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El Shaer A, Chavez Ponce AA, Ali MT, Oguz D, Pislaru SV, Nkomo VT, Padang R, Eleid MF, Guerrero M, Reeder GS, Rihal CS, Alkhouli M, Thaden JJ. Pulmonary Vein Flow Morphology After Transcatheter Mitral Valve Edge-to-Edge Repair as Predictor of Survival. J Am Soc Echocardiogr 2024; 37:530-537. [PMID: 38341053 DOI: 10.1016/j.echo.2024.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 01/10/2024] [Accepted: 01/28/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND Data on the prognostic factors after mitral valve (MV) transcatheter edge-to-edge repair (TEER; MV-TEER) are limited. Pulsed-wave Doppler interrogation of pulmonary vein flow (PVF) is a convenient method to assess the hemodynamic burden of residual mitral regurgitation (MR), which could be of utility as a predictor of outcomes. METHODS Patients that underwent MV-TEER between May 2014 and December 2021 at our institution were evaluated. Pulmonary vein flow patterns post-MV-TEER were reviewed on the procedural transesophageal echocardiogram and classified as normal (systolic dominant or codominant) or abnormal (systolic blunting or reversal). The PVF pattern was correlated with all-cause mortality at follow-up. RESULTS Two-hundred sixty-five patients had diagnostic PVF post-MV-TEER, with 73 (27.5%) categorized as normal and 192 (72.5%) categorized as abnormal. Patients with abnormal PVF morphology were more likely to have atrial fibrillation (70% vs 42%, P < .001) and greater than moderate residual MR (16% vs 3%, P = .01) and had higher mean left atrial pressure (18.1 ± 5.0 vs 15.9 ± 4.2 mm Hg, P = .002) and left atrial V wave (26.6 ± 8.5 vs 21.4 ± 7.3 mm Hg, P < .001) postprocedure. In multivariable analysis, abnormal PVF morphology post-MV-TEER was independently associated with mortality at follow-up (hazard ratio = 1.70; 95% CI, 1.06-2.74; P = .03) after correction for end-stage renal disease, atrial fibrillation, and residual MR. Results were similar in subgroups of patients with moderate or less and those with mild or less residual MR. CONCLUSIONS Pulmonary vein flow morphology is a simple and objective tool to assess MR severity immediately post-MV-TEER and offers important prognostic information to optimize procedural results. Additional studies are needed to determine whether patients with abnormal PVF pattern post-MV-TEER would benefit from more intensive goal-directed medical therapy postprocedure.
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Affiliation(s)
- Ahmed El Shaer
- Department of Internal Medicine, University of Wisconsin Hospital, Madison, Wisconsin
| | | | - Mays T Ali
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Didem Oguz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mayra Guerrero
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Guy S Reeder
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Charanjit S Rihal
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
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Dhont S, van den Acker G, van Loon T, Verbrugge FH, Verwerft J, Deferm S, Churchill TW, Mullens W, Lumens J, Bertrand PB. Mitral regurgitation in heart failure with preserved ejection fraction: The interplay of valve, ventricle, and atrium. Eur J Heart Fail 2024; 26:974-983. [PMID: 38629747 PMCID: PMC11184410 DOI: 10.1002/ejhf.3231] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/22/2024] [Accepted: 03/26/2024] [Indexed: 05/31/2024] Open
Abstract
Mitral regurgitation (MR) is highly prevalent among patients with heart failure and preserved ejection fraction (HFpEF). Despite this combination being closely associated with unfavourable outcomes, it remains relatively understudied. This is partly due to the inherent heterogeneity of patients with HFpEF. To address this gap, dissecting HFpEF into mechanism-based phenotypes may offer a promising avenue for advancing our comprehension of these complex intertwined conditions. This review employs the validated CircAdapt model to explore the haemodynamic implications of moderate to severe MR across a well-defined spectrum of myocardial disease, characterized by impaired relaxation and reduced myocardial compliance. Both heart failure and mitral valve disease share overlapping symptomatology, primarily attributed to elevated pulmonary pressures. The intricate mechanisms contributing to these elevated pressures are multifaceted, potentially influenced by diastolic dysfunction, left atrial myopathy, and MR. Accurate evaluation of the haemodynamic and clinical impact of MR necessitates a comprehensive approach, taking into account the characteristics of both the left atrium and left ventricle, as well as their intricate interactions, which may currently be underemphasized in diagnostic practice. This holistic assessment is imperative for enhancing our understanding and refining therapeutic strategies within this patient cohort.
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Affiliation(s)
- Sebastiaan Dhont
- Faculty of Medicine and Life Sciences, LCRC, Hasselt University, Diepenbeek, Belgium
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Department of Future Health, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Gitte van den Acker
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Tim van Loon
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Frederik H. Verbrugge
- Center for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Jan Verwerft
- Faculty of Medicine and Life Sciences, LCRC, Hasselt University, Diepenbeek, Belgium
- Department of Cardiology, Jessa Hospital, Hasselt, Belgium
| | - Sébastien Deferm
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Department of Cardiology, Inselspital Bern, Bern, Switzerland
| | | | - Wilfried Mullens
- Faculty of Medicine and Life Sciences, LCRC, Hasselt University, Diepenbeek, Belgium
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Department of Future Health, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Joost Lumens
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Philippe B. Bertrand
- Faculty of Medicine and Life Sciences, LCRC, Hasselt University, Diepenbeek, Belgium
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Department of Future Health, Ziekenhuis Oost-Limburg, Genk, Belgium
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Transcatheter Edge-to-Edge Repair for Atrial Functional Mitral Regurgitation: Effective Therapy or Elusive Target? JACC Cardiovasc Interv 2022; 15:1741-1747. [PMID: 36075645 DOI: 10.1016/j.jcin.2022.06.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 06/28/2022] [Indexed: 11/24/2022]
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Simard T, Reddy YNV, Thaden JJ, Padang R, Michelena HI, Nkomo VT, Lloyd JW, El Sabbagh A, Nishimura RA, Reeder GS, Guerrero M, Alkhouli M, Rihal CS, Eleid MF. Atrial mitral regurgitation: Characteristics and outcomes of transcatheter mitral valve edge-to-edge repair. Catheter Cardiovasc Interv 2022; 100:133-142. [PMID: 35535629 DOI: 10.1002/ccd.30224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 03/28/2022] [Accepted: 04/25/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Mitral transcatheter edge-to-edge repair (MTEER) is an established therapeutic approach for mitral regurgitation (MR). Functional mitral regurgitation originating from atrial myopathy (A-FMR) has been described. OBJECTIVES We sought to assess the clinical, echocardiographic and hemodynamic considerations in A-FMR patients undergoing MTEER. METHODS From 2014 to 2020, patients undergoing MTEER for degenerative MR (DMR), functional MR (FMR), and mixed MR were assessed. A-FMR was defined by the presence of MR > moderate in severity; left ventricular (LV) ejection fraction (LVEF) ≥ 50%; and severe left atrial (LA) enlargement in the absence of LV dysfunction, leaflet pathology, or LV tethering. The diagnosis of A-FMR (vs. ventricular-FMR [V-FMR]) was confirmed by three independent echocardiographers. Baseline characteristics, procedural outcomes as well as clinical and echocardiographic follow-up are reported. Device success was defined as final MR grade ≤ moderate; MR reduction ≥1 grade; and final transmitral gradient <5 mmHg. RESULTS 306 patients underwent MTEER, including DMR (62%), FMR (19%), and mixed MR (19%). FMR cases included 37 (63.8%) V-FMR and 21 (36.2%) A-FMR. Tricuspid regurgitation (≥ moderate) was higher in A-FMR (80.1%) compared to V-FMR (54%) and DMR (42%). Device success did not significantly differ between A-FMR and V-FMR (57% vs. 73%, p = 0.34) or DMR (57% vs. 64%, p = 1.0). The A-FMR cohort was less likely to achieve ≥3 grades of MR reduction compared to V-FMR (19% vs. 54%, p = 0.01) and DMR (19% vs. 49.7%, p = 0.01). Patients with V-FMR and DMR demonstrated significant reductions in mean left atrial pressure (LAP) and peak LA V-wave, though A-FMR did not (LAP -0.24 ± 4.9, p = 0.83; peak V-wave -1.76 ± 9.1, p = 0.39). In follow-up, echocardiographic and clinical outcomes were similar. CONCLUSIONS In patients undergoing MTEER, A-FMR represents one-third of FMR cases. A-FMR demonstrates similar procedural success but blunted acute hemodynamic responses compared with DMR and V-FMR following MTEER. Dedicated studies specifically considering A-FMR are needed to discern the optimal therapeutic approaches.
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Affiliation(s)
- Trevor Simard
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Yogesh N V Reddy
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Hector I Michelena
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - James W Lloyd
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Abdallah El Sabbagh
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Jacksonville, Florida, USA
| | - Rick A Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Guy S Reeder
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Mayra Guerrero
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Charanjit S Rihal
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
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Alkhouli M, Eleid MF, Nishimura RA, Rihal CS. The Role of Invasive Hemodynamics in Guiding Contemporary Transcatheter Valvular Interventions. JACC Cardiovasc Interv 2021; 14:2531-2544. [PMID: 34887047 DOI: 10.1016/j.jcin.2021.08.072] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 08/02/2021] [Accepted: 08/08/2021] [Indexed: 11/17/2022]
Abstract
Recent advances in transcatheter interventions have refueled the interest in utilizing invasive hemodynamics in the catheterization laboratory. The authors review contemporary invasive techniques used to confirm valve disease and guide transcatheter valve interventions. They also discuss the available data and the remaining questions on the role of invasive hemodynamics in current practice and in the future.
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Affiliation(s)
- Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Rick A Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Charanjit S Rihal
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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