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Naser JA, Alexandrino FB, Harada T, Michelena HI, Borlaug BA, Eleid MF, Lin G, Scott C, Kennedy AM, Pellikka PA, Nkomo VT, Pislaru SV. The Natural History of Atrial Functional Mitral Regurgitation. J Am Coll Cardiol 2024; 83:1495-1507. [PMID: 38530687 DOI: 10.1016/j.jacc.2024.02.026] [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: 01/25/2024] [Accepted: 02/20/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND The natural history of moderate/severe atrial functional mitral regurgitation (AFMR) is unknown. OBJECTIVES The authors sought to study the incidence of left ventricular (LV) systolic dysfunction (LVSD), progression or regression of ≥mild-moderate AFMR, and impact on mortality. METHODS Adults with left atrial (LA) volume index ≥40 mL/m2, ≥mild-moderate AFMR, and follow-up echocardiogram were followed for incident LVSD (ejection fraction <50% and ≥10% lower than baseline), progression of mild-moderate/moderate AFMR to severe, and persistent regression of AFMR to no/trivial. Relation of AFMR progression or regression as time-dependent covariates with all-cause mortality was studied. Incidence of LVSD was compared with patients with no/mild AFMR matched on age, sex, comorbidities and ejection fraction. Patients were followed until mitral intervention, myocardial infarction, or last follow-up. RESULTS A total of 635 patients (median age 75 years, 51% female, 96% mild-moderate/moderate AFMR, 4% severe AFMR) were included. Over a median 2.2 years (Q1-Q3: 1.0-4.3 years), incidence rates per 100 person-years were 3.2 for LVSD (P = 0.52 vs patients with no/mild AFMR), 1.9 for progression of AFMR, and 3.9 for regression. Female sex and larger LA volume index were independently associated with progression, whereas younger age, male sex, absent atrial fibrillation, and higher LA emptying fraction were independently associated with regression. Neither AFMR progression nor regression was independently associated with mortality. Instead, independent risk factors for mortality included older age, concentric LV geometry, and higher estimated LV filling and pulmonary pressures. CONCLUSIONS In patients with predominantly mild-moderate/moderate AFMR, regression of MR was more common than progression, but neither was associated with mortality. Instead, diastolic function abnormalities were more important. Over a median 2-year follow-up, LVSD risk was not increased.
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Affiliation(s)
- Jwan A Naser
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | | | - Tomonari Harada
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Hector I Michelena
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Grace Lin
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Christopher Scott
- Department of Biostatistics and Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Austin M Kennedy
- Department of Biostatistics and Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Patricia A Pellikka
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
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Grayburn PA, Mack MJ, Manandhar P, Kosinski AS, Sannino A, Smith RL, Szerlip M, Vemulapalli S. Comparison of Transcatheter Edge-to-Edge Mitral Valve Repair for Primary Mitral Regurgitation Outcomes to Hospital Volumes of Surgical Mitral Valve Repair. Circ Cardiovasc Interv 2024; 17:e013581. [PMID: 38436084 DOI: 10.1161/circinterventions.123.013581] [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: 09/01/2023] [Accepted: 01/26/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Transcatheter edge-to-edge mitral valve (MV) repair (TEER) is an effective treatment for patients with primary mitral regurgitation at prohibitive risk for surgical MV repair (MVr). High-volume MVr centers and high-volume TEER centers have better outcomes than low-volume centers, respectively. However, whether MVr volume predicts TEER outcomes remains unknown. We hypothesized that high-volume MV surgical centers would have superior risk-adjusted outcomes for TEER than low-volume centers. METHODS We combined data from the American College of Cardiology/Society of Thoracic Surgeons Transcatheter Valve Therapy registry and the Society of Thoracic Surgeons adult cardiac surgery database. MVr was defined as leaflet resection or artificial chords with or without annuloplasty and was evaluated as a continuous variable and as predefined categories (<25, 25-49, and ≥50 MV repairs/year). A generalized linear mixed model was used to evaluate risk-adjusted in-hospital/30-day mortality, 30-day heart failure readmission, and TEER success (mitral regurgitation ≤2+ and gradient <5 mm Hg). RESULTS The study comprised 41 834 patients from 500 sites of which 332 (66.4%) were low, 102 (20.4%) intermediate, and 66 (13.2%) high-volume surgical centers (P<0.001). TEER success was 54.6% and was not statistically significantly different across MV surgical site volumes (P=0.4271). TEER mortality at 30 days was 3.5% with no significant difference across MVr volume on unadjusted (P=0.141) or adjusted (P=0.071) analysis of volume as a continuous variable. One-year mortality was 15.0% and was lower for higher MVr volume centers when adjusted for clinical and demographic variables (P=0.027). Heart failure readmission at 1 year was 9.4% and was statistically significantly lower in high-volume centers on both unadjusted (P=0.017) or adjusted (P=0.015) analysis. CONCLUSIONS TEER can be safely performed in centers with low volumes of MV repair. However, 1-year mortality and heart failure readmission are superior at centers with higher MVr volume.
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Affiliation(s)
- Paul A Grayburn
- Baylor Scott and White Heart Hospital Plano, TX (P.A.G., M.J.M., A.S., R.L.S., M.S.)
| | - Michael J Mack
- Baylor Scott and White Heart Hospital Plano, TX (P.A.G., M.J.M., A.S., R.L.S., M.S.)
| | | | | | - Anna Sannino
- Baylor Scott and White Heart Hospital Plano, TX (P.A.G., M.J.M., A.S., R.L.S., M.S.)
| | - Robert L Smith
- Baylor Scott and White Heart Hospital Plano, TX (P.A.G., M.J.M., A.S., R.L.S., M.S.)
| | - Molly Szerlip
- Baylor Scott and White Heart Hospital Plano, TX (P.A.G., M.J.M., A.S., R.L.S., M.S.)
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Boyle C, Nguyen K, Steiner J, Macon CJ, Marbach JA. Mitral Regurgitation Complicated by Cardiogenic Shock: Reassessing Risk Stratification and Therapeutic Strategies. Interv Cardiol Clin 2024; 13:191-205. [PMID: 38432762 DOI: 10.1016/j.iccl.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Mitral regurgitation complicated by cardiogenic shock creates a unique and devastating risk profile for patients and poses significant difficulties for physicians who lack a comprehensive range of effective management strategies. Supportive measures such as intravenous vasodilators, intra-aortic balloon pumps, and percutaneous ventricular assist devices are often necessary to stabilize patients prior to definitive treatment with surgical mitral valve replacement or trans-catheter edge-to-edge repair. This review evaluates the evidence for the available supportive and definitive management strategies in patients with mitral regurgitation complicated by cardiogenic shock and presents a framework to aid clinicians in navigating the complex clinical decision-making process. Additionally, the authors review emerging transcatheter mitral valve replacement technologies that hold promise for expanding the therapeutic armamentarium and improving patient outcomes.
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Affiliation(s)
- Carla Boyle
- Division of Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, 3161 Southwest Pavilion Loop, Portland, OR 97239, USA
| | - Khoa Nguyen
- Division of Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, 3161 Southwest Pavilion Loop, Portland, OR 97239, USA
| | - Johannes Steiner
- Division of Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, 3161 Southwest Pavilion Loop, Portland, OR 97239, USA
| | - Conrad J Macon
- Division of Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, 3161 Southwest Pavilion Loop, Portland, OR 97239, USA
| | - Jeffrey A Marbach
- Division of Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, 3161 Southwest Pavilion Loop, Portland, OR 97239, USA.
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4
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Riccardi M, Cikes M, Adamo M, Pagnesi M, Lombardi CM, Solomon SD, Metra M, Inciardi RM. Functional Mitral Regurgitation and Heart Failure With Preserved Ejection Fraction: Clinical Implications and Management. J Card Fail 2024:S1071-9164(24)00090-3. [PMID: 38522637 DOI: 10.1016/j.cardfail.2024.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Revised: 02/01/2024] [Accepted: 02/16/2024] [Indexed: 03/26/2024]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is highly prevalent and associated with worse cardiovascular outcomes. The pathophysiology of HFpEF mostly relies on the development of elevated left ventricle filling pressure, diastolic dysfunction, and atrial dilatation and impairment. This dynamic process may eventually lead to the development of functional mitral regurgitation (MR), characterized by mitral annular dilatation and consequent leaflet remodeling, in the context of preserved left ventricular ejection fraction. These observations highlight the possible common pathophysiology of MR and HFpEF. However, less is known about the prevalence and the clinical value of MR in the context of HFpEF. This review aims to provide an overview of the association and interplay between functional MR and HFpEF, discuss the underlying mechanisms that are common to these diseases, and summarize potential targeted pharmacological treatments.
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Affiliation(s)
- Mauro Riccardi
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy.
| | - Maja Cikes
- Department of Cardiovascular Diseases, University of Zagreb School of Medicine, University Hospital Center Zagreb, Zagreb, Croatia
| | - Marianna Adamo
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Matteo Pagnesi
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Carlo Mario Lombardi
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Scott David Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marco Metra
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Riccardo Maria Inciardi
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
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Zhang Z, Xiao Y, Dai Y, Lin Q, Liu Q. Device therapy for patients with atrial fibrillation and heart failure with preserved ejection fraction. Heart Fail Rev 2024; 29:417-430. [PMID: 37940727 PMCID: PMC10943171 DOI: 10.1007/s10741-023-10366-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/29/2023] [Indexed: 11/10/2023]
Abstract
Device therapy is a nonpharmacological approach that presents a crucial advancement for managing patients with atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF). This review investigated the impact of device-based interventions and emphasized their potential for optimizing treatment for this complex patient demographic. Cardiac resynchronization therapy, augmented by atrioventricular node ablation with His-bundle pacing or left bundle-branch pacing, is effective for enhancing cardiac function and establishing atrioventricular synchrony. Cardiac contractility modulation and vagus nerve stimulation represent novel strategies for increasing myocardial contractility and adjusting the autonomic balance. Left ventricular expanders have demonstrated short-term benefits in HFpEF patients but require more investigation for long-term effectiveness and safety, especially in patients with AF. Research gaps regarding complications arising from left ventricular expander implantation need to be addressed. Device-based therapies for heart valve diseases, such as transcatheter aortic valve replacement and transcatheter edge-to-edge repair, show promise for patients with AF and HFpEF, particularly those with mitral or tricuspid regurgitation. Clinical evaluations show that these device therapies lessen AF occurrence, improve exercise tolerance, and boost left ventricular diastolic function. However, additional studies are required to perfect patient selection criteria and ascertain the long-term effectiveness and safety of these interventions. Our review underscores the significant potential of device therapy for improving the outcomes and quality of life for patients with AF and HFpEF.
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Affiliation(s)
- Zixi Zhang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan Province, People's Republic of China
| | - Yichao Xiao
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan Province, People's Republic of China.
| | - Yongguo Dai
- Department of Pharmacology, Wuhan University TaiKang Medical School (School of Basic Medical Sciences), Wuhan, 430071, Hubei Province, People's Republic of China
| | - Qiuzhen Lin
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan Province, People's Republic of China
| | - Qiming Liu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan Province, People's Republic of China.
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Tanaka T, Sugiura A, Vogelhuber J, Öztürk C, Böhm L, Wilde N, Zimmer S, Nickenig G, Weber M. Outcomes of transcatheter edge-to-edge repair for atrial functional mitral regurgitation. EUROINTERVENTION 2024; 20:e250-e260. [PMID: 38389471 PMCID: PMC10870009 DOI: 10.4244/eij-d-23-00819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 11/08/2023] [Indexed: 02/24/2024]
Abstract
BACKGROUND The prognostic benefits of transcatheter edge-to-edge repair (TEER) remain unclear in patients with atrial functional mitral regurgitation (AFMR). AIMS We aimed to investigate the clinical outcomes of TEER for patients with AFMR. METHODS We retrospectively classified functional mitral regurgitation (FMR) patients undergoing TEER into those with AFMR or ventricular FMR (VFMR). A residual MR ≤1+ at discharge was considered optimal mitral regurgitation (MR) reduction, and an elevated mean mitral valve pressure gradient (MPG) was defined as an MPG ≥5 mmHg at discharge. The primary outcome was a composite of all-cause mortality and hospitalisation due to heart failure within one year. RESULTS Of 441 FMR patients, 125 patients were considered as having AFMR. Residual MR ≤1+ was associated with a lower risk of the composite outcome in both AFMR and VFMR patients, while an MPG ≥5 mmHg was associated with a higher risk of the composite outcome in patients with AFMR but not with VFMR. AFMR patients with residual MR ≤1+ and an MPG ≥5 mmHg, as well as those with residual MR >1+, had a higher incidence of the composite outcome than those with residual MR ≤1+ and an MPG <5 mmHg (50.7%, 41.8%, and 14.3%, respectively; p<0.001). This association was consistent after adjustment for clinical and echocardiographic characteristics. CONCLUSIONS An MR reduction to ≤1+ following TEER was associated with a lower risk of clinical outcomes in patients with AFMR, while an MPG ≥5 mmHg was related to a higher risk of clinical outcomes. Optimal MR reduction by TEER may have potential benefits on the prognosis of patients with AFMR, although the prognostic benefit may be attenuated by an elevated MPG.
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Affiliation(s)
- Tetsu Tanaka
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Atsushi Sugiura
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Johanna Vogelhuber
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Can Öztürk
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Lukas Böhm
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Nihal Wilde
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Sebastian Zimmer
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Georg Nickenig
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Marcel Weber
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
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7
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Masiero G, Montonati C, Rubbio AP, Adamo M, Grasso C, Denti P, Giordano A, Godino C, Bartorelli AL, De Felice F, Mongiardo A, Monteforte I, Villa E, Giannini C, Tamburino C, Petroni AS, Montorfano M, Giulia L, Dario G, Bedogni F, Giuseppe T. Impact of Transcatheter Edge-to-Edge Mitral Valve Repair on Atrial Functional Mitral Regurgitation from the GIOTTO Registry. Am J Cardiol 2024; 211:219-227. [PMID: 37944779 DOI: 10.1016/j.amjcard.2023.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 10/23/2023] [Accepted: 11/04/2023] [Indexed: 11/12/2023]
Abstract
Atrial functional mitral regurgitation (aFMR) has a peculiar pathophysiology that may have distinctive outcomes. We investigated the impact of transcatheter edge-to-edge repair in aFMR compared with other FMR etiologies. The GIOTTO (GIse registry Of Transcatheter treatment of MR) is a multicenter, prospective study enrolling patients with symptomatic MR treated with MitraClip up to 2020. We categorized patients with FMR as aFMR, ischemic FMR (iFMR), and nonischemic ventricular FMR (niFMR). The clinical end points were defined according to the Mitral Valve Academic Research Consortium. Of 1,153 patients, 6% had aFMR, 47% iFMR, and 47% niFMR. Patients with aFMR were older, mostly women, and had a higher atrial fibrillation rate. They had better left ventricular ejection fraction and smaller left ventricular volumes, with no difference in mitral effective regurgitant orifice area. The acute device and procedural success rates were similar among the groups. At the longest available follow-up (median 478 days, interquartile range 91 to 741 days), the rate of MR ≥2+ was similar among the groups. Patients with aFMR had a lower rate of cardiovascular death and heart failure than patients with iFMR (hazard ratio [HR] 0.43, p = 0.02) and niFMR (HR 0.45, p = 0.03). The aFMR etiology remained independently associated with the composite outcome, together with postprocedural MR ≤1+ (HR 0.63, p <0.01) and peripheral arteriopathy (HR 1.82, p = 0.003). The results of this GIOTTO subanalysis suggested that aFMR is less prevalent and associated with better outcomes compared with other causes of FMR treated by transcatheter edge-to-edge repair. Postprocedural MR >1+, peripheral vasculopathy, non-aFMR were independent predictors of worse outcomes.
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Affiliation(s)
- Giulia Masiero
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Carolina Montonati
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Antonio Popolo Rubbio
- Department of Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Marianna Adamo
- Cardiology and Cardiac Catheterization Laboratory, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Carmelo Grasso
- Division of Cardiology, Centro Alte Specialità e Trapianti (CAST), Azienda Ospedaliero-universitaria Policlinico-Vittorio Emanuele, University of Catania, Catania, Italy
| | - Paolo Denti
- Cardiac Surgery Department, San Raffaele University Hospital, Milan, Italy
| | - Arturo Giordano
- Invasive Cardiology Unit, Pineta Grande Hospital, Castel Volturno, Caserta, Italy
| | - Cosmo Godino
- Cardio-Thoracic-Vascular Department, San Raffaele University Hospital, Milan, Italy
| | | | - Francesco De Felice
- Division of Interventional Cardiology, Azienda Ospedaliera S. Camillo Forlanini, Rome, Italy
| | | | - Ida Monteforte
- AORN Ospedali dei Colli, Monaldi Hospital, Naples, Italy
| | - Emmanuel Villa
- Cardiac Surgery Unit, Poliambulanza Hospital, Fondazione Poliambulanza, Brescia, Italy
| | - Cristina Giannini
- Cardiac Catheterization Laboratory, Cardiothoracic and Vascular Department, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Corrado Tamburino
- Division of Cardiology, Centro Alte Specialità e Trapianti (CAST), Azienda Ospedaliero-universitaria Policlinico-Vittorio Emanuele, University of Catania, Catania, Italy
| | - Anna Sonia Petroni
- Cardiac Catheterization Laboratory, Cardiothoracic and Vascular Department, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Matteo Montorfano
- Cardio-Thoracic-Vascular Department, San Raffaele University Hospital, Milan, Italy
| | - Lorenzoni Giulia
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Gregori Dario
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Francesco Bedogni
- Department of Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Tarantini Giuseppe
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy.
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Marchetti D, Di Lenarda F, Novembre ML, Paolisso P, Schillaci M, Melotti E, Doldi M, Terzi R, Gallazzi M, Conte E, Volpato V, Bartorelli A, Andreini D. Contemporary Echocardiographic Evaluation of Mitral Regurgitation and Guidance for Percutaneous Mitral Valve Repair. J Clin Med 2023; 12:7121. [PMID: 38002733 PMCID: PMC10672624 DOI: 10.3390/jcm12227121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 10/16/2023] [Accepted: 11/10/2023] [Indexed: 11/26/2023] Open
Abstract
Mitral valve regurgitation (MR) is a multifaceted valvular heart disease. Echocardiography plays a central role in etiology assessment, severity quantification, treatment candidacy, outcome evaluation, and patient follow-up. In this review, we describe the comprehensive echocardiographic assessment of MR, including transthoracic (TTE) and transesophageal (TEE) approaches, 2D and 3D modalities, strain imaging, stress echocardiography, and artificial intelligence (AI) applications. Transcatheter edge-to-edge mitral valve repair (TEER) has been established as a key therapy for patients with severe, symptomatic MR and high surgical risk. TEER is performed under TEE guidance. We outline a practical overview of echocardiographic guidance on TEER.
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Affiliation(s)
- Davide Marchetti
- Division of University Cardiology, IRCCS Ospedale Galeazzi Sant’Ambrogio, 20100 Milan, Italy; (D.M.); (E.M.); (R.T.); (A.B.)
| | - Francesca Di Lenarda
- Division of University Cardiology, IRCCS Ospedale Galeazzi Sant’Ambrogio, 20100 Milan, Italy; (D.M.); (E.M.); (R.T.); (A.B.)
| | - Maria Laura Novembre
- Division of University Cardiology, IRCCS Ospedale Galeazzi Sant’Ambrogio, 20100 Milan, Italy; (D.M.); (E.M.); (R.T.); (A.B.)
| | - Pasquale Paolisso
- Division of University Cardiology, IRCCS Ospedale Galeazzi Sant’Ambrogio, 20100 Milan, Italy; (D.M.); (E.M.); (R.T.); (A.B.)
| | - Matteo Schillaci
- Division of University Cardiology, IRCCS Ospedale Galeazzi Sant’Ambrogio, 20100 Milan, Italy; (D.M.); (E.M.); (R.T.); (A.B.)
| | - Eleonora Melotti
- Division of University Cardiology, IRCCS Ospedale Galeazzi Sant’Ambrogio, 20100 Milan, Italy; (D.M.); (E.M.); (R.T.); (A.B.)
| | - Marco Doldi
- Division of University Cardiology, IRCCS Ospedale Galeazzi Sant’Ambrogio, 20100 Milan, Italy; (D.M.); (E.M.); (R.T.); (A.B.)
| | - Riccardo Terzi
- Division of University Cardiology, IRCCS Ospedale Galeazzi Sant’Ambrogio, 20100 Milan, Italy; (D.M.); (E.M.); (R.T.); (A.B.)
| | - Michele Gallazzi
- Division of University Cardiology, IRCCS Ospedale Galeazzi Sant’Ambrogio, 20100 Milan, Italy; (D.M.); (E.M.); (R.T.); (A.B.)
| | - Edoardo Conte
- Division of University Cardiology, IRCCS Ospedale Galeazzi Sant’Ambrogio, 20100 Milan, Italy; (D.M.); (E.M.); (R.T.); (A.B.)
| | - Valentina Volpato
- Division of University Cardiology, IRCCS Ospedale Galeazzi Sant’Ambrogio, 20100 Milan, Italy; (D.M.); (E.M.); (R.T.); (A.B.)
| | - Antonio Bartorelli
- Division of University Cardiology, IRCCS Ospedale Galeazzi Sant’Ambrogio, 20100 Milan, Italy; (D.M.); (E.M.); (R.T.); (A.B.)
| | - Daniele Andreini
- Division of University Cardiology, IRCCS Ospedale Galeazzi Sant’Ambrogio, 20100 Milan, Italy; (D.M.); (E.M.); (R.T.); (A.B.)
- Department of Clinical and Biomedical Sciences, University of Milan, 20100 Milan, Italy
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9
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Hamada S, Ueyama H, Aikawa T, Kampaktsis PN, Misumida N, Takagi H, Kuno T, Latib A. Outcomes of transcatheter edge-to-edge repair for atrial functional mitral regurgitation: A meta-analysis of observational studies. Catheter Cardiovasc Interv 2023; 102:751-760. [PMID: 37579199 DOI: 10.1002/ccd.30806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 07/28/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND Transcatheter edge-to-edge repair (TEER) may have potential benefits in the treatment of atrial functional mitral regurgitation (AFMR), but robust evidence is currently lacking. We conducted a systematic review and meta-analysis to investigate the clinical outcomes of TEER for AFMR, including comparisons to ventricular functional MR (VFMR). METHODS MEDLINE and EMBASE were searched through January 2023 to identify studies eligible for analysis. The primary outcome was postprocedural MR severity. Postprocedural New York Heart Association (NYHA) functional class classification and all-cause mortality were also evaluated. Outcomes were stratified into short term (postprocedure to 6 months) and long term (6 months to 2 years). RESULTS A total of eight observational studies met the inclusion criteria, enrolling 539 AFMR and 3486 VFMR patients. Postprocedural MR grade ≤2 in the AFMR group was observed in 93.7% (454/491 patients; 95% confidence interval (CI), 91.1%-96.2%, I2 = 24.3%) and 97.1% (89/93 patients; 95% CI, 92.9%-100%, I2 = 26.4%) in short- and long-term follow-up, respectively. There was no difference in the rates of postprocedural MR grade ≤2 between AFMR and VFMR either in short-term (risk ratio [RR], 1.00 [95% CI, 0.95-1.06]; p = 0.90; I2 = 53%) or long-term follow-up (RR, 1.08 [95% CI, 0.89-1.32]; p = 0.44; I2 = 22%). Similarly, no difference was observed between AFMR and VFMR in the rates of postprocedural NYHA class ≤2 or all-cause mortality. CONCLUSION TEER provides similar clinical outcomes for AFMR and VFMR. A high rate of MR grade ≤2 was observed in patients at both short- and long-term follow-ups. Further prospective studies with TEER versus medical therapy and/or rhythm control for AFMR are warranted.
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Affiliation(s)
- Seiji Hamada
- Imperial College London, School of Public Health, London, UK
| | - Hiroki Ueyama
- Division of Cardiology, Emory University School of Medicine, Georgia, Atlanta, USA
| | - Tadao Aikawa
- Department of Cardiology, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Polydoros N Kampaktsis
- Division of Cardiology, Columbia University Irving Medical Center, New York City, New York, USA
| | - Naoki Misumida
- Division of Cardiovascular Medicine, Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky, USA
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Toshiki Kuno
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York City, New York, USA
- Department of Cardiology, Jacobi Medical Center, Albert Einstein College of Medicine, New York, USA
| | - Azeem Latib
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York City, New York, USA
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10
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Lander MM, Brener MI, Goel K, Tang PC, Verlinden NJ, Zalawadiya S, Lindenfeld J, Kanwar MK. Mitral Interventions in Heart Failure. JACC. HEART FAILURE 2023; 11:1055-1069. [PMID: 37611988 DOI: 10.1016/j.jchf.2023.07.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/10/2023] [Accepted: 07/19/2023] [Indexed: 08/25/2023]
Abstract
Patients with heart failure with reduced ejection fraction who have secondary mitral regurgitation (SMR) have poorer outcomes and quality of life than those without SMR. Guideline-directed medical therapy is the cornerstone of SMR treatment. Careful evaluation of landmark trials using mitral transcatheter edge-to-edge repair in SMR has led to an improved understanding of who will benefit from percutaneous interventions with emphasis on a multidisciplinary approach. The success with mitral transcatheter edge-to-edge repair in SMR has also spurred the evaluation of its role in populations that were not initially studied, such as end-stage heart failure and cardiogenic shock. A spectrum of transcatheter devices in development and clinical trials promise to further provide a growing array of management options for heart failure with reduced ejection fraction patients with symptomatic SMR.
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Affiliation(s)
- Matthew M Lander
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Michael I Brener
- Division of Cardiology at Columbia University Irving Medical Center, New York, New York, USA
| | - Kashish Goel
- Vanderbilt Heart and Vascular Institute, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Paul C Tang
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Nathan J Verlinden
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Sandip Zalawadiya
- Vanderbilt Heart and Vascular Institute, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - JoAnn Lindenfeld
- Vanderbilt Heart and Vascular Institute, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Manreet K Kanwar
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, Pennsylvania, USA.
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11
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Deferm S, Bertrand PB, Dhont S, von Bardeleben RS, Vandervoort PM. Arrythmia-Mediated Valvular Heart Disease. Heart Fail Clin 2023; 19:357-377. [PMID: 37230650 DOI: 10.1016/j.hfc.2023.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The aging population is rising at record pace worldwide. Along with it, a steep increase in the prevalence of atrial fibrillation and heart failure with preserved ejection fraction is to be expected. Similarly, both atrial functional mitral and tricuspid regurgitation (AFMR and AFTR) are increasingly observed in daily clinical practice. This article summarizes all current evidence regarding the epidemiology, prognosis, pathophysiology, and therapeutic options. Specific attention is addressed to discern AFMR and AFTR from their ventricular counterparts, given their different pathophysiology and therapeutic needs.
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Affiliation(s)
- Sébastien Deferm
- Hasselt University, Agoralaan Building D, 3590 Diepenbeek, Belgium; Department of Cardiology, Mainz University Hospital, Langenbeckstraße 1, Mainz, Germany. https://twitter.com/S_Deferm
| | - Philippe B Bertrand
- Hasselt University, Agoralaan Building D, 3590 Diepenbeek, Belgium; Department of Cardiology, Hospital Oost-Limburg Genk, Schiepse Bos 6, 3600 Genk, Belgium. https://twitter.com/Ph_Bertrand
| | - Sebastiaan Dhont
- Hasselt University, Agoralaan Building D, 3590 Diepenbeek, Belgium; Department of Cardiology, Hospital Oost-Limburg Genk, Schiepse Bos 6, 3600 Genk, Belgium. https://twitter.com/S_Dhont
| | - Ralph S von Bardeleben
- Department of Cardiology, Mainz University Hospital, Langenbeckstraße 1, Mainz, Germany. https://twitter.com/vonbardelebenRS
| | - Pieter M Vandervoort
- Hasselt University, Agoralaan Building D, 3590 Diepenbeek, Belgium; Department of Cardiology, Hospital Oost-Limburg Genk, Schiepse Bos 6, 3600 Genk, Belgium.
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12
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Cammalleri V, Antonelli G, De Luca VM, Carpenito M, Nusca A, Bono MC, Mega S, Ussia GP, Grigioni F. Functional Mitral and Tricuspid Regurgitation across the Whole Spectrum of Left Ventricular Ejection Fraction: Recognizing the Elephant in the Room of Heart Failure. J Clin Med 2023; 12:jcm12093316. [PMID: 37176756 PMCID: PMC10178924 DOI: 10.3390/jcm12093316] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/21/2023] [Accepted: 04/22/2023] [Indexed: 05/15/2023] Open
Abstract
Functional mitral regurgitation (FMR) and tricuspid regurgitation (FTR) occur due to cardiac remodeling in the presence of structurally normal valve apparatus. Two main mechanisms are involved, distinguishing an atrial functional form (when annulus dilatation is predominant) and a ventricular form (when ventricular remodeling and dysfunction predominate). Both affect the prognosis of patients with heart failure (HF) across the entire spectrum of left ventricle ejection fraction (LVEF), including preserved (HFpEF), mildly reduced (HFmrEF), or reduced (HFrEF). Currently, data on the management of functional valve regurgitation in the various HF phenotypes are limited. This review summarizes the epidemiology, pathophysiology, and treatment of FMR and FTR within the different patterns of HF, as defined by LVEF.
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Affiliation(s)
- Valeria Cammalleri
- Research Unit of Cardiovascular Science, Università e Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Giorgio Antonelli
- Research Unit of Cardiovascular Science, Università e Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Valeria Maria De Luca
- Research Unit of Cardiovascular Science, Università e Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Myriam Carpenito
- Research Unit of Cardiovascular Science, Università e Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Annunziata Nusca
- Research Unit of Cardiovascular Science, Università e Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Maria Caterina Bono
- Research Unit of Cardiovascular Science, Università e Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Simona Mega
- Research Unit of Cardiovascular Science, Università e Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Gian Paolo Ussia
- Research Unit of Cardiovascular Science, Università e Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Francesco Grigioni
- Research Unit of Cardiovascular Science, Università e Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
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13
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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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