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Scotti A, Munafò A, Margonato A, Godino C. Transcatheter therapies for secondary mitral regurgitation in advanced heart failure: what are we aiming for? Heart Fail Rev 2021; 27:1193-1200. [PMID: 34291400 PMCID: PMC9197887 DOI: 10.1007/s10741-021-10148-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/13/2021] [Indexed: 12/26/2022]
Abstract
A severe secondary mitral regurgitation (SMR) can be found in a significant portion of patients affected by advanced heart failure (AHF). Conventional therapies (optimal medical therapy, devices, surgery) present restricted clinical efficacy in this stage of the left ventricle disease which is burdened by high mortality and morbidity rates. Although the treatment of choice is represented by heart transplantation (HTx), there is an unmet need related to the limited supply of donor hearts (as opposed to the growing prevalence of AHF) and the low eligibility of highly symptomatic patients. In case of concomitant severe SMR, transcatheter mitral valve therapies (repair and replacement) may play a crucial role in this setting. While a direct prognostic improvement after correction of SMR has yet to be proved, AHF patients can benefit from the following: hemodynamic stabilization, symptomatic relief, normalization of pulmonary arterial pressures, and reduction in hospitalizations for acute heart failure. Obtaining these results may lead to the clinical consequences of reaching the HTx in good enough clinical status (bridge to heart transplantation), becoming eligible for the HTx (bridge to HTx candidacy), and being delisted for clinical improvement (bridge to recovery). Therefore, achieving traditional secondary endpoints in patients with AHF and SMR can translate into significant clinical implications.
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Affiliation(s)
- Andrea Scotti
- Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padua Medical School, Via Giustiniani 2, 35128, Padua, Italy.
| | - Andrea Munafò
- Division of Cardiology, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Alberto Margonato
- Division of Cardiology, San Raffaele Scientific Institute, Milan, Italy
| | - Cosmo Godino
- Division of Cardiology, San Raffaele Scientific Institute, Milan, Italy
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Bartko PE, Arfsten H, Heitzinger G, Pavo N, Spinka G, Kastl S, Prausmüller S, Strunk G, Mascherbauer J, Hengstenberg C, Hülsmann M, Goliasch G. Global regurgitant volume: approaching the critical mass in valvular-driven heart failure. Eur Heart J Cardiovasc Imaging 2021; 21:168-174. [PMID: 31257452 DOI: 10.1093/ehjci/jez170] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 06/04/2019] [Indexed: 11/14/2022] Open
Abstract
AIMS Recent progress in the diagnosis of functional valve regurgitation forms a coherent perception of severity thresholds by quantitative assessment. However, thresholds focused on either valve in isolation-not accounting for the global haemodynamic burden arising from concomitant functional regurgitation of the mitral and tricuspid valves. We sought to determine whether the global regurgitant volume is associated with adverse cardiac remodelling and mortality. METHODS AND RESULTS This long-term observational study included 414 patients on guideline-directed medical therapy. Baseline global regurgitant load defined as the sum of mitral and tricuspid regurgitant volume was assessed by the proximal flow convergence method. All-cause mortality during 5 years follow-up served as the primary endpoint. The median global regurgitant load was 30 mL (interquartile range 15-49) with 67% accounting for mitral and 33% accounting for tricuspid regurgitant volume. The global regurgitant load had significant impact on outcome with a crude hazard ratio of 1.46 (1.28-1.66; P < 0.001) for a 1-SD increase in global regurgitant volume, results that remained virtually unchanged after bootstrap or clinical confounder-based adjustment (P < 0.001 for adjusted models). Spline curve analysis showed a linearly increasing risk with a threshold of 50 mL and sustained increasing risk thereafter. CONCLUSIONS The present study demonstrates the detrimental effect of the global regurgitant load in patients with heart failure with reduced ejection fraction. The threshold where heart failure is driven by the valve lesions is a global regurgitant volume of 50 mL with continuously increasing risk beyond that threshold. Future studies need to address whether an attempt to reduce the global regurgitant volume can improve outcome.
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Affiliation(s)
- Philipp E Bartko
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Henrike Arfsten
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Gregor Heitzinger
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Noemi Pavo
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Georg Spinka
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Stefan Kastl
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Suriya Prausmüller
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Guido Strunk
- FH Campus Vienna and Complexity Research, Vienna, Austria
| | - Julia Mascherbauer
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Christian Hengstenberg
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Martin Hülsmann
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Georg Goliasch
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
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Kamoen V, Calle S, De Buyzere M, Timmermans F. Proportionate or disproportionate secondary mitral regurgitation: how to untangle the Gordian knot? Heart 2020; 106:1719-1725. [PMID: 32732437 DOI: 10.1136/heartjnl-2020-317040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/24/2020] [Accepted: 06/26/2020] [Indexed: 01/10/2023] Open
Abstract
Recent randomised percutaneous mitral intervention trials in patients with heart failure with secondary mitral regurgitation (SMR) have yielded contrasting results. A 'relative load' or 'proportionality' conceptual framework for SMR has been proposed to partly explain the disparate results. The rationale behind the framework is that SMR depends on the left ventricular dimension and not vice versa. In this review, we provide an in-depth analysis of the proportionality parameters used in this framework and also discuss the regurgitant fraction. We also consider haemodynamic observations in SMR that may affect the interpretation and comparisons among proportionality parameters. The conclusion is that the proportionality concept remains hypothetical and requires prospective validation before envisaging its use at individual patient level for risk stratification or therapeutic decision-making.
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Affiliation(s)
- Victor Kamoen
- Cardiology, University Hospital Ghent, Ghent, Belgium
| | - Simon Calle
- Cardiology, University Hospital Ghent, Ghent, Belgium
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Godino C, Munafò A, Sisinni A, Margonato A, Saia F, Montorfano M, Agricola E, Alfieri O, Colombo A, Senni M. MitraClip Treatment of Secondary Mitral Regurgitation in Heart Failure with Reduced Ejection Fraction: Lessons and Implications from Trials and Registries. STRUCTURAL HEART-THE JOURNAL OF THE HEART TEAM 2020. [DOI: 10.1080/24748706.2020.1753899] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Cosmo Godino
- Cardiothoracic Vascular Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Andrea Munafò
- Cardiothoracic Vascular Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Antonio Sisinni
- Cardiothoracic Vascular Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Margonato
- Cardiothoracic Vascular Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Saia
- Institute of Cardiology, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Matteo Montorfano
- Cardiothoracic Vascular Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Eustachio Agricola
- Cardiothoracic Vascular Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Ottavio Alfieri
- Cardiothoracic Vascular Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Antonio Colombo
- Interventional Cardiology Unit GVM Care & Research, Maria Cecilia Hospital, Cotignola, Italy
| | - Michele Senni
- Cardiology Division, Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
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5
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Marwick TH, Lancellotti P. The Keys to Personalizing the Decision for Valvular Intervention in Secondary Mitral Regurgitation. J Am Coll Cardiol 2019; 73:2518-2520. [PMID: 31118145 DOI: 10.1016/j.jacc.2019.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 04/04/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Thomas H Marwick
- Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia.
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Lancellotti P, Dulgheru R, Marchetta S, Oury C, Garbi M. Valve Disease in Heart Failure: Secondary but Not Irrelevant. Heart Fail Clin 2019; 15:219-227. [PMID: 30832813 DOI: 10.1016/j.hfc.2018.12.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Secondary regurgitation caused by the remodeling and dysfunction of the left or right heart chamber may complicate heart failure, worsening both symptoms and prognosis. Outcome studies have shown that patients' prognosis worsened as the severity of secondary regurgitation increases. Imaging and more specifically echocardiography plays a central role for diagnosis and serial assessment of secondary regurgitation as well as for timing the intervention and guiding the procedure.
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Affiliation(s)
- Patrizio Lancellotti
- Department of Cardiology, Heart Valve Clinic, University of Liege Hospital, GIGA Cardiovascular Sciences, CHU Sart Tilman, Domaine Universitaire du Sart Tilman, Batiment B35, Liege, Belgium; Gruppo Villa Maria Care and Research, Anthea Hospital, Bari, Italy.
| | - Raluca Dulgheru
- Department of Cardiology, Heart Valve Clinic, University of Liege Hospital, GIGA Cardiovascular Sciences, CHU Sart Tilman, Domaine Universitaire du Sart Tilman, Batiment B35, Liege, Belgium
| | - Stella Marchetta
- Department of Cardiology, Heart Valve Clinic, University of Liege Hospital, GIGA Cardiovascular Sciences, CHU Sart Tilman, Domaine Universitaire du Sart Tilman, Batiment B35, Liege, Belgium
| | - Cécile Oury
- Department of Cardiology, Heart Valve Clinic, University of Liege Hospital, GIGA Cardiovascular Sciences, CHU Sart Tilman, Domaine Universitaire du Sart Tilman, Batiment B35, Liege, Belgium
| | - Madalina Garbi
- King's Health Partners, King's College Hospital NHS Foundation Trust, King's College Hospital, Denmark Hill, London SE5 9RS, UK
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Godino C, Scotti A, Munafò A, Taramasso M, Adamo M, Russo M, Toscano E, Salerno A, Cappelletti A, Stella S, Fragasso G, Montorfano M, Agricola E, Ettori F, Margonato A, Maisano F, Colombo A. Observed versus predicted mortality after MitraClip treatment in patients with symptomatic heart failure and significant functional mitral regurgitation. Eur J Heart Fail 2018; 20:1495-1496. [DOI: 10.1002/ejhf.1291] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 07/01/2018] [Accepted: 07/03/2018] [Indexed: 11/06/2022] Open
Affiliation(s)
- Cosmo Godino
- Cardiothoracic Vascular Department; San Raffaele Scientific Institute; Milan Italy
| | - Andrea Scotti
- Department of Cardiac, Thoracic and Vascular Sciences; University Hospital of Padova; Padova Italy
| | - Andrea Munafò
- Cardiothoracic Vascular Department; San Raffaele Scientific Institute; Milan Italy
| | | | - Marianna Adamo
- Cardiac Catheterization Laboratory, Cardiothoracic Department; Spedali Civili, Brescia Italy
| | - Marco Russo
- Division of Cardiac Surgery; University Hospital Zurich; Switzerland
| | - Evelina Toscano
- Cardiothoracic Vascular Department; San Raffaele Scientific Institute; Milan Italy
| | - Anna Salerno
- Cardiothoracic Vascular Department; San Raffaele Scientific Institute; Milan Italy
| | - Alberto Cappelletti
- Cardiothoracic Vascular Department; San Raffaele Scientific Institute; Milan Italy
| | - Stefano Stella
- Cardiothoracic Vascular Department; San Raffaele Scientific Institute; Milan Italy
| | - Gabriele Fragasso
- Cardiothoracic Vascular Department; San Raffaele Scientific Institute; Milan Italy
| | - Matteo Montorfano
- Cardiothoracic Vascular Department; San Raffaele Scientific Institute; Milan Italy
| | - Eustachio Agricola
- Cardiothoracic Vascular Department; San Raffaele Scientific Institute; Milan Italy
| | - Federica Ettori
- Cardiac Catheterization Laboratory, Cardiothoracic Department; Spedali Civili, Brescia Italy
| | - Alberto Margonato
- Cardiothoracic Vascular Department; San Raffaele Scientific Institute; Milan Italy
| | - Francesco Maisano
- Division of Cardiac Surgery; University Hospital Zurich; Switzerland
| | - Antonio Colombo
- Cardiothoracic Vascular Department; San Raffaele Scientific Institute; Milan Italy
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