regular follow-up or delayed surgery on survival rates, as pharmacological therapy has limited long-term efficacy for DMR.

Perspectives on Secondary Mitral Regurgitation in Heart Failure

PURPOSE OF THE REVIEW

This review focuses on broader perspectives of mitral regurgitation (MR) in patients with heart failure.

RECENT FINDINGS

The ratio of regurgitant volume to end-diastolic volume appears to help identify patients who may benefit from valve interventions. Secondary MR is not only attributed to geometric changes of the LV but also related to the structural changes in the mitral valve that include fibrosis of the mitral leaflets and changes in the extracellular matrix. The transition from mild to severe secondary MR can occur at different rates, from a slow LV remodeling process to a more abrupt process precipitated by an inciting event such as atrial fibrillation. Septal flash and apical rocking, two new visual markers of LV mechanical dyssynchrony, appear to be predictive of MR reduction following cardiac resynchronization therapy. Optimal guideline-directed medical therapy has been shown to decrease the severity of secondary MR effectively. A theoretical framework to characterize secondary MR as it relates to the onset of MR is proposed. Type A: Early onset of MR contemporaneous with myocardial injury. The maladaptive LV remodeling occurs in parallel with MR. Type B: LV remodeling proceeds without significant MR until the LV is moderately dilated, which coincides with or without inciting factors such as atrial fibrillation. Type C: LV remodeling proceeds after myocardial injury without significant MR until the LV is severely dilated. MR is a late manifestation of LV remodeling.

The impact of gender and frailty on the outcome of older patients with functional mitral regurgitation

AIMS

Functional mitral regurgitation (MR) is the second most common valvular heart disease worldwide and is increasing with age. The present study investigates the gender distribution and 1 year prognosis of older patients (≥65 years) with pharmacologically treated MR in a real-world population with moderate to severe functional MR.

METHODS AND RESULTS

This a single-centre retrospective observational cohort study and included 243 medically treated patients with moderate to severe MR from 2014 to 2020. Echocardiography was performed at baseline. The combined endpoint was hospitalization due to heart failure and all-cause death. There were more female than male patients (42% vs. 58%) without differences regarding age (81 ± 7 years in males vs. 82 ± 8 years in females, P = 0.24). Heart failure symptoms were distributed equally in both groups. Almost half of the patients evidenced a high EuroSCORE II (41%/42%). Atrial fibrillation was frequent, affecting 65% male and 64% female patients (P = 0.89). There were no differences regarding medical treatment. In both genders, two-thirds of the patients displayed MR grade II° (71% (72), and 69% (97)), and one-third showed MR grade III° (29% (30) vs. 31% (44), respectively, P = 0.76). Although males had larger left ventricular end-diastolic diameter, lower ejection fraction (39% (16) vs. 48% (14), P < 0.001), and more dilated left atria. After 1 year, genders did not differ regarding the combined primary endpoint of hospitalization due to heart failure and all-cause mortality (32% (33) for males vs. 29% (41) for females, P = 0.61). One-year mortality was low and equal in both cohorts (11% in males and 9% in females, P = 0.69). In univariate Cox regression proportion hazard model, being female was not associated with the primary endpoint (hazard ratio 0.87 (95% confidence interval 0.55 to 1.37), P = 0.54). Multivariable adjustment for EuroSCORE II and frailty did not result in a significant change regarding the impact of the female gender.

CONCLUSIONS

Despite better left ventricular systolic function, mortality in medically treated older female patients suffering from functional mitral regurgitation is not lower than in males. In this real-world cohort, frailty was a stronger predictor of clinical outcome than gender.

Sex Differences in Epidemiology, Morphology, Mechanisms, and Treatment of Mitral Valve Regurgitation

Sex-related disparities have been recognized in incidence, pathological findings, pathophysiological mechanisms, and diagnostic pathways of non-rheumatic mitral regurgitation. Furthermore, access to treatments and outcomes for surgical and interventional therapies among women and men appears to be different. Despite this, current European and US guidelines have identified common diagnostic and therapeutic pathways that do not consider patient sex in decision-making. The aim of this review is to summarize the current evidence on sex-related differences in non-rheumatic mitral regurgitation, particularly regarding incidence, imaging modalities, surgical-derived evidence, and outcomes of transcatheter edge-to-edge repair, with the goal of informing clinicians about sex-specific challenges to consider when making treatment decisions for patients with mitral regurgitation.

European Society of Cardiology: cardiovascular disease statistics 2021

AIMS

This report from the European Society of Cardiology (ESC) Atlas Project updates and expands upon the widely cited 2019 report in presenting cardiovascular disease (CVD) statistics for the 57 ESC member countries.

METHODS AND RESULTS

Statistics pertaining to 2019, or the latest available year, are presented. Data sources include the World Health Organization, the Institute for Health Metrics and Evaluation, the World Bank, and novel ESC sponsored data on human and capital infrastructure and cardiovascular healthcare delivery. New material in this report includes sociodemographic and environmental determinants of CVD, rheumatic heart disease, out-of-hospital cardiac arrest, left-sided valvular heart disease, the advocacy potential of these CVD statistics, and progress towards World Health Organization (WHO) 2025 targets for non-communicable diseases. Salient observations in this report: (i) Females born in ESC member countries in 2018 are expected to live 80.8 years and males 74.8 years. Life expectancy is longer in high income (81.6 years) compared with middle-income (74.2 years) countries. (ii) In 2018, high-income countries spent, on average, four times more on healthcare than middle-income countries. (iii) The median PM2.5 concentrations in 2019 were over twice as high in middle-income ESC member countries compared with high-income countries and exceeded the EU air quality standard in 14 countries, all middle-income. (iv) In 2016, more than one in five adults across the ESC member countries were obese with similar prevalence in high and low-income countries. The prevalence of obesity has more than doubled over the past 35 years. (v) The burden of CVD falls hardest on middle-income ESC member countries where estimated incidence rates are ∼30% higher compared with high-income countries. This is reflected in disability-adjusted life years due to CVD which are nearly four times as high in middle-income compared with high-income countries. (vi) The incidence of calcific aortic valve disease has increased seven-fold during the last 30 years, with age-standardized rates four times as high in high-income compared with middle-income countries. (vii) Although the total number of CVD deaths across all countries far exceeds the number of cancer deaths for both sexes, there are 15 ESC member countries in which cancer accounts for more deaths than CVD in males and five-member countries in which cancer accounts for more deaths than CVD in females. (viii) The under-resourced status of middle-income countries is associated with a severe procedural deficit compared with high-income countries in terms of coronary intervention, ablation procedures, device implantation, and cardiac surgical procedures.

CONCLUSION

Risk factors and unhealthy behaviours are potentially reversible, and this provides a huge opportunity to address the health inequalities across ESC member countries that are highlighted in this report. It seems clear, however, that efforts to seize this opportunity are falling short and present evidence suggests that most of the WHO NCD targets for 2025 are unlikely to be met across ESC member countries.

Transcatheter mitral valve intervention

Mitral regurgitation is a common valvular heart disorder increasing with age. Many patients are ineligible for mitral valve surgery due to their age and other comorbidities. Left untreated, patients develop severe disease with a poor prognosis. The development of lower risk percutaneous mitral valve interventions has helped meet the needs of this previously untreated patient group. This review explores the recent and more established developments that have expanded the armamentarium for transcatheter mitral valve intervention.

Sex differences in prognosis of significant secondary mitral regurgitation

AIMS

Secondary mitral regurgitation (MR) is more frequent in men than in women. However, little is known about differences in prognosis between men and women with secondary MR. The objective of this study is to investigate the sex distribution of secondary MR and the prognostic differences between sexes.

METHODS

Patients with significant secondary MR, of both ischaemic and non-ischaemic aetiologies, were identified through the departmental electronic patient files and retrospectively analysed. The primary endpoint was all-cause mortality.

RESULTS

A total of 698 patients (mean age 66 ± 11 years) with significant secondary MR were included: 471 (67%) men and 227 (33%) women. Ischaemic heart failure was significantly more common in men (61%), whereas non-ischaemic heart failure was more prevalent in women (63%). Women had significantly smaller left ventricular (LV) volumes when compared with men and more preserved LV systolic function when assessed with LV global longitudinal strain (GLS; 8.5 ± 4.1% vs. 7.5 ± 3.6%; P = 0.004). Women more often underwent surgical mitral valve repair (34%) when compared with men (26%), although no differences were observed for transcatheter mitral valve repair. During a median follow-up of 57 [interquartile range 29-110] months, 373 (53%) patients died. Women showed significantly lower mortality rates at 1-, 2- and 5-year follow-up (9%, 16% and 33% vs. 10%, 20% and 42%) when compared with men (P = 0.001).

CONCLUSIONS

Significant secondary MR is more frequently observed in men as compared with women and is associated with worse prognosis.

Mitral Regurgitation in Patients Undergoing Noncardiac Surgery

Mitral regurgitation (MR) is one of the most frequently encountered types of valvular heart disease in the United States. Patients with significant MR (moderate-to-severe or severe) undergoing noncardiac surgery have an increased risk of perioperative cardiovascular complications. MR can arise from a diverse array of causes that fall into 2 broad categories: primary (diseases intrinsic to the valvular apparatus) and secondary (diseases that disrupt normal valve function via effects on the left ventricle or mitral annulus). This article highlights key guideline updates from the American College of Cardiologists (ACC) and the American Heart Association (AHA) that inform decision-making for the anesthesiologist caring for a patient with MR undergoing noncardiac surgery. The pathophysiology and natural history of acute and chronic MR, staging of chronic primary and secondary MR, and considerations for timing of valvular corrective surgery are reviewed. These topics are then applied to a discussion of anesthetic management, including preoperative risk evaluation, anesthetic selection, hemodynamic goals, and intraoperative monitoring of the noncardiac surgical patient with MR.

Sex-Specific Outcomes of Transcatheter Mitral-Valve Repair and Medical Therapy for Mitral Regurgitation in Heart Failure

OBJECTIVES

This study sought to assess the sex-specific outcomes in patients with heart failure (HF) with 3+ and 4+ secondary mitral regurgitation (SMR) treated with transcatheter mitral valve repair (TMVr) plus guideline-directed medical therapy (GDMT) versus GDMT alone in the COAPT trial.

BACKGROUND

The impact of sex in patients with HF and severe SMR treated with TMVr with the MitraClip compared with GDMT alone is unknown.

METHODS

Patients were randomized 1:1 to TMVr versus GDMT alone. Two-year outcomes were examined according to sex.

RESULTS

Among 614 patients, 221 (36.0%) were women. Women were younger than men and had fewer comorbidities, but reduced quality of life and functional capacity at baseline. In a joint frailty model accounting for the competing risk of death, the 2-year cumulative incidence of the primary endpoint of all HF hospitalizations (HFH) was higher in men compared with women treated with GDMT alone. However, the relative reduction in HFHs with TMVr was greater in men (HR: 0.43; 95% CI: 0.34-0.54) than women (HR: 0.78; 95% CI: 0.57-1.05) (P_interaction = 0.002). A significant interaction between TMVr versus GDMT alone treatment and time was present for all HFHs in women (HR: 0.57; 95% CI: 0.39-0.84, and HR: 1.39; 95% CI: 0.83-2.33 between 0-1 year and 1-2 years after randomization, respectively, P_interaction = 0.007) but not in men (HR: 0.48; 95% CI: 0.36-0.64, and HR: 0.33; 95% CI: 0.21-0.51; P_interaction = 0.16). Female sex was independently associated with a lower adjusted risk of death at 2 years (HR: 0.64; 95% CI: 0.46-0.90; P = 0.011). TMVr consistently reduced 2-year mortality compared with GDMT alone, irrespective of sex (P_interaction = 0.99).

CONCLUSIONS

In the COAPT trial, TMVr with the MitraClip resulted in improved clinical outcomes compared with GDMT alone, irrespective of sex. However, the impact of TMVr in reducing HFH was less pronounced in women compared with men beyond the first year after treatment. (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation [The COAPT Tria] [COAPT]; NCT01626079).

New insights of tricuspid regurgitation: a large-scale prospective cohort study

AIMS

To evaluate the burden of tricuspid regurgitation (TR) in a large cohort, determine the right ventricle involvement of patients with TR and determine the characteristics of isolated TR.

METHODS AND RESULTS

Prospective study where consecutive patients undergoing an echocardiographic study in 10 centres were included. All studies with significant TR (at least moderate) were selected. We considered that patients with one of pulmonary systolic hypertension >50 mmHg, left ventricular ejection fraction <35%, New York Heart Association III-IV, or older than 85 years, had a high surgical risk. A total of 35 088 echocardiograms were performed. Significant TR was detected in 6% of studies. Moderate TR was found in 69.6%, severe in 25.5%, massive in 3.9%, and torrential in 1.0% of patients. Right ventricle was dilated in 81.7% of patients with massive/torrential TR, in 55.9% with severe TR, and in 29.3% with moderate TR (P < 0.001). Primary TR was present in 7.4% of patients whereas secondary TR was present in 92.6%. Mitral or aortic valve disease was the most common aetiology (54.6%), following by isolated TR (16%). Up to 51.9% of patients with severe, massive, or torrential primary TR and 57% of patients with severe, massive, or torrential secondary TR had a high surgical risk.

CONCLUSION

Significant TR is a prevalent condition and a high proportion of these patients have an indication for valve intervention. More than a half of patients with severe, massive, or torrential TR had a high surgical risk. Massive/torrential TR may have implications regarding selection and monitoring patients for percutaneous treatment.

A Nationwide Survey of Surgical Treatment for Severe Ischemic Mitral Regurgitation

Objective: Mitral subvalvular procedures in addition to restrictive annuloplasty are promising for ischemic mitral regurgitation (IMR). However, the prevalence and efficacy of specific subvalvular repair in severe IMR have not been elucidated. This is the first nationwide survey regarding surgeons’ attitudes toward IMR in Japan.

Methods: A questionnaire was sent to 543 institutions. From 2015 to 2019, numbers of elective first-time mitral valve replacement (MVR) with/without complete chordal preservation (CCP)/papillary muscle approximation (PMA) and mitral valvuloplasty (MVP) with/without papillary muscle relocation (PMR)/PMA in patients with severe IMR were collected. Concomitant procedures for coronary artery, tricuspid valve, and arrhythmia could be included but left ventricular reconstruction was excluded.

Results: Completed questionnaires were received from 286 institutions (52.7%). The majority (90%) had less than 20 cases within 5 years. The number of MVP (1413, 61.5%) surpassed MVR (886, 38.5%). CCP was performed in half of MVR (50.0%), while PMA was included in only 1.9% of MVR. PMA and PMR were also performed infrequently, in only 7.7% and 10.9% of MVP, respectively.

Conclusion: Japanese surgeons aggressively perform MVP for severe IMR. Subvalvular repair was also aggressively performed in addition to MVR, but not to MVP. A multicenter registry study is in progress.

Percutaneous mitral valve repair with MitraClip device in hemodynamically unstable patients: A systematic review

BACKGROUND

Very few data exist on percutaneous mitral valve repair (PMVr) in unstable patients with concomitant moderate-severe mitral regurgitation (MR). The purpose of this systematic review was to evaluate baseline characteristics, management and clinical outcomes of critically ill patients undergoing PMVr with MitraClip.

METHODS

We conducted a systematic review of the published data on MitraClip from its first use in 2003 to December 2020. Studies referring to critically ill patients in cardiogenic shock or acute refractory pulmonary edema were included. A total of 40 publications including 254 patients with significant MR (Grade 4 in 91%) were included.

RESULTS

Mean age was 70 ± 12 years with mean Euroscore II and STS of 21 ± 13 and 20.5 ± 16, respectively. Clinical presentation was with cardiogenic shock and acute myocardial infarction in 72.8 and 60.0% of patients, respectively. Device success was achieved in 238 (93.7%) patients with a significant reduction in MR (Grade ≤ 2 in 91.8%, p < .001). The median weaning time from the procedure, to discontinuation of mechanical circulatory or respiratory support, was 2 days (IQR 1-4), with an in-hospital mortality and non-fatal complication rate of 12.6 and 9.1%, respectively. Kaplan-Meier curves estimated an overall mortality rate of 39.1% at 12-month follow-up, with persistent reduction in MR severity for survivors (Grade ≤ 2 in 81.3%) and one case of mitral valve reintervention.

CONCLUSIONS

Percutaneous mitral valve repair with MitraClip device is a technically feasible and potentially viable management option in high-risk patients with cardiogenic shock or refractory pulmonary edema and concomitant moderate-severe MR. Prospective trials are required to confirm these findings, and definitively determine the value of MitraClip in hemodynamically unstable patients.

Transcatheter Repair of the Mitral Valve: Relevant Pathophysiology, Investigation, and Management

Mitral regurgitation (MR) is a common condition causing significant morbidity and mortality in the Western world. Although surgical therapy has developed over 5 decades to provide solutions, only a minority of patients undergo surgery. The last decade has seen the emergence and application of multiple transcatheter techniques in attempts to address this undertreated population with the large clinical experience of MitraClip providing the most insight. Clear understanding of the pathophysiology of different MR types as well as the role of particularly secondary MR on patient's clinical syndrome allow for better prediction as to which patient subgroups will benefit from different repair techniques or intervention at all. Most of the techniques are based on surgical technique and are applied as single-device/technique solutions, whether leaflet, chordal, or annular solutions, but with broadening experience, combination therapies are likely to find a place in creating a more complete and surgical-like solution.

Sex and Race Differences in the Pathophysiology, Diagnosis, Treatment, and Outcomes of Valvular Heart Diseases

Valvular heart diseases have long been considered to be similar in men and women and across races/ethnicities. Recently, studies have demonstrated major differences between sexes. Unfortunately, studies on valvular heart diseases, as on other cardiovascular diseases, are mostly performed in Caucasian men or in cohorts with a vast majority of Caucasian men. Therefore, our knowledge on valvular diseases in women and non-Caucasians remains limited. Nevertheless, aortic stenosis has been shown to be almost as prevalent in women as in men, and less prevalent in African Americans. Men appear to have a more calcified aortic valve lesion, and women tend to have a more fibrosed one. Primary mitral regurgitation is more frequent in women who have more rheumatic and Barlow etiologies, whereas men have more fibroelastic deficiency and posterior leaflet prolapse/flail. Left ventricular remodelling due to valvular heart diseases is sex related in terms of geometry and probably also in composition of the tissue. Outcomes seem to be worse in women after surgical interventions and better than or equivalent to men after transcatheter ones. Regarding other valvular heart diseases, very few studies are available: Aortic regurgitation is more frequent in men, isolated tricuspid regurgitation more frequent in women. Rheumatic valve diseases are more frequent in women and are mostly represented by mitral and aortic stenoses. Many other sex/gender- and race/ethnic-specific studies are still needed in epidemiology, pathophysiology, presentation, management, and outcomes. This review aims to report the available data on sex differences and race specificities in valvular heart diseases, with a primary focus on aortic stenosis and mitral regurgitation.

Presentation and outcomes of mitral valve surgery in France in the recent era: a nationwide perspective

Objectives

Unbiased information regarding the surgical management of patients with mitral regurgitation (MR) at the nationwide level are scarce and mainly US-based. The Programme de Médicalisation des Systèmes d’Information, a mandatory national database, offers the unique opportunity to assess the presentation and outcomes of all consecutive mitral valve (MV) surgeries performed in France in the contemporary era.

Methods

We collected all MV surgeries performed for MR in France in 2014–2016. MR aetiology was classified as degenerative (DMR), secondary (SMR) or Other (rheumatic or congenital disease and infective endocarditis).

Results

During the 3-year period, 18 167 MV surgeries were performed in France (55% repair and 45% replacement; 52% isolated). Age was 66±12 years and 59% were male. Aetiology was DMR in 42%, SMR in 16% and other in 42% including 19% with uncertain aetiologies. Overall, in-hospital mortality was 6.5% and increased with age, female gender, Charlson Comorbidity Index, type of surgery (replacement vs repair), associated surgery (combined vs isolated) and MR aetiology (all p<0.01). In-hospital mortality and rate of death/readmission for heart failure (HF) at 1 year were 3.4% and 13%, respectively for DMR (2.4% and 11% for isolated DMR) and 7.8% and 27%, respectively for SMR (5.5% and 23% for isolated SMR). Repair rate was 55% overall, 68% in DMR and 72% for isolated DMR surgery (70% of all DMR). Repair rates decreased with age, Charlson Comorbidity Index and female sex (all p<0.0001).

Conclusion

In this cross-sectional contemporary prospective nationwide database, in-hospital mortality and 1 year rate of death and HF readmission were considerable overall and in all subsets. Repair rates were suboptimal overall especially in the elderly and women subsets. These results underline the need to develop strategies to improve management and outcomes of patients with both DMR and SMR.

Pattern of Cardiac Diseases and Co-Existing Morbidities Among Newly Registered Cardiac Patients in an Adult Cardiac Referral Clinic of Hawassa University Comprehensive Specialized Hospital, Southern-Ethiopia

Background

Currently, cardiovascular diseases (CVDs) are rising in the world and require great concern because the consequences are not only morbidity and mortality, but also a high economic burden. However, the pattern of CVDs in Ethiopia is not well known. Therefore, this study aimed to describe CVD and co-existing morbidities among newly registered cardiac patients in Hawassa University Comprehensive Specialized Hospital.

Methods

A retrospective cross-sectional study was conducted from January 1 to December 31, 2016 among newly registered cardiac patients in an adult cardiac referral clinic. Records and cardiac referral clinic logbooks were used to collect relevant information using structured checklists.

Results

Of the total 310 records of cardiac patients, 236 were explored and included in the study, while the records of 74 patients were absent in the cards room when tracing and/or incomplete to assess cardiac pattern. Rheumatic heart disease (RHD) was the leading cardiac problem and diagnosed in 70 (29.7%) cases followed by non-ischemic cardiomyopathy (55, 23.3%), ischemic heart disease (41, 17.4%), hypertensive heart disease (29, 12.3%), and cor pulmonale (14, 5.9%). The mean age of RHD patients was 28.7 (±13.1) years. Eighty-two (35%) females and 23 (19.8%) males had RHD, while 69 (29.2%) females and 23 (19.8%) males had non-ischemic cardiomyopathy. The overall rate of mitral stenosis, mitral regurgitation, and aortic regurgitation among patients with RHD were 39 (55.7%), 48 (68.6%), and 26 (37.1%), respectively. Moreover, the overall coexisted morbidity was 81 (34.3%), with a high rate of hypertension alone at 44 (18.6%) followed by hypertension with diabetes at 11 (4.7%).

Conclusion

This study indicated that more than one-third of cardiac patients had at least one of the co-existing morbidities like hypertension, diabetes mellitus, asthma and other diseases. Therefore, careful diagnosis and management of cardiac patients plays an important role to minimize comorbidity-linked complications. Moreover, population-based studies are recommended for better representing and generalization.

Left atrial strain as a pre-operative prognostic marker for patients with severe mitral regurgitation

BACKGROUND

In patients with severe mitral regurgitation (MR), additional echocardiographic indices could be helpful to optimize surgical timing before irreversible left heart myocardial dysfunction has occurred. We investigated the correlation of left atrial (LA) strain by speckle tracking echocardiography with prognosis after mitral surgery for severe MR, and its association with LA fibrosis.

METHOD

71 patients with primary severe MR undergoing pre-operative echocardiographic assessment were initially enrolled. Exclusion criteria were: other valvular disease>moderate, history of coronary artery disease, heart failure (HF), hypertrophic cardiomyopathy, left bundle branch block, previous pacemaker implantation, heart transplantation, poor acoustic window. The primary endpoint was the occurrence of composite events (HF and mortality); the secondary endpoint was post-operative functional capacity (NYHA and Borg CR10 class). LA fibrosis was assessed by atrial biopsy specimens in a subset of patients.

RESULTS

Of 65 eligible patients, the primary endpoint occurred in 30 patients (medium follow-up: 3.7 ± 1 years for event-group, 6.8 ± 1 years for non-event group). After Kaplan-Meier analysis, peak atrial longitudinal strain (PALS) provided good risk stratification (5-year event-free survival:90 ± 5% for PALS≥21% vs 30 ± 9% for PALS<21%, p < 0.0001); it was an independent and incremental predictor of outcome in four multivariate Cox adjusted models. There was also an association between PALS and the secondary endpoint (NYHA: r² = 0.11, p = 0.04; Borg CR10: r² = 0.10, p = 0.02) and an inverse correlation between PALS<21% and LA fibrosis (r² 0.80, fibrosis: 76.6 ± 20.7% vs 31.9 ± 20.8%;p < 0.0001).

CONCLUSIONS

Global PALS emerged as a reliable predictor of outcome and functional capacity for severe primary MR, and as a marker of LA fibrosis.

Dismal Outcomes and High Societal Burden of Mitral Valve Regurgitation in France in the Recent Era: A Nationwide Perspective

Background Although US recent data suggest that mitral regurgitation (MR) is severely undertreated and carries a poor outcome, population-based views on outcome and management are limited. We aimed to define the current treatment standards, clinical outcomes, and costs related to MR at the nationwide level. Methods and Results In total, 107 412 patients with MR were admitted in France in 2014 to 2015. Within 1 year, 8% were operated and 92% were conservatively managed and constituted our study population (68% primary MR and 32% secondary MR). The mean age was 77±15 years; most patients presented with comorbidities. In-hospital and 1-year mortality rates were 4.1% and 14.3%, respectively. Readmissions were common (63% at least once and 37% readmitted ≥2 times). Rates of 1-year mortality or all-cause readmission and 1-year mortality or heart failure readmission were 67% and 34%, respectively, and increased with age, Charlson index, heart failure at admission, and secondary MR etiology; however, the event rate remained notably high in the primary MR subset (64% and 28%, respectively). The mean costs of hospital admissions and of readmissions were 5345±6432 and 10 080±10 847 euros, respectively. Conclusions At the nationwide level, MR was a common reason for admission and affected an elderly population with frequent comorbidities. Less than 10% of patients underwent a valve intervention. All subsets of patients who were conservatively managed incurred high mortality and readmissions rates, and MR represented a major societal burden with an extrapolated annual cost of 350 to 550 million euros (390-615 million US dollars). New strategies to improve the management and outcomes of patients with both primary and secondary MR are critical and warranted.

Mechanism of Eccentric Cardiomyocyte Hypertrophy Secondary to Severe Mitral Regurgitation

BACKGROUND

Primary valvular heart disease is a prevalent cause of morbidity and mortality in both industrialized and developing countries. Although the primary consequence of valvular heart disease is myocardial dysfunction, treatment of valvular heart diseases centers around valve repair or replacement rather than prevention or reversal of myocardial dysfunction. This is particularly evident in primary mitral regurgitation (MR), which invariably results in eccentric hypertrophy and left ventricular (LV) failure in the absence of timely valve repair or replacement. The mechanism of LV dysfunction in primary severe MR is entirely unknown.

METHODS

Here, we developed the first mouse model of severe MR. Valvular damage was achieved by severing the mitral valve leaflets and chords with iridectomy scissors, and MR was confirmed by echocardiography. Serial echocardiography was performed to follow up LV morphology and systolic function. Analysis of cardiac tissues was subsequently performed to evaluate valve deformation, cardiomyocyte morphology, LV fibrosis, and cell death. Finally, dysregulated pathways were assessed by RNA-sequencing analysis and immunofluorescence.

RESULTS

In the ensuing 15 weeks after the induction of MR, gradual LV dilatation and dysfunction occurred, resulting in severe systolic dysfunction. Further analysis revealed that severe MR resulted in a marked increase in cardiac mass and increased cardiomyocyte length but not width, with electron microscopic evidence of sarcomere disarray and the development of sarcomere disruption. From a mechanistic standpoint, severe MR resulted in activation of multiple components of both the mammalian target of rapamycin and calcineurin pathways. Inhibition of mammalian target of rapamycin signaling preserved sarcomeric structure and prevented LV remodeling and systolic dysfunction. Immunohistochemical analysis uncovered a differential pattern of expression of the cell polarity regulator Crb2 (crumbs homolog 2) along the longitudinal axis of cardiomyocytes and close to the intercalated disks in the MR hearts. Electron microscopy images demonstrated a significant increase in polysome localization in close proximity to the intercalated disks and some areas along the longitudinal axis in the MR hearts.

CONCLUSIONS

These results indicate that LV dysfunction in response to severe MR is a form of maladaptive eccentric cardiomyocyte hypertrophy and outline the link between cell polarity regulation and spatial localization protein synthesis as a pathway for directional cardiomyocyte growth.

Right ventricular mechanical pattern in patients undergoing mitral valve surgery: a predictor of post-operative dysfunction?

Aims

The PREPARE‐MVR study (PRediction of Early PostoperAtive Right vEntricular failure in Mitral Valve Replacement/Repair patients) sought to investigate the alterations of right ventricular (RV) contraction pattern in patients undergoing mitral valve replacement/repair (MVR) and to explore the associations between pre‐operative RV mechanics and early post‐operative RV dysfunction (RVD).

Methods and results

We prospectively enrolled 42 patients (63 ± 11 years, 69% men) undergoing open‐heart MVR. Transthoracic three‐dimensional (3D) echocardiography was performed pre‐operatively, at intensive care unit discharge, and 6 months after surgery. The 3D model of the RV was reconstructed, and RV ejection fraction (RVEF) was calculated. We decomposed the motion of the ventricle to compute longitudinal ejection fraction (LEF) and radial ejection fraction (REF). Pulmonary artery catheterization was performed to monitor RV stroke work index (RVSWi). RVEF was slightly decreased after MVR [52 (50–55) vs. 51 (46–54)%; P = 0.001], whereas RV contraction pattern changed notably. Before MVR, the longitudinal shortening was the main contributor to global systolic RV function [LEF/RVEF vs. REF/RVEF; 0.53 (0.47–0.58) vs. 0.33 (0.22–0.42); P < 0.001]. Post‐operatively, the radial motion became dominant [0.33 (0.28–0.43) vs. 0.46 (0.37–0.51); P = 0.004]. However, this shift was temporary as 6 months later the two components contributed equally to global RV function [0.44 (0.38–0.50) vs. 0.41 (0.36–0.49); P = 0.775]. Pre‐operative LEF was an independent predictor of post‐operative RVD defined as RVSWi < 300 mmHg⋅mL/m² [OR = 1.33 (95% CI: 1.08–1.77), P < 0.05].

Conclusions

MVR induces a significant shift in the RV mechanical pattern. Advanced indices of RV mechanics are associated with invasively measured parameters of RV contractility and may predict post‐operative RVD.

Global longitudinal strain is a hallmark of cardiac damage in mitral regurgitation: the Italian arm of the European Registry of mitral regurgitation (EuMiClip)

BACKGROUND

The search for reliable cardiac functional parameters is crucial in patients with mitral regurgitation (MR). In the Italian arm of the European Registry of MR, we compared the ability of global longitudinal strain (GLS) and left ventricular (LV) ejection fraction (LVEF) to detect cardiac damage in MR.

METHODS

Five hundred four consecutive patients with MR underwent a complete echo-Doppler exam. A total of 431, 53 and 20 patients had degenerative, secondary and mixed MR, respectively. The main echocardiographic parameters, including LV and left atrial (LA) size measurements, pulmonary artery systolic pressure (PASP) and GLS were compared between patients with mild MR (n = 392) vs. moderate to severe MR (n = 112).

RESULTS

LVEF and GLS were related one another in the pooled population, and separately in patients with mild and moderate/severe MR (all p < 0.0001). However, a certain number of patients were above the upper or below the lower limits of the 95% confidence interval (CI) of the normal relation in the pooled population and in patients with mild MR. Only 2 patients were below the 95% CI in moderate to severe MR. After adjusting for confounders by separate multivariate models, LVEF and GLS were independently associated with LV and left atrial size in the pooled population and in mild and moderate/severe MR. GLS, but not LVEF, was also independently associated with PASP in patients with mild and moderate to severe MR.

CONCLUSIONS

Both LVEF and GLS are independently associated with LV and LA size, but only GLS is related to pulmonary arterial pressure. GLS is a powerful hallmark of cardiac damage in MR.

Phenotyping progression of secondary mitral regurgitation in chronic systolic heart failure

BACKGROUND

Secondary mitral regurgitation (sMR) drives adverse cardiac remodelling in patients with heart failure with reduced ejection fraction (HFrEF). Progression in severity over time contributes to a transition towards more advanced HF stages. Early identification of patients at risk for sMR progression remains challenging. We therefore sought to assess a broad spectrum of neurohumoral biomarkers in patients with HFrEF to explore their ability to predict progression of sMR.

METHODS

A total of 249 HFrEF patients were enrolled. Biomarkers encompassing key neurohumoral pathways in heart failure were sampled at baseline, and sMR progression was assessed over 3 years of follow-up.

RESULTS

Of 191 patients with nonsevere sMR at baseline, 18% showed progressive sMR within three years after study enrolment. Progression of sMR was associated with higher levels of MR-proADM (adj.OR 2.25, 95% CI 1.29-3.93; P = .004), MR-proANP (adj.OR 1.84, 95% CI 1.14-3.00; P = .012), copeptin (adj.OR 1.66, 95% CI 1.04-2.67; P = .035) and CT-pro-ET1 (adj.OR 1.68, 95% CI 1.06-2.68; P = .027) but not with NT-proBNP (P = .54).

CONCLUSION

Increased plasma levels of neurohumoral cardiac biomarkers are predictors of sMR progression in patients with HFrEF and add easily available incremental prognostic information for risk stratification. Importantly, NT-proBNP was not useful to predict progressive sMR in the present analysis. On the contrary, MR-proANP, primarily produced in the atria, copeptin partly triggered by intra-cardiac and intra-arterial pressures and MR-proADM, a marker of forward failure and peripheral released vasoactive CT-proET1, increase based on a progressive loading burden by sMR and may thus serve as better predictors of sMR progression.

Safety and outcomes of MitraClip implantation in functional mitral regurgitation according to degree of left ventricular dysfunction

INTRODUCTION AND OBJECTIVES

Recent randomized trials of the MitraClip system have reported controversial results in the treatment of patients with functional mitral regurgitation (FMR). The aim of the present study was to evaluate the safety and impact of MitraClip implantation on outcomes in FMR according to left ventricular (LV) status.

METHODS

Patients with FMR undergoing MitraClip implantation in our center were retrospectively screened and divided into 2 groups according to LV ejection fraction (LVEF) and LV end-diastolic dimension: "very poor LV" (LVEF ≤ 20% and/or LV end-diastolic dimension ≥ 70 mm) and "poor LV" (LVEF> 20% and LV end-diastolic dimension <70 mm). Survival analysis of cardiovascular outcomes included hospital admission due to congestive heart failure, heart transplant, and cardiovascular death. Likewise, we compared the number of hospital admissions and functional class the year before and after the intervention.

RESULTS

Fifty-eight consecutive patients with FMR were included (28 with very poor LV and 30 with poor LV). The mean follow-up was 19.5± 13 months. Patients with poor LV showed a significantly better event-free survival for cardiovascular events (log-rank 3.706, P=.010). One year after the intervention, both groups showed symptom improvement. Most of the patients were in New York Heart Association functional class I-II (100% poor LV and 84% very poor LV) and both groups showed a decrease in the number of hospital admissions due to congestive heart failure.

CONCLUSIONS

MitraClip implantation seems to be safe and effective in reducing FMR. Although patients with very low LVEF and/or very enlarged LV seemed to have worse cardiovascular outcomes, the intervention was safe and resulted in symptom improvement.

The year 2018 in the European Heart Journal - Cardiovascular Imaging: Part I

The European Heart Journal - Cardiovascular Imaging has become one of the leading multimodality cardiovascular imaging journal, since it was launched in 2012. The impact factor is an impressive 8.366 and it is now established as one of the top 10 cardiovascular journals. The journal is the most important cardiovascular imaging journal in Europe. The most important studies from 2018 will be highlighted in two reports. Part I of the review will focus on studies about myocardial function and risk prediction, myocardial ischaemia, and emerging techniques in cardiovascular imaging, while Part II will focus on valvular heart disease, heart failure, cardiomyopathies, and congenital heart disease.

Cardiac surgery 2018 reviewed

For the year 2018, more than 22,000 published references can be found in PubMed when entering the search term "cardiac surgery". As in the last 4 years, this review focusses on conventional cardiac surgery publications which provide important and interesting information especially relevant for non-surgical colleagues. Interventional techniques have been considered if they were published in the context of classic surgical techniques. We have again reviewed the fields of coronary revascularization and valve surgery and briefly touched on aortic surgery and surgery for terminal heart failure. For revascularization of complex coronary artery disease, bypass grafting was reconfirmed as gold standard and computer-tomographic angiography established equipoise for decision-making with classic angiography. For aortic valve treatment, some new longer-term outcomes from TAVI vs. SAVR trials confirmed equipoise of both treatments for high and medium risk. New information was provided for INR-management of mechanical aortic valves as well as long-term experiences for alternatives to mechanical valves (i.e., Ross and the relatively new Ozaki procedure). In the mitral and tricuspid field, prevalence data illustrate a significant amount of under-treatment for mitral and tricuspid valve regurgitation and evidence for life prolonging-effects of surgery. Finally, elongation of the ascending aorta was identified as new risk factor for aortic dissection and 2 years outcome of the newest generation of left ventricular assist devices demonstrate impressive improvements in outcome. While this article attempts to summarize the most pertinent publications, it does not expect to be complete and cannot be free of individual interpretation. As in recent years, it provides a condensed summary that is intended to give the reader "solid ground" for up-to-date decision-making in cardiac surgery and a stimulus for in-depth reading.

Comparison of mitral annulus geometry between patients with ischemic and non-ischemic functional mitral regurgitation: implications for transcatheter mitral valve implantation

Background

Transcatheter mitral valve replacement (TMVR) is a new therapeutic option for high surgical risk patients with mitral regurgitation (MR). Mitral valve (MV) geometry quantification is of paramount importance for success of the procedure and transthoracic 3D echocardiography represents a useful screening tool. Accordingly, we sought to asses MV geometry in patients with functional MR (FMR) that would potentially benefit of TMVR, focusing on the comparison of mitral annulus (MA) geometry between patients with ischemic (IMR) and non ischemic mitral regurgitation (nIMR).

Methods

We retrospectively selected 94 patients with severe FMR: 41 (43,6%) with IMR and 53 (56,4%) with nIMR. 3D MA analysis was performed on dedicated transthoracic 3D data sets using a new, commercially-available software package in two moments of the cardiac cycle (early-diastole and mid-systole). We measured MA dimension and geometry parameters, left atrial and left ventricular volumes.

Results

Maximum (MA area 10.7 ± 2.5 cm² vs 11.6 ± 2.7 cm², p > 0.05) and the best fit plane MA area (9.9 ± 2.3 cm² vs 10.7 ± 2.5 cm², p > 0.05, respectively) were similar between IMR and nIMR. nIMR patients showed larger mid-systolic 3D area (9.8 ± 2.3 cm² vs 10.8 ± 2.7 cm², p < 0.05) and perimeter (11.2 ± 1.3 cm vs 11.8 ± 1.5 cm, p < 0.05) with longer and larger leaflets, and wider aorto-mitral angle (135 ± 10° vs 141 ± 11°, p < 0.05). Conversely, the area of MA at the best fit plane did not differ between IMR and nIMR patients (9 ± 1.1 cm² vs 9.9 ± 1.5 cm², p > 0.05).

Conclusions

Patients with ischemic and non-ischemic etiology of FMR have similar maximum dimension, yet systolic differences between the two groups should be taken into account to tailor prosthesis’s selection.

Trial registration

N.A.

Transcatheter Mitral Valve Therapy: Defining the Patient Who Will Benefit

PURPOSE OF REVIEW

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

RECENT FINDINGS

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