High Prevalence of Clinically Silent Severe Mitral Regurgitation in Patients with Heart Failure: Role for Echocardiography

Left Atrial Improvement in Patients With Secondary Mitral Regurgitation and Heart Failure: The COAPT Trial

BACKGROUND

Functional mitral regurgitation induces adverse effects on the left ventricle and the left atrium. Left atrial (LA) dilatation and reduced LA strain are associated with poor outcomes in heart failure (HF). Transcatheter edge-to-edge repair (TEER) of the mitral valve reduces heart failure hospitalization (HFH) and all-cause death in selected HF patients.

OBJECTIVES

The aim of this study was to evaluate the impact of LA strain improvement 6 months after TEER on the outcomes of patients enrolled in the COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation) trial.

METHODS

The difference in LA strain between baseline and the 6-month follow-up was calculated. Patients with at least a 15% improvement in LA strain were labeled as "LA strain improvers." All-cause death and HFH were assessed between the 6 and 24-month follow-up.

RESULTS

Among 347 patients (mean age 71 ± 12 years, 63% male), 106 (30.5%) showed improvement of LA strain at the 6-month follow-up (64 [60.4%] from the TEER + guideline-directed medical therapy [GDMT] group and 42 [39.6%] from the GDMT alone group). An improvement in LA strain was significantly associated with a reduction in the composite of death or HFH between the 6-month and 24-month follow-up, with a similar risk reduction in both treatment arms (Pinteraction = 0.27). In multivariable analyses, LA strain improvement remained independently associated with a lower risk of the primary composite endpoint both as a continuous variable (adjusted HR: 0.94 [95% CI: 0.89-1.00]; P = 0.03) and as a dichotomous variable (adjusted HR: 0.49 [95% CI: 0.27-0.89]; P = 0.02). The best outcomes were observed in patients treated with TEER in whom LA strain improved.

CONCLUSIONS

In symptomatic HF patients with severe mitral regurgitation, improved LA strain at the 6-month follow-up is associated with subsequently lower rates of the composite endpoint of all-cause mortality or HFH, both after TEER and GDMT alone. (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation [COAPT]; NCT01626079).

Functional Mitral Regurgitation: Patient Selection and Optimization

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.

Prognostic value of mitral valve regurgitation in patients with heart failure with mildly reduced ejection fraction

BACKGROUND

Although mitral valve regurgitation (MR) is a common valvular heart disease in patients with heart failure (HF), there is a paucity of data on the characterization and outcomes of patients with HF with mildly reduced ejection fraction (HFmrEF) and concomitant MR.

METHODS

From 2016 to 2022, consecutive patients hospitalized with HFmrEF (i.e., left ventricular ejection fraction from 41% to 49% and signs and/or symptoms of HF) were retrospectively included at one institution. Patients with MR were compared with patients without MR. Further risk stratification was performed according to MR severity and etiology (i.e., primary vs. secondary MR). The primary end point was all-cause mortality at 30 months (median follow-up), and the key secondary end point was hospitalization for worsening HF.

RESULTS

Of 2181 patients hospitalized with HFmrEF, 59% presented with mild, 10% with moderate, and 2% with severe MR. MR was associated with increased all-cause mortality at 30 months (HR = 1.756; 95% CI 1.458-2.114; p = 0.001), with higher risk in more advanced stages. Furthermore, MR patients had higher risk of HF-related re-hospitalization at 30 months (HR = 1.560; 95% CI 1.172-2.076; p = 0.002). Even after multivariable adjustment, mild, moderate, and severe MR were still associated with all-cause mortality. Finally, the risk of all-cause mortality was lower in patients with secondary MR compared with patients with primary MR (HR = 0.592; 95% CI 0.366-0.956; p = 0.032).

CONCLUSION

MR is common in HFmrEF and independently associated with higher risk of all-cause mortality and HF hospitalization.

Persistence of significant secondary mitral regurgitation post-cardiac resynchronization therapy and survival: a systematic review and meta-analysis : Mitral regurgitation and mortality post-CRT

Cardiac resynchronization therapy (CRT) significantly reduces secondary mitral regurgitation (MR) in patients with severe left ventricular systolic dysfunction. However, uncertainty remains as to whether improvement in secondary MR correlates with improvement with mortality seen in CRT. We conducted a meta-analysis to determine the association of persistent unimproved significant secondary MR (defined as moderate or moderate-to-severe or severe MR) compared to improved MR (no MR or mild MR) post-CRT with all-cause mortality, cardiovascular mortality, and heart failure hospitalization. A systematic search of PubMed, EMBASE, and Cochrane Library databases till July 31, 2022 identified studies reporting clinical outcomes by post-CRT secondary MR status. In 12 prospective studies of 4954 patients (weighted mean age 66.8 years, men 77.8%), the median duration of follow-up post-CRT at which patients were re-evaluated for significant secondary MR was 6 months and showed significant relative risk reduction of 30% compared to pre-CRT. The median duration of follow-up post-CRT for ascertainment of main clinical outcomes was 38 months. The random effects pooled hazard ratio (95% confidence interval) of all-cause mortality in patients with unimproved secondary MR compared to improved secondary MR was 2.00 (1.57-2.55); p < 0.001). There was insufficient data to evaluate secondary outcomes in a meta-analysis, but limited data that examined the relationship showed significant association of unimproved secondary MR with increased cardiovascular mortality and heart failure hospitalization. The findings of this meta-analysis suggest that lack of improvement in secondary MR post-CRT is associated with significantly elevated risk of all-cause mortality and possibly cardiovascular mortality and heart failure hospitalization. Future studies may investigate approaches to address persistent secondary MR post-CRT to help improved outcome in this population.

Changes in Left Ventricular Global Longitudinal Strain in Patients With Heart Failure and Secondary Mitral Regurgitation: The COAPT Trial

Background Left ventricular (LV) global longitudinal strain (GLS) provides incremental prognostic information over LV ejection fraction in patients with heart failure (HF) and secondary mitral regurgitation. We examined the prognostic impact of LV GLS improvement in this population. Methods and Results The COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation) trial randomized symptomatic patients with HF with severe (3+/4+) mitral regurgitation to transcatheter edge-to-edge repair with the MitraClip device plus maximally tolerated guideline-directed medical therapy (GDMT) versus GDMT alone. LV GLS was measured at baseline and 6-month follow-up. The relationship between the improvement in LV GLS from baseline to 6 months and the composite of all-cause death or HF hospitalization between 6- and 24-month follow-up were assessed. Among 383 patients, 174 (45.4%) had improved LV GLS at 6-month follow-up (83/195 [42.6%] with transcatheter edge-to-edge repair+GDMT and 91/188 [48.4%] with GDMT alone; P=0.25). Improvement in LV GLS was strongly associated with reduced death or HF hospitalization between 6 and 24 months (P<0.009), with similar risk reduction in both treatment arms (Pinteraction=0.40). By multivariable analysis, LV GLS improvement at 6 months was independently associated with a lower risk of death or HF hospitalization (hazard ratio [HR], 0.55 [95% CI, 0.36-0.83]; P=0.009), death (HR, 0.48 [95% CI, 0.29-0.81]; P=0.006), and HF hospitalization (HR, 0.50 [95% CI, 0.31-0.81]; P=0.005) between 6 and 24 months. Conclusions Among patients with HF and severe mitral regurgitation in the COAPT trial, improvement in LV GLS at 6-month follow-up was associated with improved outcomes after both transcatheter edge-to-edge repair and GDMT alone between 6 and 24 months. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01626079.

Subannular repair in secondary mitral regurgitation with restricted leaflet motion during systole

OBJECTIVE

Ventricular secondary mitral regurgitation (SMR) (Carpentier type IIIb) results from left ventricular (LV) remodelling, displacement of papillary muscles and tethering of mitral leaflets. The most appropriate treatment approach remains controversial. We aimed to assess the safety and efficacy of standardised relocation of both papillary muscles (subannular repair) at 1-year follow-up (FU).

METHODS

REFORM-MR (Reform-Mitral Regurgitation) is a prospective, multicentre registry that enrolled consecutive patients with ventricular SMR (Carpentier type IIIb) undergoing standardised subannular mitral valve (MV) repair in combination with annuloplasty at five sites in Germany. Here, we report survival, freedom from recurrence of MR >2+, freedom from major adverse cardiac and cerebrovascular events (MACCEs), including cardiovascular death, myocardial infarction, stroke, MV reintervention and echocardiographic parameters of residual leaflet tethering at 1-year FU.

RESULTS

A total of 94 patients (69.1% male) with a mean age of 65.1±9.7 years met the inclusion criteria. Advanced LV dysfunction (mean left ventricular ejection fraction 36.4±10.5%) and severe LV dilatation (mean left ventricular end-diastolic diameter 61.0±9.3 mm) resulted in severe mitral leaflet tethering (mean tenting height 10.6±3.0 mm) and an elevated mean EURO Score II of 4.8±4.6 prior to surgery. Subannular repair was successfully performed in all patients, without operative mortality or complications. One-year survival was 95.5%. At 12 months, a durable reduction of mitral leaflet tethering resulted in a low rate (4.2%) of recurrent MR >2+. In addition to a significant improvement in New York Heart Association (NYHA) class (22.4% patients in NYHA III/IV vs 64.5% patients at baseline, p<0.001), freedom from MACCE was observed in 91.1% of patients.

CONCLUSIONS

Our study demonstrates the safety and feasibility of standardised subannular repair to treat ventricular SMR (Carpentier type IIIb) in a multicentre setting. By addressing mitral leaflet tethering, papillary muscle relocation results in very satisfactory 1-year outcomes and has the potential to durably restore MV geometry; nevertheless, long-term FU is mandatory.

TRIAL REGISTRATION NUMBER

NCT03470155.

Peak left atrial longitudinal strain is associated with all-cause mortality in patients with ventricular functional mitral regurgitation

PURPOSE

Chronic mitral regurgitation promotes left atrial (LA) remodeling. However, the significance of LA dysfunction in the setting of ventricular functional mitral regurgitation (FMR) has not been fully investigated. Our aim was to assess the prognostic impact of peak atrial longitudinal strain (PALS), a surrogate of LA function, in patients with FMR and reduced left ventricular ejection fraction (LVEF).

METHODS

Patients with at least mild ventricular FMR and LVEF < 50% under optimized medical therapy who underwent transthoracic echocardiography at a single center were retrospectively identified in the laboratory database. PALS was assessed by 2D speckle tracking in the apical 4-chamber view and the study population was divided in two groups according to the best cut-off value of PALS, using receiver operating characteristics (ROC) curve analysis. The primary endpoint-point was all-cause mortality.

RESULTS

A total of 307 patients (median age 70 years, 77% male) were included. Median LVEF was 35% (IQR: 27 - 40%) and median effective regurgitant orifice area (EROA) was 15mm² (IQR: 9 - 22mm²). According to current European guidelines, 32 patients had severe FMR (10%). During a median follow-up of 3.5 years (IQR 1.4 - 6.6), 148 patients died. The unadjusted mortality incidence per 100 persons-years increased with progressively lower values of PALS. On multivariable analysis, PALS remained independently associated with all-cause mortality (adjusted hazard ratio 1.052 per % decrease; 95% CI: 1.010 - 1.095; P = 0.016), even after adjustment for several (n = 14) clinical and echocardiographic confounders.

CONCLUSION

PALS is independently associated with all-cause mortality in patients with reduced LVEF and ventricular FMR.

Early Outcomes of Endoscopic Papillary Muscle Relocation for Secondary Mitral Regurgitation Type IIIb in Patients With Severe Left Ventricular Dysfunction

Objective: Subannular mitral valve (MV) repair techniques have been developed to address increased rates of recurrent mitral regurgitation (MR) in patients with secondary MR (SMR) type IIIb. Endoscopic papillary muscle relocation (PMR) is feasible via minithoracotomy. Nevertheless, the periprocedural outcome of patients with severe left ventricular (LV) dysfunction remains unknown. Methods: A total of 98 consecutive patients with SMR type IIIb underwent PMR at our institution. Due to concomitant coronary artery bypass grafting, 62 patients underwent sternotomy and were excluded from the current analysis, whereas 36 patients were treated by a minimally invasive technique using 3-dimensional endoscopy. Of these, 18 patients had severely depressed LV ejection fraction (LVEF) ≤35% (study group) and were compared to the remaining 18 patients with LVEF >35% (control group). Periprocedural outcome was retrospectively analyzed. Results: Although LVEF was significantly worse in the study group (30% ± 4% vs 43% ± 6%, P < 0.001), the severity of SMR and the degree of MV leaflet tethering were similar. The prevalence of concomitant procedures and the duration of surgery, cardiopulmonary bypass, and aortic cross-clamp were comparable. Periprocedural low cardiac output syndrome was favorably low in both groups (16.7% vs 5.6%, P = 0.29). Postoperative ventilation time (5.7 h [4.2 to 8.7 h] vs 6.0 h [4.6 to 9.8 h], P = 0.43) and duration of intensive care unit stay (2 days [1 to 3 days] vs 2 days [1 to 3 days], P = 0.22) were similar. There was no 30-day mortality in either group. Conclusions: Standardized endoscopic PMR resulted in favorable periprocedural outcomes in patients with severe LV dysfunction, suggesting that minimally invasive surgery can safely be extended to this patient population.

All-Cause Mortality in Ischemic Heart Failure Patients with Functional Mitral Regurgitation Undergoing Percutaneous Coronary Intervention

This study aimed to evaluate the association between percutaneous coronary intervention (PCI) treatment and all-cause mortality in patients with ischemic heart failure with left ventricular systolic dysfunction and functional mitral regurgitation (FMR). We included 1,483 patients of which 39.5% (n = 586) had moderate-to-severe FMR. Multivariable Cox proportional hazard model was used to assess the association between PCI treatment and all-cause mortality. Furthermore, propensity score matching was used to account for nonrandom treatment assignment. In those with none-to-mild FMR, after a median follow-up of 3.1 years, the cumulative rate of all-cause mortality between the PCI and non-PCI groups was comparable (10.1% vs 14.2%), with an adjusted hazard ratio (HR) of 0.731 (95% confidence interval [CI] 0.438 to 1.221, p = 0.232). In those with moderate-to-severe FMR, after a median follow-up of 2.9 years, the cumulative rate of all-cause mortality was lower in the PCI group (20.4% vs 31.6%), with an adjusted HR of 0.660 (95% CI 0.469 to 0.929, p = 0.017). The result was confirmed with propensity matching (HR 0.596 and 95% CI 0.363 to 0.977, p = 0.038). The mortality benefit associated with PCI treatment in patients with moderate-to-severe FMR was consistent regardless of the age, gender, reason for admission, presence of diabetes mellitus, left ventricular ejection fraction value, left main and 3-vessels disease. In conclusion, in patients with ischemic heart failure with left ventricular systolic dysfunction and moderate-to-severe FMR, PCI treatment was associated with improvement in all-cause mortality. Randomized clinical trials are needed to confirm the current results.

Standardized papillary muscle relocation for type IIIb secondary mitral regurgitation improves two-year outcome

OBJECTIVES

The major drawback of isolated annuloplasty for treatment of secondary mitral regurgitation (SMR) with restricted leaflet motion during systole (type IIIb) is recurrence of SMR, leading to adverse clinical outcome. Additional papillary muscles relocation (PMR) specifically addresses leaflet tethering to restore mitral valve geometry. We aimed to compare the two-year outcome of annuloplasty with additional PMR vs isolated annuloplasty.

METHODS

A total of 105 consecutive type IIIb SMR patients with preoperative LVEF <45%, LVEDD >55mm and a tenting height >10mm, reached two-year postoperative follow-up after MV repair and were included in the current analysis. 51 patients underwent annuloplasty and additional PMR (study group). 54 patients underwent isolated annuloplasty (control group). Primary composite study end-point comprised death or recurrence of MR ≥2 at two years postoperatively.

RESULTS

Echocardiographic baseline variables indicating the severity of left ventricular (LV) dysfunction and mitral leaflet tethering were similar. Procedural and periprocedural outcome was comparable in both groups. The primary composite end-point was significantly improved in the study group 19.6% [10/51] in comparison to the control group 44.4% [24/54] (p = 0.009). 2-year all-cause mortality was 7.8% [4/51] in the study group, vs 18.5% [10/54] in the control group (p = 0.098). After two years, significant improvement of NYHA functional class as compared to the baseline values was observed in the study group.

CONCLUSIONS

Additional PMR to treat SMR type IIIb resulted in an improved 2-year outcome in comparison to isolated annuloplasty. PMR specifically addressing mitral leaflet tethering represents a valid therapeutic option for heart-failure patients with SMR type IIIb.

Integrative echocardiographic assessment of patients with secondary mitral regurgitation undergoing transcatheter edge-to-edge repair

OBJECTIVES

To investigate whether the integrative echocardiographic criteria used in the cardiovascular outcomes assessment of the mitraclip percutaneous therapy (COAPT) for heart failure patients with functional mitral regurgitation study predict outcomes after edge-to-edge trancatheter mitral valve repair (TMVr) for the treatment of secondary mitral regurgitation (SMR).

BACKGROUND

Two randomized controlled trials comparing TMVr to medical treatment reported conflicting findings. Differences in patient selection criteria may have contributed to these diverging results.

METHODS

Patients undergoing TMVr were stratified following the integrative COAPT echocardiographic criteria in noneligible and eligible patients who were further classified into three tiers according to effective regurgitant orifice (EROA) (Tier 1: EROA ≥ 0.3cm² ; Tier 2: EROA 0.2cm² and 0.29cm² ; Tier 3: EROA<0.2cm² ) combined with several other severity criteria. We assessed between group differences in all-cause mortality, successful SMR reduction, and symptom relief from baseline to 2-year follow-up.

RESULTS

Between March 2011 and March 2018, 138 patients (mean age 75 years) satisfying the inclusion criteria underwent TMVr for treatment of symptomatic SMR. The mean EROA area was 0.35 ± 0.17 mm² . Ten patients (7%) died within 30 days, 29 (21%) within 12 months, and 41 (30%) within 2 years. After stratification according to the COAPT echocardiographic criteria that were fulfilled in 72% of the studied population, Tier 2 patients (45%), as well as noneligible patients (38%) had a higher mortality rate compared to those in Tier 1 (19%).

CONCLUSIONS

SMR patients stratified into tiers according to the COAPT integrative echocardiographic criteria have diverging prognostic and symptomatic benefit after edge-to-edge TMVr.

The role of transcatheter mitral valve leaflet approximation for the treatment of secondary mitral regurgitation: current status and future prospects

Introduction: Secondary mitral regurgitation (SMR) is one of the most common valvulopathies and is associated with poor prognosis. Over the past years, medical management and mitral valve repair options have rapidly evolved offering new opportunities for a wide range of patients.Areas covered: We provide an up-to-date review of the value of medical and transcatheter mitral valve leaflet approximation for SMR integrating the results of most recent trials and putting their findings into clinical perspective.Expert opinion: Treatment of SMR requires a multidisciplinary approach with a long-term perspective. After optimization of medical treatment, transcatheter mitral valve repair should be considered in patients with persisting symptomatic severe SMR to improve symptoms and prognosis.

The management of secondary mitral regurgitation in patients with heart failure: a joint position statement from the Heart Failure Association (HFA), European Association of Cardiovascular Imaging (EACVI), European Heart Rhythm Association (EHRA), and European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC

Secondary (or functional) mitral regurgitation (SMR) occurs frequently in chronic heart failure (HF) with reduced left ventricular (LV) ejection fraction, resulting from LV remodelling that prevents coaptation of the valve leaflets. Secondary mitral regurgitation contributes to progression of the symptoms and signs of HF and confers worse prognosis. The management of HF patients with SMR is complex and requires timely referral to a multidisciplinary Heart Team. Optimization of pharmacological and device therapy according to guideline recommendations is crucial. Further management requires careful clinical and imaging assessment, addressing the anatomical and functional features of the mitral valve and left ventricle, overall HF status, and relevant comorbidities. Evidence concerning surgical correction of SMR is sparse and it is doubtful whether this approach improves prognosis. Transcatheter repair has emerged as a promising alternative, but the conflicting results of current randomized trials require careful interpretation. This collaborative position statement, developed by four key associations of the European Society of Cardiology-the Heart Failure Association (HFA), European Association of Percutaneous Cardiovascular Interventions (EAPCI), European Association of Cardiovascular Imaging (EACVI), and European Heart Rhythm Association (EHRA)-presents an updated practical approach to the evaluation and management of patients with HF and SMR based upon a Heart Team approach.

The treatment of mitral insufficiency in refractory heart failure

Secondary mitral insufficiency (SMI) is caused by dilatation and left ventricular dysfunction and is a frequent finding in patients with heart failure (HF). It is associated with a mortality of between 40% and 50% at 3 years. The first-line treatment is represented by medical therapy, possibly associated, when indicated, with cardiac re-synchronization. If the patient remains symptomatic, corrective action should be considered. Surgery is indicated in cases of severe SMI with ejection fraction >30% and the need for myocardial revascularization. The management of patients in whom revascularization is not an option remains extremely complex and the evidence in this field is extremely limited. Percutaneous transcatheter therapies, reparative or replacement, are rapidly emerging as valid alternatives in cases of patients at high surgical risk. In particular, edge-to-edge repair (MitraClip) has proven effective in improving symptoms and reducing hospitalizations for HF. However, neither transcatheter nor surgical mitral repair or replacement has been shown to significantly improve prognosis, with mortality remaining high (14–20% at 1 year). Randomized trials aimed at assessing the effect of these treatments and establishing their long-term outcomes are urgently required.

Treatment of Functional Mitral Regurgitation in Heart Failure

PURPOSE OF REVIEW

To analyze the current state of the art of functional mitral regurgitation (FMR) treatment.

RECENT FINDINGS

The first-line treatment of severe FMR consists of guideline medical therapy (GMT) and resynchronization therapy when indicated; the impact of new medical therapies like sacubitril/valsartan needs further assessment. Valvular intervention may be considered in FMR symptomatic patients despite GMT, and can be performed surgically or percutaneously. MitraClip is a safe percutaneous procedure associated with symptoms improvement. Recently, the COAPT trial showed superior outcomes for MitraClip versus GMT contrasting the MITRA-FR trial which showed no benefit of MitraClip compared with GMT. These results should be interpreted as complementary rather than opposite. The COAPT trial provided a "proof of concept" that percutaneous treatment of severe FMR in patients without too advanced left ventricular disease translates into a prognostic benefit. Careful patient selection will play a critical role in defining the clinical niche for successful interventions.

Valvular Heart Disease in Patients ≥80 Years of Age

In the United States, the octogenarian population is projected to triple by 2050. With this aging population, the prevalence of valvular heart disease (VHD) is on the rise. The etiology, approach to treatment, and expected outcomes of VHD are different in the elderly compared with younger patients. Both stenotic and regurgitant lesions are associated with unfavorable outcomes if left untreated. Surgical mortality remains high due to multiple co-morbidities, and long-term survival benefit is dependent on many variables including valvular pathology. Quality of life is an important consideration in treatment decisions in this age group. Increasingly, octogenarian patients are receiving transcatheter therapies, with transcatheter aortic valve replacement having the greatest momentum. Numerous transcatheter devices for management of other valve lesions are currently in early clinical trials. This review will describe the epidemiology, etiology, diagnosis, and therapeutic options for VHD in the oldest old, with a focus on transcatheter technologies.

Cardiovascular events and hospital resource utilization pre- and post-transcatheter mitral valve repair in high-surgical risk patients

MitraClip is an approved therapy for mitral regurgitation (MR); however, health care resource utilization pre- and post-MitraClip remains understudied.

METHODS

Patients with functional and degenerative MR at high surgical risk in the EVEREST II High-Risk Registry and REALISM Continued-Access Study were linked to Medicare data. Pre- and post-MitraClip all-cause death, stroke, myocardial infarction, heart failure (HF), and bleeding hospitalizations were identified. Inpatient costs, adjusted to 2010 US dollars, were calculated, and event rate ratios and cost ratios were estimated with multivariable modeling.

RESULTS

Among 403 linked patients, the mean age was 80 years, 60% were male, mean baseline left ventricular ejection fraction was 49.6%, 83.3% were New York Heart Association class III/IV, 78.2% were MR grade 3+/4+, and 63.3% had functional MR. All-cause hospitalization decreased from 1,854 to 1,435/1,000 person-years (P<.001). HF hospitalization decreased following MitraClip (749 vs 332/1000 person-years, P<.001), but bleeding increased (199 vs 298/1000 person-years, P<.001). Changes in stroke and myocardial infarction were not statistically significant. Overall mean Medicare costs per patient were similar pre- and post-MitraClip, although there was a significant decrease in mean costs among those that survived a full year after MitraClip ($18,131 [SD $25,130] vs $11,679 [SD $22,486], P=.02).

CONCLUSIONS

MitraClip was associated with a reduced rate of all-cause and HF hospitalizations and an increased rate of bleeding hospitalizations. One-year Medicare costs were reduced in those who survived a full year after the MitraClip procedure. Payors and providers seeking to reduce HF hospitalizations and associated Medicare costs may consider MitraClip among appropriate patients likely to survive 1 year.

Non-invasive measurement of volume-time curves in patients with mitral regurgitation and in healthy volunteers, using a new operator-independent screening tool

Left ventricular volume-time curves (VTCs) provide hemodynamic data, and may help clinical decision making. The generation of VTCs using echocardiography, however, is time-consuming and prone to inter-operator variability. In this study, we used a new non-invasive, operator-independent technique, the hemodynamic cardiac profiler (HCP), to generate VTCs. The HCP, which uses a low-intensity, patient-safe, high-frequency applied AC current, and 12 standard ECG electrodes attached on the thorax in a pre-defined pattern, was applied to five young healthy volunteers, five older healthy volunteers, and five patients with severe mitral regurgitation. From the VTCs generated by the HCP, the presence or absence of an isovolumetric contraction phase (ICP) was assessed, as well as the left ventricular ejection time (LVET), time of the pre-ejection period (tPEP), and ratio of the volumes of the early (E) and late (A) diastolic filling (E _V/A _V ratio), and compared to 2D transthoracic echocardiography (2D TTE) at rest. The reproducibility by two different operators showed good results (RMS  =  5.2%). For intra-patient measurement RMS was 2.8%. Both LVET and the E _V/A _V ratio showed a strong significant correlation between HCP and 2D TTE derived parameters (p  <  0.05). For tPEP, the correlation was still weak (p  =  0.32). In all five patients with mitral regurgitation, the ICP was absent in the VTC from the HCP, whereas it was present in the 10 healthy volunteers, which is in accordance with pathophysiology. We conclude that the HCP seems to be a method for reproducible VTC generation, and may become a useful early screening tool for cardiac dysfunction in the future.

Misconceptions and Facts About Mitral Regurgitation

Mitral regurgitation is a common heart valve disease. It is defined to be primary when it results from the pathology of the mitral valve apparatus itself and secondary when it is caused by distortion of the architecture or function of the left ventricle. Although the diagnosis and management of mitral regurgitation rely heavily on echocardiography, one should bear in mind the caveats and shortcomings of such an approach. Clinical decision making commonly focuses on the indications for surgery, but it is complex and mandates precise assessment of the mitral pathology, symptom status of the patient, and ventricular performance (right and left) among other descriptors. It is important for healthcare providers at all levels to be familiar with the clinical picture, diagnosis, disease course, and management of mitral regurgitation.

A Short History of Cardiac Inspection: A Quest "To See with a Better Eye"

Cardiac examination has evolved over centuries. The goal of cardiac evaluation, regardless the era, is to "see" inside the heart to diagnose congenital and acquired intra-cardiac structural and functional abnormalities. This article briefly reviews the history of cardiac examination and discusses contemporary best, evidence-based methods of cardiac inspection.

Impact of DRG billing system on health budget consumption in percutaneous treatment of mitral valve regurgitation in heart failure

OBJECTIVE

Percutaneous correction of mitral regurgitation (MR) by MitraClip (Abbot Vascular, Abbot Park, Illinois, USA) trans-catheter procedure (MTP) may represent a treatment for an unmet need in heart failure (HF), but with a largely unclear economic impact.

RESEARCH DESIGN AND METHODS

This study estimated the economic impact of the MTP in common practice using the disease-related group (DRG) billing system, duration and average cost per day of hospitalization as main drivers. Life expectancy was estimated based on the Seattle Heart Failure Model. Quality-of-life was derived by standard questionnaires to compute quality-adjusted year-life costs.

RESULTS

Over 5535 discharges between 2012-2013, HF as DRG 127 was the main diagnosis in 20%, yielding a reimbursement of €3052.00/case; among the DRG 127, MR by ICD-9 coding was found in 12%. Duration of hospitalization was longer for DRG 127 with than without MR (9 vs 8 days, p < 0.05). HF in-hospital management generated most frequently deficit, in particular in the presence of MR, due to the high costs of hospitalization, higher than reimbursement. MTP to treat MR allowed DRG 104-related reimbursement of €24,675.00. In a cohort of 34 HF patients treated for MR by MTP, the global budget consumption was 2-fold higher compared to that simulated for those cases medically managed at 2-year follow-up. Extrapolated cost per quality-adjusted-life-years (QALY) for MTP at year-2 follow-up was ∼ €16,300.

CONCLUSIONS

Based on DRG and hospitalization costing estimates, MTP might be cost-effective in selected HF patients with MR suitable for such a specific treatment, granted that those patients have a clinical profile predicting high likelihood of post-procedural clinical stability in sufficiently long follow-up.

Economic burden of functional and organic mitral valve regurgitation

BACKGROUND

Very little is known about the costs of mitral regurgitation (MR) in Europe.

AIM

To evaluate the cost of MR from a French National Payer perspective, based on annual costs of surgical and non-surgical patients.

METHODS

A 12-month retrospective population-based analysis of patient demographics, outcomes and acute hospital and post-discharge resource utilizations, extracted from the 2009 French Medical Information System.

RESULTS

A total of 19,868 patients with MR were identified. Surgical group (n=4099): index hospitalization length of stay (LOS), 17±14.7 days; patients discharged to rehabilitation, 72% (LOS 23±16 days); 12-month rehospitalization rate, 25%; total cost per surgical patient, €24,871±13,940 (ranging from €21,970±11,787 for mitral valve repair [n=2567, 62.6%] to €29,732±15,796 for mitral valve replacement). Non-surgical group (n=15,769): number of hospitalizations over 12 months, 3.1±1.5 (LOS 23.5±20.4 days); admitted to rehabilitation, 24% (LOS 38.8±37.6 days); total cost per patient, €12,177±10,913 (varying between €9957±9080 and €13,538±11,692 for those without and with heart failure [HF], respectively). The total observed cost for 19,868 MR patients over 12 months was €292.8 million: surgical group, €100.8 million; medical group €192.0 million. Patients with MR and HF who were managed medically consumed 45% (€132.3 million) of the overall annual cost of MR.

CONCLUSION

The costs of care associated with MR are highly heterogeneous. There are significant differences in costs and resources used between the surgical and medical MR subgroups, with further differences depending on type of surgery and presence of HF.

Epidemiology of acquired valvular heart disease

Population-based studies including systematic echocardiographic examinations are required to assess the prevalence of valvular heart disease. In industrialized countries, the prevalence of valvular heart disease is estimated at 2.5%. Because of the predominance of degenerative etiologies, the prevalence of valvular disease increases markedly after the age of 65 years, in particular with regard to aortic stenosis and mitral regurgitation, which accounts for 3 in 4 cases of valvular disease. Rheumatic heart disease still represents 22% of valvular heart disease in Europe. The prevalence of secondary mitral regurgitation cannot be assessed reliably but it seems to be a frequent disease. The incidence of infective endocarditis is approximately 30 cases per million individiuals per year. Its stability is associated with marked changes in its presentation. Patients are getting older and staphylococcus is now becoming the microorganism most frequently responsible. Heath care-associated infections are the most likely explanation of changes in the microbiology of infective endocarditis. In developing countries, rheumatic heart disease remains the leading cause of valvular heart disease. Its prevalence is high, between 20 and 30 cases per 1000 subjects when using systematic echocardiographic screening. In conclusion, the temporal and geographical heterogeneity illustrates the effect of socioeconomic status and changes in life expectancy on the frequency and presentation of valvular heart disease. A decreased burden of valvular disease would require the elaboration of preventive strategies in industrialized countries and an improvement in the socioeconomic environment in developing countries.

Echocardiographic quantitation of mitral regurgitation

Mitral valve regurgitation is a common valvular problem, particularly in developing nations. It causes significant morbidity and mortality, especially if the severity of valve regurgitation is underestimated. Echocardiography plays a significant role in the diagnoses, serial follow-up and management of patients with valvular heart disease. However, precise quantitation of the severity of mitral regurgitation is a crucial element in the therapeutic decisions for managing mitral regurgitation. An accurate assessment of the severity of mitral regurgitation allows for optimal timing of surgical intervention, culminating in improved patient outcomes. This review provides a systematic approach to the quantitation of mitral regurgitation using the echocardiography and Doppler methodologies that are available in the modern noninvasive imaging and hemodynamic laboratory. Additional, novel and evolving noninvasive imaging modalities are reviewed briefly.