Beta-blockade therapy in chronic heart failure: diastolic function and mitral regurgitation improvement by carvedilol

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.

Frailty as a predictor of mortality and readmission rate in secondary mitral regurgitation

INTRODUCTION

Selection in patients with functional mitral regurgitation (MR) to identify responders to interventions is challenging. In these patients, frailty might be used as a multidimensional parameter to summarize the resilience to stressors. Our objective was to evaluate frailty as a predictor of outcome in patients with moderate to severe secondary MR.

METHODS

We conducted a single-center retrospective observational cohort study and included 239 patients with moderate to severe secondary MR aged 65 years or older between 2014 and 2020. Echocardiography was performed at baseline; frailty was evaluated using the clinical frailty scale (CFS). The combined primary endpoint was hospitalization for heart failure and all-cause mortality.

RESULTS

A total of 53% (127) of all patients were classified as CFS 4 (living with mild frailty) or higher. Frail patients had a higher risk for the combined endpoint (hazard ratio, HR 3.70, 95% confidence interval, CI 2.12-6.47; p < 0.001), 1‑year mortality (HR 5.94, 95% CI 1.76-20.08; p < 0.001) even after adjustment for EuroSCORE2. The CFS was predictive for the combined endpoint (AUC 0.69, 95% CI 0.62-0.75) and outperformed EuroSCORE2 (AUC 0.54, 95% CI 0.46-0.62; p = 0.01). In sensitivity analyses, we found that frailty was associated with adverse outcomes at least in trend in all subgroups.

CONCLUSION

For older, medically treated patients with moderate to severe secondary mitral regurgitation, frailty is an independent predictor for the occurrence of death and heart failure-related readmission within 1 year and outperformed the EuroSCORE2. Frailty should be assessed routinely in patients with heart failure to guide clinical decision making for mitral valve interventions or conservative treatment.

Impact of Transcatheter Edge-to-Edge Mitral Valve Repair on Guideline-Directed Medical Therapy Uptitration

BACKGROUND

Guideline-directed medical therapy (GDMT) optimization is mandatory before transcatheter edge-to-edge mitral valve repair (M-TEER) in patients with secondary mitral regurgitation (SMR) and heart failure (HF) with reduced ejection fraction (HFrEF). However, the effect of M-TEER on GDMT is unknown.

OBJECTIVES

The authors sought to evaluate frequency, prognostic implications and predictors of GDMT uptitration after M-TEER in patients with SMR and HFrEF.

METHODS

This is a retrospective analysis of prospectively collected data from the EuroSMR Registry. The primary events were all-cause death and the composite of all-cause death or HF hospitalization.

RESULTS

Among the 1,641 EuroSMR patients, 810 had full datasets regarding GDMT and were included in this study. GDMT uptitration occurred in 307 patients (38%) after M-TEER. Proportion of patients receiving angiotensin-converting enzyme inhibitors/angiotensin receptor blockers/angiotensin receptor-neprilysin inhibitors, beta-blockers, and mineralocorticoid receptor antagonists was 78%, 89%, and 62% before M-TEER and 84%, 91%, and 66% 6 months after M-TEER (all P < 0.001). Patients with GDMT uptitration had a lower risk of all-cause death (adjusted HR: 0.62; 95% CI: 0.41-0.93; P = 0.020) and of all-cause death or HF hospitalization (adjusted HR: 0.54; 95% CI: 0.38-0.76; P < 0.001) compared with those without. Degree of MR reduction between baseline and 6-month follow-up was an independent predictor of GDMT uptitration after M-TEER (adjusted OR: 1.71; 95% CI: 1.08-2.71; P = 0.022).

CONCLUSIONS

GDMT uptitration after M-TEER occurred in a considerable proportion of patients with SMR and HFrEF and is independently associated with lower rates for mortality and HF hospitalizations. A greater decrease in MR was associated with increased likelihood for GDMT uptitration.

Medical Therapy for Functional Mitral Regurgitation

Functional mitral regurgitation (FMR) can be broadly categorized into 2 main groups: ventricular and atrial, which often coexist. The former is secondary to left ventricular remodeling usually in the setting of heart failure with reduced ejection fraction or less frequently due to ischemic papillary muscle remodeling. Atrial FMR develops due to atrial and annular dilatation related to atrial fibrillation/flutter or from increased atrial pressures in the setting of heart failure with preserved ejection fraction. Guideline-directed medical therapy is the first step and prevails as the mainstay in the treatment of FMR. In this review, we address the medical therapeutic options for FMR management and highlight a targeted approach for each FMR category. We further address important clinical and echocardiographic characteristics to aid in determining when medical therapy is expected to have a low yield and an appropriate window for effective interventional approaches exists.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021.

STRUCTURE

Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

Clinical impact of changes in mitral regurgitation severity after medical therapy optimization in heart failure

Background

Few data are available regarding changes in mitral regurgitation (MR) severity with guideline-recommended medical therapy (GRMT) in heart failure (HF). Our aim was to evaluate the evolution and impact of MR after GRMT in the Biology study to Tailored treatment in chronic heart failure (BIOSTAT-CHF).

Methods

A retrospective post-hoc analysis was performed on HF patients from BIOSTAT-CHF with available data on MR status at baseline and at 9-month follow-up after GRMT optimization. The primary endpoint was a composite of all-cause death or HF hospitalization.

Results

Among 1022 patients with data at both time-points, 462 (45.2%) had moderate-severe MR at baseline and 360 (35.2%) had it at 9-month follow-up. Regression of moderate-severe MR from baseline to 9 months occurred in 192/462 patients (41.6%) and worsening from baseline to moderate-severe MR at 9 months occurred in 90/560 patients (16.1%). The presence of moderate-severe MR at 9 months, independent from baseline severity, was associated with an increased risk of the primary endpoint (unadjusted hazard ratio [HR], 2.03; 95% confidence interval [CI], 1.57–2.63; p < 0.001), also after adjusting for the BIOSTAT-CHF risk-prediction model (adjusted HR, 1.85; 95% CI 1.43–2.39; p < 0.001). Younger age, LVEF ≥ 50% and treatment with higher ACEi/ARB doses were associated with a lower likelihood of persistence of moderate-severe MR at 9 months, whereas older age was the only predictor of worsening MR.

Conclusions

Among patients with HF undergoing GRMT optimization, ACEi/ARB up-titration and HFpEF were associated with MR improvement, and the presence of moderate-severe MR after GRMT was associated with worse outcome.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s00392-022-01991-7.

Secondary valve regurgitation in patients with heart failure with preserved ejection fraction, heart failure with mid-range ejection fraction, and heart failure with reduced ejection fraction

Secondary mitral regurgitation and secondary tricuspid regurgitation due to heart failure (HF) remain challenging in almost every aspect: increasing prevalence, poor prognosis, notoriously elusive in diagnosis, and complexity of therapeutic management. Recently, defined HF subgroups according to three ejection fraction (EF) ranges (reduced, mid-range, and preserved) have stimulated a structured understanding of the HF syndrome but the role of secondary valve regurgitation (SVR) across the spectrum of EF remains undefined. This review expands this structured understanding by consolidating the underlying phenotype of myocardial impairment with each type of SVR. Specifically, the current understanding, epidemiological considerations, impact, public health burden, mechanisms, and treatment options of SVR are discussed separately for each lesion across the HF spectrum. Furthermore, this review identifies important gaps in knowledge, future directions for research, and provides potential solutions for diagnosis and treatment. Mastering the challenge of SVR requires a multidisciplinary collaborative effort, both, in clinical practice and scientific approach to optimize patient outcomes.

Revisiting the Role of Guideline-Directed Medical Therapy for Patients with Heart Failure and Severe Functional Mitral Regurgitation

Patients with heart failure often have mitral regurgitation, which can generate a vicious cycle. Medical therapy remains the cornerstone of their treatment in this setting. This review revisits the role of medical therapy and its optimization for severe functional mitral regurgitation in the contemporary era.

The current diagnosis and treatment of high-risk patients with chronic primary and secondary mitral valve regurgitation

Mitral valve regurgitation (MR) is due primarily to either primary degeneration of the mitral valve with Barlow's or fibroelastic disease or is secondary to ischemic or nonischemic cardiomyopathies. Echocardiography is essential to assess MR etiology and severity, the remodeling of cardiac chambers and to characterize longitudinal chamber changes to determine optimal therapies. Surgery is recommended for severe primary MR if persistent symptoms are present or if left ventricle dysfunction is present with an EF <60% or a left ventricle end-systolic diameter ≥40 mm. For secondary MR, therapy of heart failure with vasodilators and diuretics improves forward cardiac output. Coronary artery bypass grafts (CABG) or percutaneous coronary intervention (PCI) should be considered for severe MR due to ischemia. This review summarizes the pathophysiology, the characteristics, the management and the different interventions for high risk patients with chronic primary and secondary MR.

Percutaneous Mitral Valve Intervention Using MitraClip for Functional Mitral Regurgitation and Heart Failure

Functional mitral regurgitation (FMR) frequently coexists with left ventricular systolic dysfunction and advanced heart failure, and typically has poor clinical outcomes. Although various therapeutic options including cardiac resynchronization therapy and surgical mitral intervention, have been proposed, an optimal treatment strategy for functional mitral regurgitation has not yet been established. Over the last decade, transcatheter mitral valve repair using MitraClip has emerged as a novel alternative therapeutic option for functional mitral regurgitation. In 2018, the COAPT trial demonstrated that MitraClip treatment reduced rehospitalization due to heart failure and all-cause death in patients with functional mitral regurgitation and heart failure. As a consequence, the MitraClip has become a very promising potential treatment for functional mitral regurgitation. In this review, we discuss and summarize the current status and future perspectives of the treatment for functional mitral regurgitation and heart failure.

Treatment of Secondary Mitral Regurgitation in Heart Failure: A Shifting Paradigm in the Wake of the COAPT Trial

Secondary mitral regurgitation (MR) is common in patients with left heart dysfunction and it is associated with poor outcomes. Findings from the Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation (COAPT) trial, published in 2018, suggest that in a subset of people with heart failure with secondary MR that persists despite optimization of guideline-directed medical therapies, there is now a role for percutaneous mitral valve repair using the MitraClip device. Defining which patients are most likely to benefit from MitraClip, and when, requires both a multidisciplinary approach centered on heart failure, as well as a recognition of the need for further research in this area.

Treatment options for ischemic mitral regurgitation: A meta-analysis

BACKGROUND

Treatment of ischemic mitral regurgitation (IMR) is in evolution, as percutaneous procedures and complex surgical repair have been recently investigated in randomized clinical trials and matched studies. This study aims to review and compare the current treatment options for IMR.

METHODS

A comprehensive literature search was conducted using electronic databases. The primary outcome was all-cause long-term mortality. The secondary outcomes were perioperative mortality, unplanned rehospitalization, reoperation, and composite end points as defined in the original articles.

RESULTS

A total of 12 articles met the inclusion criteria and were included in the final meta-analysis. The MitraClip procedure did not confer a significant benefit in mortality and repeated hospitalization compared with medical therapy alone. In patients with moderate IMR, the adjunct of mitral procedure over coronary artery bypass graft is not associated with clinical improvements. When evaluating mitral valve (MV) replacement versus repair, hospital mortality was greater among patients undergoing replacement (odds ratio [OR], 1.91; P = .009), but both reoperation and readmission rates were lower (OR, 0.60, P = .05; and OR, 0.45, P < .02, respectively). Comparing restrictive annuloplasty alone with adjunctive subvalvular repair, subvalvular procedures resulted in fewer readmissions (OR, 0.50; P = .06) and adverse composite end points (P = .009).

CONCLUSIONS

MitraClip procedure is not associated with improved outcomes compared with medical therapy. MV replacement is associated with increased early mortality but reduced reoperation rate and readmission rate compared with MV repair using annuloplasty in moderate-to-severe IMR. Despite no significant benefit in isolated outcomes comparing annular and adjunct subvalvular procedures, the adjunct of subvalvular procedures reduces the risk of major postoperative adverse events.

Structural heart disease: the year in valvular and complex coronary intervention trials

The need for treatment strategies targeting complex structural heart and obstructive epicardial coronary artery disease (CAD) is rapidly growing. The demographics in referral centers has shifted to an older population with greater co-morbidities and higher risk. Indeed, nearly one quarter of patients in tertiary-care settings have moderate or severe valvular heart disease, and despite a decrease in overall CAD burden in the United States over the past two decades the prevalence of myocardial infarction remains high. The 2019 societal scientific sessions included novel research and landmark presentations on less invasive valvular and safer complex coronary interventions in the aforementioned populations, in hopes of improving patient outcomes and expanding treatment indications. Transcatheter aortic valve replacement (TAVR), percutaneous mitral and tricuspid valve therapy, and complex coronary interventions, were the focus of important clinical trials and registry data. Herein, we provide a select and concise review of the most pivotal studies presented.

Mitral regurgitation: lessons learned from COAPT and MITRA-Fr

Recent studies about percutaneous treatment of secondary mitral regurgitation (MR) underlined the importance of left ventricular geometry and features of mitral valve as determinants of procedural and long-term success. Guideline-directed medical therapy (GDMT), transcatheter mitral valve treatment (TMVT) and surgical procedures (mitral valve replacement, mitral valve repair at level of the annulus or subvalvular apparatus) have been extensively evaluated but not adequately compared in current clinical studies. A detailed analysis of the results of the study about transcatheter mitral valve repair would allow to evaluate the safety and effectiveness of such procedure and would provide potential indications for improving the quality of percutaneous and surgical repair in patients with moderate-to-severe secondary MR. Patients with proportionate MR (i.e., MR severity is proportional to the amount of left ventricular dilatation) are prone to respond to the optimization of medical therapy, while patients with disproportionate MR (i.e., MR severity is disproportionately higher than predicted by left ventricular dilatation, with high EROA and small left ventricle) are likely to benefit from additional repair. The identification of specific subpopulation of "high responders", based on the anatomic characteristics of the mitral valve and the relative dimensions of the annulus, the regurgitation and the left ventricle, can also apply to medical therapy. However, some pivotal component of MR (such as the symmetry of tethering and the differences in biomechanical features of leaflets) are not adequately investigated in current studies and warrant further evaluation.

Contrasting Effects of Pharmacological, Procedural, and Surgical Interventions on Proportionate and Disproportionate Functional Mitral Regurgitation in Chronic Heart Failure

Two distinct pathways can lead to functional mitral regurgitation (MR) in patients with chronic heart failure and a reduced ejection fraction. When remodeling and enlargement of the left ventricle (LV) cause annular dilatation and tethering of the mitral valve leaflets, there is a linear relationship between LV end-diastolic volume and the effective regurgitant orifice area of the mitral valve. These patients, designated as having proportionate MR, respond favorably to treatments that lead to reversal of LV remodeling and a decrease in LV volumes (eg, neurohormonal antagonists and LV assist devices), but they may not benefit from interventions that are directed only at the mitral valve leaflets (eg, transcatheter mitral valve repair). In contrast, when ventricular dyssynchrony causes functional MR attributable to unequal contraction of the papillary muscles, the magnitude of regurgitation is greater than that predicted by LV volumes. These patients, designated as having severe but disproportionate MR, respond favorably to treatments that are directed to the mitral valve leaflets or their supporting structures (eg, cardiac resynchronization or transcatheter mitral valve repair), but they may derive little benefit from interventions that act only to reduce LV cavity size (eg, pharmacological treatments). This novel conceptual framework reflects the important interplay between LV geometry and mitral valve function in determining the clinical presentation of patients, and it allows characterization of the determinants of functional MR to guide the most appropriate therapy in the clinical setting.

The Choice of Treatment in Ischemic Mitral Regurgitation With Reduced Left Ventricular Function

BACKGROUND

Ischemic mitral regurgitation is a condition characterized by mitral insufficiency secondary to an ischemic left ventricle. Primarily, the pathology is the result of perturbation of normal regional left ventricular geometry combined with adverse remodeling. We present a comprehensive review of contemporary surgical, medical, and percutaneous treatment options for ischemic mitral regurgitation, rigorously examined by current guidelines and literature.

METHODS

We conducted a literature search of the PubMed database, Embase, and the Cochrane Library (through November 2018) for studies reporting perioperative or late mortality and echocardiographic outcomes after surgical and nonsurgical intervention for ischemic mitral regurgitation.

RESULTS

Treatment of this condition is challenging and often requires a multimodality approach. These patients usually have multiple comorbidities that may preclude surgery as a viable option. A multidisciplinary team discussion is crucial in optimizing outcomes. There are several options for treatment and management of ischemic mitral regurgitation with differing benefits and risks. Guideline-directed medical therapy for heart failure is the treatment choice for moderate and severe ischemic mitral regurgitation, with consideration of coronary revascularization, mitral valve surgery, cardiac resynchronization therapy, or a combination of these, in appropriate candidates. The use of transcatheter mitral valve therapy is considered appropriate in high-risk patients with severe ischemic mitral regurgitation, heart failure, and reduced left ventricular ejection fraction, especially in those with hemodynamic instability.

CONCLUSIONS

The role of mitral valve surgery and transcatheter mitral valve therapy continues to evolve.

The Role of Arterial Hypertension in Mitral Valve Regurgitation

PURPOSE OF REVIEW

To review medical literature for evidence of association between hypertension and mitral regurgitation (MR) and summarize potential favorable effects of antihypertensive drugs on MR natural history and treatment.

RECENT FINDINGS

Hypertension and MR are common diseases affecting a large proportion of the general population. Contemporary evidence suggests that hypertension may worsen the progression and prognosis of MR through augmented mechanical stress and increased regurgitation volume. Renin-angiotensin axis inhibitors, beta-blockers, and vasodilators have been tested in order to prevent or decrease primary or secondary MR. Although antihypertensive agents may improve hemodynamic parameters and left ventricular remodeling in primary MR, there is no strong evidence of benefit on clinical outcomes. On the other hand, a beneficial effect of these drugs on secondary MR is better established. Moreover, there are no studies evaluating a possible benefit of lower blood pressure targets in MR. Randomized controlled trials are warranted to elucidate the precise role of antihypertensive therapy on treatment of MR.

Left ventricular remodelling in chronic primary mitral regurgitation: implications for medical therapy

Surgical repair or replacement of the mitral valve is currently the only recommended therapy for severe primary mitral regurgitation. The chronic elevation of wall stress caused by the resulting volume overload leads to structural remodelling of the muscular, vascular and extracellular matrix components of the myocardium. These changes are initially compensatory but in the long term have detrimental effects, which ultimately result in heart failure. Understanding the changes that occur in the myocardium due to volume overload at the molecular and cellular level may lead to medical interventions, which potentially could delay or prevent the adverse left ventricular remodelling associated with primary mitral regurgitation. The pathophysiological changes involved in left ventricular remodelling in response to chronic primary mitral regurgitation and the evidence for potential medical therapy, in particular beta-adrenergic blockers, are the focus of this review.

Secondary mitral regurgitation: percutaneous edge-to-edge repair on the cutting edge?

PURPOSE OF REVIEW

Secondary mitral regurgitation commonly complicates heart failure. Although the evidence for its management is most robust for treating the underlying cardiomyopathy, treatment aimed at additionally reducing the severity of mitral regurgitation with a percutaneous edge-to-edge device, MitraClip, has recently emerged.

RECENT FINDINGS

Despite the use of contemporary evidence-based heart failure therapies, patients with secondary mitral regurgitation and heart failure continue to remain at high risk for adverse clinical events; in both the MITRA-FR and COAPT trials, an extremely high event rate was evident in the medically managed arms over the respective 12-24-month follow-up. Data supporting the use of MitraClip to mitigate adverse outcomes in secondary mitral regurgitation is, however, conflicting. In MITRA-FR no difference was noted between MitraClip compared with the medically managed arm for the composite of all-cause death or heart failure hospitalization at 12 months. However, in COAPT, a significant reduction in the rate of heart failure re-hospitalization over 2 years was evident with MitraClip compared with medical therapy alone.

SUMMARY

Recommendations exist for the use of MitraClip in patients with primary mitral regurgitation and prohibitive surgical risk. However, with the divergent results of two recent high-quality randomized trials, its role in patients with secondary mitral regurgitation remains controversial.

Clinical manifestations, diagnosis, and treatment of ischemic mitral regurgitation: a review

Ischemic mitral regurgitation (IMR) is a frequent complication after acute myocardial infarction (AMI) associated with a worse prognosis. The pathophysiological mechanisms of IMR are not fully understood, but it is known to be a complex process in which ventricular remodelling is the main causal factor. The various imaging techniques in cardiology and echocardiography fundamentally have contributed significantly to clarify the mechanisms that cause and progressively aggravate IMR. At present, different therapeutic options, the most important of which are cardio-surgical, address this problem. Nowadays the improvement in cardiac surgery and transcatheter therapies, have shown a therapeutic advance in IMR management. IMR is a predictor of poor prognosis in patients with heart failure and depressed left ventricular (LV) systolic function. However, it remains controversial whether mitral regurgitation (MR) in these patients is a consequence of dilation and dysfunction of the LV, or whether it contributes to worsening the prognosis of the ventricular dysfunction. Given that echocardiography has a fundamental reference role in the identification, graduation of severity and evaluation of the therapeutics used in the treatment of MR, we are going to focus on it over the rest of the imaging techniques. In contrast to primary MR the benefits of mitral surgery in patients with secondary MR are uncertain. Therefore, we will comment fundamentally on the role of mitral surgery in patients with IMR, with an update of the different surgical interventions available, without forgetting to mention the other therapeutic options currently available.

Contemporary Management of Ischemic Mitral Regurgitation: A Review

Ischemic mitral regurgitation occurs relatively frequently in patients with coronary artery disease and is associated with an increased long-term risk. The pathophysiology of ischemic mitral regurgitation is vexing and poses both diagnostic and therapeutic challenges, leading to the need for a comprehensive, multidisciplinary approach. The management is largely focused on medical therapy, and for those eligible, coronary revascularization or cardiac resynchronization therapy may be considered. In select patients, mitral valve surgery or catheter-based therapy may be undertaken with careful consideration of the underlying pathophysiology, surgical risk, and expected long-term outcomes. The appropriate evaluation of patients with ischemic mitral regurgitation involves a careful multidisciplinary approach that carefully considers symptomatology, the etiology and severity of the mitral regurgitation, and the assessment of comorbidities and operative risk to individualize the care of these patients.

Functional Mitral Regurgitation: An Interventional Cardiologist's Perspective

Functional mitral regurgitation (FMR) is common in patients with heart failure and portends a poor prognosis. The etiology is secondary to nonischemic or ischemic (postmyocardial infarction) adverse remodeling. Treatment includes guideline-directed medical therapy, cardiac resynchronization therapy, and in some cases, surgical repair or replacement. Transcatheter mitral valve (MV) repair with the MitraClip device is approved in patients with degenerative MR and is currently under investigation for use in FMR, as are several transcatheter MV replacement devices. This review discusses the basis of FMR pathophysiology, classification, and prognosis; provides an overview of current therapeutic approaches; examines the available literature on the use of MitraClip in patients with FMR; and provides insight into ongoing clinical trials and new investigational devices for the treatment of FMR.

Effects of carvedilol therapy in patients with heart failure with preserved ejection fraction - Results from the Croatian heart failure (CRO-HF) registry

BACKGROUND AND OBJECTIVE

According to recent guidelines, the best approach for treatment of heart failure patients with preserved ejection function is still not defined. The aim of this study was to investigate how carvedilol therapy influences the survival rate, ejection fraction and NYHA class in these patients.

PATIENTS AND METHODS

We conducted study on heart failure patients with preserved systolic function from the Croatian heart failure registry who were hospitalized in the period between 2005 and 2010. We enrolled patients with carvedilol listed as treatment on their discharge letters and patients who had been using carvedilol for at least 4 years, while for the control group we selected patients with no beta-blockers on their discharge letters (113 vs 204 respectively). The primary outcome was the overall survival rate and the secondary outcome was the change in ejection fraction of the left ventricle and NYHA class during the study.

RESULTS

Patients in the carvedilol group had a higher overall survival rate compared to patients in the control group (chi-square=14.1, P<0.001). Patients in the carvedilol group in two measurements had a significantly higher ejection fraction compared to the control group (F=148.04, P<0.001). Also, patients in the carvedilol group showed improvement in NYHA class (chi-square=29.768, P<0.001).

CONCLUSION

Long term carvedilol therapy appears to be associated with a higher overall survival rate, improvement in ejection fraction and NYHA class in heart failure patients with preserved ejection fraction.

Reverse remodeling in Dilated Cardiomyopathy: Insights and future perspectives

Dilated Cardiomyopathy (DCM) has been classically considered a progressive disease of the heart muscle that inexorably progresses towards refractory heart failure, ventricular arrhythmias and heart transplant. However, the prognosis of DCM has significantly improved in the past few years, mostly as the result of successful therapy-induced reverse remodeling. Reverse remodeling is a complex process that involves not only the left ventricle, but also many other cardiac structures and it is now recognized both as a measure of therapeutic effectiveness and as an important prognostic tool. Nevertheless, several aspects of reverse remodeling remain unclear, including the best timing for its quantification, its predictors and its interaction with individual genetic backgrounds. In this review, we summarize our current understanding of reverse remodeling in patients with DCM and provide practical recommendations for the clinical management of this challenging patient population.

Percutaneous Mitral Valve Interventions and Heart Failure

Mitral regurgitation (MR) is the most frequent Valvular Heart Disease (VHD) and is an important cause of heart failure. MR can be caused by primary valve abnormality (Degenerative MR/Primary MR) or it can be secondary to cardiomyopathy (Functional MR/Secondary MR). Medical management alleviates symptoms but does not alter the progression of the disease. Current guidelines recommend surgery for moderate-to-severe (Grade > 3) MR in patients with symptoms or evidence of left ventricular dysfunction. Despite current practice guidelines, the majority of patients with severe MR do not undergo surgery. The reasons include high surgical risk from advanced age or multiple comorbidities, and a lack of clear data supporting valve surgery for secondary MR with LV dysfunction. The recent emergence of percutaneous interventional approaches in treating MR has expanded therapeutic options for patients who are at high risk for conventional Mitral Valve (MV) surgery. In this chapter, we will review the novel advancements in the field of percutaneous MV interventions that could potentially become the standard of care for patients with MR and heart failure.

Pathophysiology of Aortic Stenosis and Mitral Regurgitation

The global impact of the spectrum of valve diseases is a crucial, fast-growing, and underrecognized health problem. The most prevalent valve diseases, requiring surgical intervention, are represented by calcific and degenerative processes occurring in heart valves, in particular, aortic and mitral valve. Due to the increasing elderly population, these pathologies will gain weight in the global health burden. The two most common valve diseases are aortic valve stenosis (AVS) and mitral valve regurgitation (MR). AVS is the most commonly encountered valve disease nowadays and affects almost 5% of elderly population. In particular, AVS poses a great challenge due to the multiple comorbidities and frailty of this patient subset. MR is also a common valve pathology and has an estimated prevalence of 3% in the general population, affecting more than 176 million people worldwide. This review will focus on pathophysiological changes in both these valve diseases, starting from the description of the anatomical aspects of normal valve, highlighting all the main cellular and molecular features involved in the pathological progression and cardiac consequences. This review also evaluates the main approaches in clinical management of these valve diseases, taking into account of the main published clinical guidelines. © 2017 American Physiological Society. Compr Physiol 7:799-818, 2017.

Exercise Dynamics in Secondary Mitral Regurgitation: Pathophysiology and Therapeutic Implications

Secondary mitral valve regurgitation (MR) remains a challenging problem in the diagnostic workup and treatment of patients with heart failure. Although secondary MR is characteristically dynamic in nature and sensitive to changes in ventricular geometry and loading, current therapy is mainly focused on resting conditions. An exercise-induced increase in secondary MR, however, is associated with impaired exercise capacity and increased mortality. In an era where a multitude of percutaneous solutions are emerging for the treatment of patients with heart failure, it becomes important to address the dynamic component of secondary MR during exercise as well. A critical reappraisal of the underlying disease mechanisms, in particular the dynamic component during exercise, is of timely importance. This review summarizes the pathophysiological mechanisms involved in the dynamic deterioration of secondary MR during exercise, its functional and prognostic impact, and the way current treatment options affect the dynamic lesion and exercise hemodynamics in general.

Functional Mitral Regurgitation: Appraising the Evidence Behind Recommended Treatment Strategies

Functional mitral regurgitation (MR) is the most common type of MR encountered in clinical practice. Because the disease arises from the ventricular aspect of the mitral valve apparatus, treatment therapies are less defined and outcomes are poor. In this review, the state of evidence for medical and surgical therapy in functional MR is appraised. Future directions for research in this area are also defined.

Higher hemoglobin A1c levels are associated with impaired left ventricular diastolic function and higher incidence of adverse cardiac events in patients with nonischemic dilated cardiomyopathy

We aimed to elucidate the relationship between glycated hemoglobin (HbA1c), cardiac systolic/diastolic function, and heart failure (HF) prognosis during guideline-directed medical therapy in patients with nonischemic dilated cardiomyopathy (NIDCM). We evaluated 283 hospitalized NIDCM patients, who were grouped according to baseline (BL) and 1-year (1Y) levels of HbA1c (<6.0, 6.0-6.9, and ≥7.0 %). The primary endpoint was defined as either readmission for HF worsening or cardiac death. Approximately half of the patients had BL- or 1Y-HbA1c ≥6.0 % (31 % at BL, 34 % at 1Y had 6.0-6.9 %; 12 % at BL, 12 % at 1Y had ≥7.0 %). The absolute value of left ventricular ejection fraction (LVEF) and its improvement during 1 year showed no significant difference among the 1Y-HbA1c groups (p = 0.273), whereas a lower absolute value and a more significant reduction in the early diastolic velocity of the mitral annulus (E _a) were seen in the group with 1Y-HbA1c ≥7.0 % (both p < 0.001). In multiple regression analysis, higher 1Y-plasma B-type natriuretic peptide and lower 1Y-Ea were independently associated with higher 1Y-HbA1c (both adjusted p < 0.05). The cumulative incidence of the primary endpoint was highest in the group with 1Y-HbA1c ≥7.0 % (log-rank p = 0.001). Multivariate analysis demonstrated that higher 1Y-HbA1c was independently associated with a higher incidence of the primary endpoint (adjusted p = 0.005). In conclusion, hyperglycemia during clinical follow-up is a risk factor for progression of concomitant LV abnormal relaxation, leading to poor HF prognosis in patients with NIDCM.

Effects of carvedilol on ventricular remodeling and the expression of β3-adrenergic receptor in a diabetic rat model subjected myocardial infarction

BACKGROUND

This study was to assess effects of carvedilol on ventricular remodeling and expression of β3-adrenergic receptor (β3-AR) and Gi protein in a rat model of diabetes subjected to myocardial infarction (MI).

METHODS

Rat model of type II diabetes was established by injection of streptozotion. MI was then induced by ligating the left anterior descending coronary artery. Rats were then randomly divided into two groups treated with either placebo (PL) or carvedilol (CA - 10mg·kg(-1)·d(-)(1)). Additional controls consisted of sham-operated rats with diabetes (DS) and rats fed a normal diet subjected to myocardial infarction (NM). Echocardiographic and hemodynamic studies were performed to assess the structural and functional changes. β3-AR and Gi mRNA in the myocardium distal from the infarction region were measured, and β3-AR and Gi protein were measured with western blot.

RESULTS

There were no significant differences in MI size among the three MI groups. In the PL group, LVEDd, LVWI, E/A and CVF were significantly increased, while LVEF and PW% significantly decreased as compared with the DS and NM groups. Compared with the DS group, the expression of β3-AR and Gi mRNA and protein in the PL group was significantly increased, however, in the CA group, β3-AR and Gi mRNA and protein were decreased.

CONCLUSIONS

The expression of β3-AR and Gi mRNA and protein was increased in diabetic rats subjected to MI as compared with rats subject to either condition alone. Carvedilol treatment prevented many of these deleterious effects.

Two-Year Outcomes of Surgical Treatment of Moderate Ischemic Mitral Regurgitation

BACKGROUND

In a trial comparing coronary-artery bypass grafting (CABG) alone with CABG plus mitral-valve repair in patients with moderate ischemic mitral regurgitation, we found no significant difference in the left ventricular end-systolic volume index (LVESVI) or survival after 1 year. Concomitant mitral-valve repair was associated with a reduced prevalence of moderate or severe mitral regurgitation, but patients had more adverse events. We now report 2-year outcomes.

METHODS

We randomly assigned 301 patients to undergo either CABG alone or the combined procedure. Patients were followed for 2 years for clinical and echocardiographic outcomes.

RESULTS

At 2 years, the mean (±SD) LVESVI was 41.2±20.0 ml per square meter of body-surface area in the CABG-alone group and 43.2±20.6 ml per square meter in the combined-procedure group (mean improvement over baseline, -14.1 ml per square meter and -14.6 ml per square meter, respectively). The rate of death was 10.6% in the CABG-alone group and 10.0% in the combined-procedure group (hazard ratio in the combined-procedure group, 0.90; 95% confidence interval, 0.45 to 1.83; P=0.78). There was no significant between-group difference in the rank-based assessment of the LVESVI (including death) at 2 years (z score, 0.38; P=0.71). The 2-year rate of moderate or severe residual mitral regurgitation was higher in the CABG-alone group than in the combined-procedure group (32.3% vs. 11.2%, P<0.001). Overall rates of hospital readmission and serious adverse events were similar in the two groups, but neurologic events and supraventricular arrhythmias remained more frequent in the combined-procedure group.

CONCLUSIONS

In patients with moderate ischemic mitral regurgitation undergoing CABG, the addition of mitral-valve repair did not lead to significant differences in left ventricular reverse remodeling at 2 years. Mitral-valve repair provided a more durable correction of mitral regurgitation but did not significantly improve survival or reduce overall adverse events or readmissions and was associated with an early hazard of increased neurologic events and supraventricular arrhythmias. (Funded by the National Institutes of Health and Canadian Institutes of Health Research; ClinicalTrials.gov number, NCT00806988.).

Mechanical dyssynchrony and deformation imaging in patients with functional mitral regurgitation

Chronic functional mitral regurgitation (FMR) is a frequent finding of ischemic heart disease and dilated cardiomyopathy (DCM), associated with unfavourable prognosis. Several pathophysiologic mechanisms are involved in FMR, such as annular dilatation and dysfunction, left ventricle (LV) remodeling, dysfunction and dyssynchrony, papillary muscles displacement and dyssynchrony. The best therapeutic choice for FMR is still debated. When optimal medical treatment has already been set, a further option for cardiac resynchronization therapy (CRT) and/or surgical correction should be considered. CRT is able to contrast most of the pathophysiologic determinants of FMR by minimizing LV dyssynchrony through different mechanisms: Increasing closing forces, reducing tethering forces, reshaping annular geometry and function, correcting diastolic MR. Deformation imaging in terms of two-dimensional speckle tracking has been validated for LV dyssynchrony assessment. Radial speckle tracking and three-dimensional strain analysis appear to be the best methods to quantify intraventricular delay and to predict CRT-responders. Speckle-tracking echocardiography in patients with mitral valve regurgitation has been usually proposed for the assessment of LV and left atrial function. However it has also revealed a fundamental role of intraventricular dyssynchrony in determining FMR especially in DCM, rather than in ischemic cardiomyopathy in which MR severity seems to be more related to mitral valve deformation indexes. Furthermore speckle tracking allows the assessment of papillary muscle dyssynchrony. Therefore this technique can help to identify optimal candidates to CRT that will probably demonstrate a reduction in FMR degree and thus will experience a better outcome.

The Three-Decade Long Journey in Heart Failure Drug Development

Heart failure is a global disease with increasing prevalence due to an aging worldwide population with increasing co-morbidities. Despite several therapeutic options available to treat HFrEF, morbidity and mortality remain high. Importantly, no approved therapies are available to treat HFpEF. This paper will briefly summarize the burden of disease, HF classification and definitions and the landmark clinical trials in both HFrEF and HFpEF. Given the increasing incidence and prevalence of HF and the high morbidity and mortality associated with this disease, continued development efforts are essential to address the unmet needs of these patients.

The MitraClip and survival in patients with mitral regurgitation at high risk for surgery: A propensity-matched comparison

BACKGROUND

We compared 30-day and 1-year survival among high-risk mitral regurgitation (MR) patients treated with the MitraClip (Abbott Vascular, Abbott Park, IL) with matched non-surgically treated patients from the Duke Echocardiography Laboratory Database (DELD).

METHODS AND RESULTS

High-risk patients with 3+/4+ MR managed non-surgically between years 2000 and 2010 in the longitudinal DELD were matched to high-risk MitraClip patients. Patient matching was performed using the method of nearest available Mahalanobis distance metric within calipers defined by the propensity score. Kaplan-Meier estimates and stratified Cox proportional hazards models were used to compare survival at 30 days and 1 year. Among 953 high-risk DELD patients available for matching, 30-day and 1-year mortality were 6.5% and 26.2%. Close matches were obtained for 239 of the 351 MitraClip patients. The 30-day mortality in MitraClip patients was lower (4.2%) when compared with matched DELD patients (7.2%). The 1-year relative risk of mortality of the MitraClip compared with non-surgical treatment was 0.64 (95% CI 0.45-0.91; log-rank P = .013). These results in favor of the MitraClip remained significant upon further adjustment for baseline differences between groups (P = .043).

CONCLUSIONS

This matched comparison of severe MR patients at high surgical risk supports the safety of the MitraClip relative to medical therapy at 30 days and a survival benefit at 1 year.

Comparative effectiveness of Mitraclip plus medical therapy versus medical therapy alone in high-risk surgical patients: a comprehensive review

In recent years, Mitraclip has become available as a treatment option for mitral regurgitation in high-risk surgical patients. Focusing on the incremental effectiveness of Mitraclip versus the current standard of care, this article provides a comparative review of the evidence on Mitraclip and standard medical therapy (MT) in high-risk mitral regurgitation patients. Evidence was retrieved from seven major databases. Results suggest that Mitraclip presents a high safety profile and a good middle-term effectiveness performance. Evidence on long-term effectiveness is limited both for Mitraclip and MT. Few studies allow a comparison with MT and comparative results on different endpoints are mixed. Therefore, the available evidence does not conclusively inform whether or under which circumstances Mitraclip should be preferred over MT in the treatment of high-risk patients. Head-to-head real-world studies would be needed, as they would provide great and timely insights to support policy decisions when medical devices are at stake.