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The impact of intraprocedural results following transcatheter edge-to-edge repair (TEER) in primary mitral regurgitation (MR) is controversial. This study sought to investigate the prognostic impact of intraprocedural residual mitral regurgitation (rMR) and mean mitral valve gradient (MPG) in patients with primary MR undergoing TEER. The PRIME-MR (Outcomes of Patients Treated With Mitral Transcatheter Edge-to-Edge Repair for Primary Mitral Regurgitation) registry included consecutive patients with primary MR undergoing TEER from 2008 to 2022 at 27 international sites. Clinical outcomes were assessed according to intraprocedural rMR and mean MPG. Patients were categorized according to rMR (optimal result: ≤1+, suboptimal result: ≥2+) and MPG (low gradient: ≤5 mm Hg, high gradient: > 5 mm Hg). The prognostic impact of rMR and MPG was evaluated in a Cox regression analysis. The primary endpoint was 2-year all-cause mortality or heart failure hospitalization. Intraprocedural rMR and mean MPG were available in 1,509 patients (median age = 82 years [Q1-Q3: 76.0-86.0 years], 55.1% male). Kaplan-Meier analysis according to rMR severity showed significant differences for the primary endpoint between rMR ≤1+ (29.1%), 2+ (41.7%), and ≥3+ (58.0%; P < 0.001), whereas there was no difference between patients with a low (32.4%) and high gradient (42.1%; P = 0.12). An optimal result/low gradient was achieved in most patients (n = 1,039). The worst outcomes were observed in patients with a suboptimal result/high gradient. After adjustment, rMR ≥2+ was independently linked to the primary endpoint (HR: 1.87; 95% CI: 1.32-2.65; P < 0.001), whereas MPG >5 mm Hg was not (HR: 0.78; 95% CI: 0.47-1.31; P = 0.35). Intraprocedural rMR but not MPG independently predicted clinical outcomes following TEER for primary MR. When performing TEER in primary MR, optimal MR reduction seems to outweigh the impact of high transvalvular gradients. [Display omitted] [ABSTRACT FROM AUTHOR]

Background The Clinical Frailty Scale (CFS) is a useful frailty marker for predicting clinical outcomes in patients undergoing invasive therapy. However, the clinical impact of CFS after transcatheter edge‐to‐edge repair in patients with mitral regurgitation (MR) remains unclear. This study aimed to elucidate the association between the baseline frail status defined by the CFS and clinical outcomes with or without postprocedural MR ≥2+ (post‐MR ≥2+) after transcatheter edge‐to‐edge repair. Methods and Results Based on a Japanese multicenter registry (OCEAN [Optimized Catheter Valvular Intervention]‐Mitral), data from 2078 patients with MR who underwent transcatheter edge‐to‐edge repair were analyzed. The patients were classified into 5 groups: CFS 1 to 3, 4, 5, 6, and ≥7. The procedural and clinical outcomes and post‐MR ≥2+ were compared among the groups. All‐cause mortality for up to 2 years was explored using Cox proportional hazards regression analysis. Although the rates of acute procedural success and post‐MR ≥2+ were similar, all‐cause mortality at 2 years was significantly increased across the 5 CFS categories (15.5%, 23.8%, 27.7%, 34.6%, and 48.8%, respectively, P

Objective: This study aimed to biomechanically evaluate the force profiles on the anterior primary and secondary chordae after neochord repair for anterior valve prolapse with varied degrees of residual mitral regurgitation using an ex vivo heart simulator. Methods: The experiment used 8 healthy porcine mitral valves. Chordal forces were measured using fiber Bragg grating sensors on primary and secondary chordae from A2 segments. The anterior valve prolapse model was generated by excising 2 primary chordae at the A2 segment. Neochord repair was performed with 2 pairs of neochords. Varying neochord lengths simulated postrepair residual mitral regurgitation with regurgitant fraction at >30% (moderate), 10% to 30% (mild), and

Multidetector computed tomography (MDCT) can provide valuable information for preprocedural planning of transcatheter mitral valve interventions. However, no data exist on MDCT parameters predicting residual mitral regurgitation (MR) post-MitraClip (Abbott Laboratories, Abbott Park, IL, USA). We analyzed preprocedural MDCTs of 78 consecutive patients with secondary MR undergoing MitraClip implantation at our institution. Moderate-or-severe mitral leaflet calcification (MLC) was defined as calcification, with-or-without mitral annular calcification, extending beyond the mitral leaflet base. Residual MR was assessed by postprocedural transesophageal echocardiography, and clinical outcomes were assessed at 1-year. Fifteen patients (19 %) had residual MR ≥2+. Compared to patients with none-or-mild residual MR, MDCT-derived mitral valve orifice area (MVOA) to mitral annulus area (MAA) ratio was significantly lower (0.32 ± 0.06 vs. 0.39 ± 0.09; p = 0.003), and the prevalence of MLC was higher (40 % vs. 18 %; p = 0.057) in those with residual MR ≥2+. Furthermore, the MVOA/MAA ratio and MLC were independent predictors of residual MR ≥2+ post-MitraClip [adjusted odds ratio (OR adj): 0.88 (0.80–0.97) and 5.50 (1.16–26.23), respectively]. On receiver-operating-characteristic-curve analysis, MVOA/MAA ratio <0.31 had a sensitivity of 87 % and a specificity of 60 % for residual MR ≥2+. When patients were classified according to the presence of MLC and an MVOA/MAA ratio <0.31, those with both parameters had significantly higher rates of postprocedural residual MR ≥2+ and mitral reintervention at 1-year than those with only one, and those without both parameters. In patients with secondary MR undergoing the MitraClip procedure, preprocedural MDCT parameters, specifically MVOA/MAA ratio and MLC, are useful to predict postprocedural residual MR. The top panel represents patients with secondary MR who have high (left) and low (right) MVOA/MAA ratios by preprocedural MDCT. The mid panel represents the absence (left) and the presence (right) of moderate-or-severe MLC. In the bottom panel, the risks of residual MR ≥2+ after MitraClip are stratified according to the MVOA/MAA ratio and the presence of MLC. MAA, mitral annulus diameter; MDCT, multidetector computed tomography; MLC, mitral leaflet calcification; MR, mitral regurgitation; MVOA, mitral valve orifice area; TMVr, transcatheter mitral valve edge-to-edge repair. [Display omitted] • Residual mitral regurgitation (MR) after MitraClip impacts long-term outcomes • Computed tomography is useful to predict residual MR • Mitral valve orifice area/mitral annulus area (MVOA/MAA) ratio and leaflet calcium were predictors of residual MR • MVOA/MAA <0.31 and leaflet calcium increased risk of mitral reintervention at 1 year [ABSTRACT FROM AUTHOR]

Aims: Guideline‐directed medical therapy (GDMT), based on the combination of beta‐blockers (BB), renin–angiotensin system inhibitors (RASI), and mineralocorticoid receptor antagonists (MRA), is known to have a major impact on the outcome of patients with heart failure with reduced ejection fraction (HFrEF). Although GDMT is recommended prior to mitral valve transcatheter edge‐to‐edge repair (M‐TEER), not all patients tolerate it. We studied the association of GDMT prescription with survival in HFrEF patients undergoing M‐TEER for secondary mitral regurgitation (SMR). Methods and results: EuroSMR, a European multicentre registry, included SMR patients with left ventricular ejection fraction <50%. The outcome was 2‐year all‐cause mortality. Of 1344 patients, BB, RASI, and MRA were prescribed in 1169 (87%), 1012 (75%), and 765 (57%) patients at the time of M‐TEER, respectively. Triple GDMT prescription was associated with a lower 2‐year all‐cause mortality compared to non‐triple GDMT (hazard ratio [HR] 0.74; 95% confidence interval [CI] 0.60–0.91). The association persisted in patients with glomerular filtration rate <30 ml/min, ischaemic aetiology, or right ventricular dysfunction. Further, a positive impact of triple GDMT prescription on survival was observed in patients with residual mitral regurgitation of ≥2+ (HR 0.62; 95% CI 0.44–0.86), but not in patients with residual mitral regurgitation of ≤1+ (HR 0.83; 95% CI 0.64–1.08). Conclusion: Triple GDMT prescription is associated with higher 2‐year survival after M‐TEER in HFrEF patients with SMR. This association was consistent also in patients with major comorbidities or non‐optimal results after M‐TEER. [ABSTRACT FROM AUTHOR]

Background: The Clinical Frailty Scale (CFS) is a useful frailty marker for predicting clinical outcomes in patients undergoing invasive therapy. However, the clinical impact of CFS after transcatheter edge-to-edge repair in patients with mitral regurgitation (MR) remains unclear. This study aimed to elucidate the association between the baseline frail status defined by the CFS and clinical outcomes with or without postprocedural MR ≥2+ (post-MR ≥2+) after transcatheter edge-to-edge repair., Methods and Results: Based on a Japanese multicenter registry (OCEAN [Optimized Catheter Valvular Intervention]-Mitral), data from 2078 patients with MR who underwent transcatheter edge-to-edge repair were analyzed. The patients were classified into 5 groups: CFS 1 to 3, 4, 5, 6, and ≥7. The procedural and clinical outcomes and post-MR ≥2+ were compared among the groups. All-cause mortality for up to 2 years was explored using Cox proportional hazards regression analysis. Although the rates of acute procedural success and post-MR ≥2+ were similar, all-cause mortality at 2 years was significantly increased across the 5 CFS categories (15.5%, 23.8%, 27.7%, 34.6%, and 48.8%, respectively, P <0.001). The incremental CFS categories and post-MR ≥2+ were independent predictive risk factors of all-cause mortality (all P <0.05). Among the patients with 5 CFS categories, the incidence of all-cause mortality was higher in those with post-MR ≥2+ than in those without (all P <0.05)., Conclusions: Although prognosis was poor in patients with higher CFS grade after transcatheter edge-to-edge repair, minimizing modifiable factors of residual MR is warranted to improve the clinical outcomes., Registration Information: URL: https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr&#95;view.cgi?recptno=R000027188; Unique identifier: UMIN000023653.

Background: Transcatheter edge-to-edge repair (TEER) has emerged to address symptomatic atrial functional mitral regurgitation (aFMR) in patients who are at high operative risk., Aims: No clinical data is available on the impact of residual mitral regurgitation (MR) following TEER in aFMR compared to ventricular functional MR (vFMR)., Methods: In the MITRA-PRO registry, 846 patients with FMR and MitraScore assessment for residual MR quantification were included (722 patients with vFMR and 124 patients with aFMR)., Results: Compared to vFMR similar procedural results in regard of residual MR following TEER were found in aFMR patients (MitraScore post TEER 2.5 ± 1.8 vs. 2.7 ± 1.9), while the amount of implanted TEER devices was increased in vFMR. 1-year survival was better in aFMR compared to vFMR regardless of relevant residual MR (MitraScore ≥ 4), while 1-year rehospitalization was comparable for both MR entities. Patients with aFMR and mild residual MR had a lower mortality rate (6.6% vs. 10.3%) and rehospitalization rate (29.1% vs. 46.2%) 1 year after mitral TEER. However, in contrast to vFMR a MitraScore ≥4 was no independent predictor of mortality in aFMR indicating a better tolerance toward residual MR., Conclusions: Residual MR is an independent predictor of 1-year mortality in vFMR patients, whereas in aFMR patients, a MitraScore of ≥4 is associated with higher mortality but is not an independent predictor in multivariate analysis. Therefore, minimizing MR through mitral TEER is crucial for survival in vFMR patients, while aFMR patients tolerate significant residual MR better 1 year after the procedure., (© 2024 The Author(s). Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.)

The aim of this study was to assess the impact of residual mitral regurgitation (resMR) on mortality with respect to left ventricular dilatation (LV-Dil) or right ventricular dysfunction (RV-Dys) in patients with secondary mitral regurgitation (SMR) who underwent mitral valve transcatheter edge-to-edge repair (TEER). The presence of LV-Dil and RV-Dys correlates with advanced stages of heart failure in SMR patients, which may impact the outcome after TEER. SMR patients in a European multicenter registry were evaluated. Investigated outcomes were 2-year all-cause mortality and improvement in New York Heart Association functional class with respect to MR reduction, LV-Dil (defined as LV end-diastolic volume ≥159 ml), and RV-Dys (defined as tricuspid annular plane systolic excursion-to-systolic pulmonary artery pressure ratio of <0.274 mm/mm Hg). Among 809 included patients, resMR ≤1+ was achieved in 546 (67%) patients. Overall estimated 2-year mortality rate was 32%. Post-procedural resMR was significantly associated with mortality (p = 0.031). Although the improvement in New York Heart Association functional class persisted regardless of either LV-Dil or RV-Dys, the beneficial treatment effect of resMR ≤1+ on 2-year mortality was observed only in patients without LV-Dil and RV-Dys (hazard ratio: 1.75; 95% confidence interval: 1.03 to 3.00). Achieving optimal MR reduction by TEER is associated with improved survival in SMR patients, especially if the progress in heart failure is not too advanced. In SMR patients with advanced stages of heart failure, as evidenced by LV-Dil or RV-Dys, the treatment effect of TEER on symptomatic improvement is maintained, but the survival benefit appears to be reduced. [Display omitted] [ABSTRACT FROM AUTHOR]

Residual mitral regurgitation reduces the efficacy of mitral repair and is associated with worse outcomes. We adopted a policy using a second bypass run for patients with residual mitral regurgitation (>+1) and described our decision-making algorithm and outcomes. From January 1, 2011, to December 31, 2016, 40 patients with degenerative disease underwent a second bypass run to address residual mitral regurgitation. The echocardiographic criteria for a second bypass run was the presence of moderate or greater mitral regurgitation or mild mitral regurgitation with unfavorable mechanism. A second bypass run was used in 40 patients. The mean age was 57.3 ± 13.5 years (21-79 years), and 14 patients (35%) were asymptomatic. Residual mitral regurgitation was mild in 25 patients, moderate in 9 patients, and moderate/severe in 6 patients. The cause of postbypass mitral regurgitation was technical or residual pathology in 35 patients and systolic anterior motion in 5 patients. Re-repair techniques were cleft closure in 22 patients, primary suture repair in 13 patients, and expanded polytetrafluoroethylene chordoplasty in 9 patients. After re-repair, 34 patients (85%) had no mitral regurgitation, 4 patients (10%) had trace mitral regurgitation, and 2 patients (5%) had mild mitral regurgitation. Median total cardiopulmonary bypass time was 208.5 minutes, first crossclamp time was 106 minutes, and second crossclamp time was 34 ± 12 minutes. Median intensive care stay was 2 days, and hospital stay was 8 days. On discharge, there was no mitral regurgitation in 13 patients (33%), trace in 23 patients (58%), and mild mitral regurgitation in 4 patients (10%). Freedom from moderate or greater mitral regurgitation at 5 years was 100%. Residual mitral regurgitation can be effectively treated using a second bypass run with good long-term outcome and minimal incremental risk. [ABSTRACT FROM AUTHOR]

Aims: MitraClip therapy for the treatment of functional mitral regurgitation (FMR) is an increasingly used intervention for high-risk surgical patients. The aim of this observational study was to assess the impact of residual mitral regurgitation (rMR) at discharge on long-term outcome after MitraClip therapy in patients with FMR.Methods and Results: Overall, 458 patients (mean age 73.8 ± 8.9 years) underwent MitraClip implantation between September 2008 and December 2017. The impact of rMR ≤ 1+ at discharge (n = 251) was retrospectively compared to patients graded as rMR 2+ (n = 173) and rMR ≥3+ (n = 34) at discharge. Median follow-up time was 5.09 years (5.00-5.26) with maximum follow-up of 10.02 years. The primary outcome was survival, and Kaplan-Meier analyses revealed significant differences among all rMR subgroups with highest survival rates for rMR ≤ 1+ patients. This was further confirmed by composite outcome analyses (P < 0.02). The inferior outcomes of rMR 2+ and rMR ≥ 3+ at discharge were confirmed by increased adjusted hazard ratios when rMR 2+ (1.54, P = 0.0039) and rMR ≥ 3+ (2.16, P = 0.011) were compared to rMR ≤ 1+. Moreover, patients with stable rMR ≤ 1+ grades within 12 months showed significantly higher survival rates compared to patients with rMR ≤ 1+ at discharge and rMR ≥ 2+ at 12-month follow-up or rMR ≥ 2+ at discharge and 12-month follow-up (P = 0.029).Conclusions: Patients with optimal and durable rMR ≤ 1+ at discharge and 12-month follow-up showed better outcome compared to patients with rMR 2+ and rMR ≥ 3+. Treatment success and durability characterized by rMR ≤ 1+ at discharge and 12 months seem to be important factors for long-term outcomes, which has to be further confirmed by prospective randomized trials. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES After mitral repair for degenerative mitral regurgitation (MR), no or mild (≤1+/4+) residual MR should remain. Occasionally patients are left with more than mild residual MR (>1+/4+) for a number of reasons. The aim of this study was to assess the late implications of such a suboptimal repair in a matched cohort study. METHODS From 2006 to 2013, a total of 2158 patients underwent mitral repair for degenerative MR in our institution. Fifty patients (2.3%) with residual MR >1+ at hospital discharge (study group) were matched up to 1:2 with 91 patients operated on during the same period who were discharged with MR ≤1+ (control group). The median follow-up was 8 years (interquartile range 6.3–10.1, longest 12.7 years). A comparative analysis of the outcomes in the 2 groups was performed. RESULTS Overall survival at 8 years was 87 ± 8% in the study group and 92 ± 3% in the control group (P  = 0.23). There were 3 late deaths (6.0%) in the study group and 6 deaths (6.6%) in the control group. Freedom from reoperation was similar (P  = 1.0). At 8 years the prevalence of MR ≥3+ was significantly higher in the study group (15.6% vs 2.1%, P  < 0.001) as was the use of diuretics, beta-blockers and angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers. Interestingly, even in the control group, a gradual progression of MR was observed because 13.3% of the patients had MR ≥2+ at 8 years with a significant increase over time (P  < 0.001). CONCLUSIONS Residual MR more than mild at hospital discharge is associated with lower durability of mitral repair and the need for more medical therapy in the long term. However, even an initial optimal result does not completely arrest the progression of the degenerative process. [ABSTRACT FROM AUTHOR]

National registry data show wide variability in degenerative mitral repair rates and infrequent use of intraoperative repair revision to eliminate residual mitral regurgitation (MR). The consequence of uncorrected mild residual MR is also not clear. We identified factors associated with intraoperative revision of degenerative mitral repair and evaluated long-term effects of intraoperative mild residual MR. A prospective institutional registry of 858 patients with degenerative MR undergoing robotic mitral surgery was linked to statewide databases. Univariate logistic regression identified factors associated with intraoperative repair revision. Survival was estimated using the Kaplan-Meier method and adjusted with Cox regression. Late freedom from more-than-moderate MR or reintervention was estimated with death as a competing risk. Repair rate was 99.3%. Repair was revised intraoperatively in 19 patients and was associated with anterior or bileaflet prolapse, adjunctive repair techniques, and annuloplasty band size (all P <.05). Intraoperative repair revision did not result in increased postoperative complications. Intraoperative mild residual MR (n = 111) was independently associated with inferior 8-year survival (hazard ratio, 2.97; 95% CI, 1.33-6.23), worse freedom from more than moderate MR (hazard ratio, 3.35; 95% CI, 1.60-7.00), and worse freedom from mitral reintervention (hazard ratio, 6.40; 95% CI, 2.19-18.72) (all P <.01). A near 100% repair rate with acceptable durability may be achieved safely with intraoperative revision of postrepair residual MR. Mild residual MR was independently associated with reduced survival, worse freedom from more-than-moderate MR, and worse freedom from mitral reintervention at 8-year follow-up. [Display omitted] [ABSTRACT FROM AUTHOR]

Background MitraClip (MC) is an alternative treatment for mitral regurgitation (MR). Although residual MR is common after MC, little was known about the impact of residual MR after MC. Methods We examined 255 consecutive patients who underwent MC. The primary endpoint was the composite endpoint including all-cause death, left ventricular (LV) assist device, and mitral valve surgery. Results Procedure failure defined as unsuccessful MC implantation (n = 6) and residual MR ≥ 3 + (n = 19) was associated with worse outcomes including the primary endpoint and all-cause death than those with acute procedure success (APS) defined as residual MR 2 + (n = 125) or 1 + (n = 105). Among patient with APS, background characteristics including age, MR etiology, heart failure severity, and LV function were not different. Although MR grade and NT-pro BNP level at 6 months after MC were higher in patients with residual MR 2 +, there was no significant difference in the incidence of the primary endpoint and all-cause death. Subanalysis showed that the primary endpoint occurred more frequently in patients with MR 2 + in patients with LV ejection fraction ≤ 40%, chronic kidney disease, and baseline NYHA-class IV. Conclusion Procedure failure was associated with adverse outcomes after MC. Among patients with APS, residual MR 2 + was not significantly associated with overall worse outcomes than residual MR 1 +. However, residual MR 2 + was associated with poorer prognosis in patients with impaired LV function, renal dysfunction, and severe heart failure, suggesting that the optimal endpoint of MC procedure should be individualized according to each patient's baseline characteristic. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to biomechanically evaluate the force profiles on the anterior primary and secondary chordae after neochord repair for anterior valve prolapse with varied degrees of residual mitral regurgitation using an ex vivo heart simulator., Methods: The experiment used 8 healthy porcine mitral valves. Chordal forces were measured using fiber Bragg grating sensors on primary and secondary chordae from A2 segments. The anterior valve prolapse model was generated by excising 2 primary chordae at the A2 segment. Neochord repair was performed with 2 pairs of neochords. Varying neochord lengths simulated postrepair residual mitral regurgitation with regurgitant fraction at >30% (moderate), 10% to 30% (mild), and <10% (perfect repair)., Results: Regurgitant fractions of baseline, moderate, mild, and perfect repair were 4.7% ± 0.8%, 35.8% ± 2.1%, 19.8% ± 2.0%, and 6.0% ± 0.7%, respectively ( P  < .001). Moderate had a greater peak force of the anterior primary chordae (0.43 ± 0.06 N) than those of baseline (0.19 ± 0.04 N; P  = .011), mild (0.23 ± 0.05 N; P  = .041), and perfect repair (0.21 ± 0.03 N; P  = .006). In addition, moderate had a greater peak force of the anterior secondary chordae (1.67 ± 0.17 N) than those of baseline (0.64 ± 0.13 N; P  = .003), mild (0.84 ± 0.24 N; P  = .019), and perfect repair (0.68 ± 0.14 N; P  = .001). No significant differences in peak and average forces on both primary and secondary anterior chordae were observed between the baseline and perfect repair as well as the mild and perfect repair., Conclusions: Moderate residual mitral regurgitation after neochord repair was associated with increased anterior primary and secondary chordae forces in our ex vivo anterior valve prolapse model. This difference in chordal force profile may influence long-term repair durability, providing biomechanical evidence in support of obtaining minimal regurgitation when repairing mitral anterior valve prolapse., (© 2023 The Author(s).)

The correlation between residual mitral regurgitation (rMR) grade or mitral valve pressure gradient (MVPG), at transcatheter edge-to-edge mitral valve repair (TEEMr) completion and at discharge, is unknown. Furthermore, there is disagreement regarding rMR grade or MVPG from which prognosis diverts. We retrospectively studied 82 patients that underwent TEEMr. We tested the correlation between rMR or MVPG and evaluated their association, with outcomes. Moderate or less rMR (rMR ≤ 2) at TEEMr completion was associated with improved survival, whereas mild or less rMR (rMR ≤ 1) was not. Patients with rMR ≤ 1 at discharge demonstrated a longer time of survival, of first heart failure hospitalization and of both. The correlation for both rMR grade (r = 0.5, p < 0.001) and MVPG (r = 0.51, p < 0.001), between TEEMr completion and discharge, was moderate. MR ≤ 2 at TMEER completion was the strongest predictor for survival (HR 0.08, p < 0.001) whereas rMR ≤ 1 at discharge was independently associated with a lower risk of the combined endpoint (HR 4.17, p = 0.012). MVPG was not associated with adverse events. We conclude that the assessments for rMR grade and MVPG, at the completion of TEEMr and at discharge, should be distinctly reported. Improved outcome is expected with rMR ≤ 2 at TEEMr completion and rMR ≤ 1 at discharge. Higher MVPG is not associated with unfavorable outcomes. [ABSTRACT FROM AUTHOR]

During degenerative mitral repair, surgeons must decide if further repair is warranted for residual mild mitral regurgitation. We examined the incidence of mild mitral regurgitation, late echocardiographic and clinical outcomes, and influence of surgical experience in decision making. From April 2004 to June 2018, 1155 of 1195 patients with pure degenerative disease underwent repair (97% repair rate). Propensity score matching was performed between patients with trace/no mitral regurgitation and patients with mild residual mitral regurgitation. Late echocardiographic outcome and freedom from reoperation were compared using competing-risks models. A comparison of outcomes of the referent surgeon (89.8% of repairs) with all other surgeons was performed. Mild mitral regurgitation was present in 73 patients (6%). Propensity score–matched analyses compared 69 patients with mild mitral regurgitation with 198 patients without mitral regurgitation. Late moderate or greater mitral regurgitation was higher in those with mild mitral regurgitation than in those with no mitral regurgitation (17% vs 7%, P =.033), as was late moderate-severe or greater mitral regurgitation (6% vs 1%, P =.016). Ten-year freedom from reoperation was low in both groups (99.5% no vs 96.9% mild; P =.10). The referent surgeon had fewer patients with mild residual mitral regurgitation (6% vs 11%, P =.027) and less progression of mitral regurgitation compared with other surgeons (late moderate or greater mitral regurgitation 6% vs 15%, P =.002). Residual mild mitral regurgitation was uncommon, and late progression to moderate or greater mitral regurgitation was rare and never led to late mitral reoperation. Experienced surgeons may be better able to determine repairs likely to remain stable, and most mild residual mitral regurgitation does not require re-repair. [ABSTRACT FROM AUTHOR]

Patients with advanced heart failure often have functional mitral regurgitation. Left ventricular assist device implantation improves functional mitral regurgitation through left ventricular unloading. However, residual mitral regurgitation after left ventricular assist device implantation leads to adverse outcomes, and whether patients need concomitant mitral valve surgery is not fully elucidated. Therefore, this study aimed to elucidate the predictors of residual mitral regurgitation and to describe the temporal changes in residual mitral regurgitation. We retrospectively enrolled 15 patients with implantable continuous-flow left ventricular assist device, who had significant mitral regurgitation on echocardiography before left ventricular assist device implantation. Three patients had residual mitral regurgitation (mitral regurgitation color jet area/left atrial area >0.2) 1 month after left ventricular assist device implantation. We investigated factors associated with residual mitral regurgitation and compared patients with or without residual mitral regurgitation. On univariate analysis, mitral valve tethering area and mitral regurgitation vena contracta before left ventricular assist device implantation were significantly associated with residual mitral regurgitation (odds ratio, 1.03; p  = 0.036 and odds ratio, 10.45; p  = 0.0087). One month after left ventricular assist device implantation, the mean pulmonary capillary wedge pressure and pulmonary artery pressure were higher in patients with residual mitral regurgitation (pulmonary capillary wedge pressure: 11.3 ± 3.5 vs 6.4 ± 3.4 mmHg, p  = 0.029 and pulmonary artery pressure: 21.3 ± 4.0 vs 15.9 ± 3.3 mmHg, p  = 0.023). However, the mitral regurgitation grading and hemodynamics were not significantly different 6 months after left ventricular assist device implantation. The hospitalization-free survival was not significantly different between the two groups. Mitral valve tethering area and mitral regurgitation vena contracta were predictors of residual mitral regurgitation. Residual mitral regurgitation improved until 6 months after left ventricular assist device implantation and might not affect the prognosis.

Objectives: After mitral repair for degenerative mitral regurgitation (MR), no or mild (≤1+/4+) residual MR should remain. Occasionally patients are left with more than mild residual MR (>1+/4+) for a number of reasons. The aim of this study was to assess the late implications of such a suboptimal repair in a matched cohort study., Methods: From 2006 to 2013, a total of 2158 patients underwent mitral repair for degenerative MR in our institution. Fifty patients (2.3%) with residual MR >1+ at hospital discharge (study group) were matched up to 1:2 with 91 patients operated on during the same period who were discharged with MR ≤1+ (control group). The median follow-up was 8 years (interquartile range 6.3-10.1, longest 12.7 years). A comparative analysis of the outcomes in the 2 groups was performed., Results: Overall survival at 8 years was 87 ± 8% in the study group and 92 ± 3% in the control group (P = 0.23). There were 3 late deaths (6.0%) in the study group and 6 deaths (6.6%) in the control group. Freedom from reoperation was similar (P = 1.0). At 8 years the prevalence of MR ≥3+ was significantly higher in the study group (15.6% vs 2.1%, P < 0.001) as was the use of diuretics, beta-blockers and angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers. Interestingly, even in the control group, a gradual progression of MR was observed because 13.3% of the patients had MR ≥2+ at 8 years with a significant increase over time (P < 0.001)., Conclusions: Residual MR more than mild at hospital discharge is associated with lower durability of mitral repair and the need for more medical therapy in the long term. However, even an initial optimal result does not completely arrest the progression of the degenerative process., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Few reports have focused on which patients with moderate ischemic mitral regurgitation (IMR) were not good candidates for coronary artery bypass grafting (CABG) alone. This single-center study aimed to assess risk factors for moderate or more residual regurgitation within two years after CABG alone for the treatment of moderate chronic IMR to optimize the operation strategy and prognosis.A total of 189 eligible patients were entered into a failure group (n = 108) or an improved group (n = 81) according to whether moderate or more residual regurgitation occurred within two years after surgery. Baseline and surgical characteristics were analyzed, and clinical outcomes were compared between groups.Prior myocardial infarction (MI)/chronic myocardial ischemia and region wall motion abnormality (anterior/inferior-posterior wall) were two independent risk factors for moderate or more residual regurgitation, following CABG alone, for the treatment of moderate chronic IMR (OR = 3.15, 95% CI 1.66-5.75, and OR = 2.45, 95% CI 1.36-4.84, respectively). During a median follow-up of 40 months, compared with the improved group, the failure group was more likely to present with New York Heart Association (NYHA) class III-IV and cardiac re-hospitalization (57.4% versus 11.1%, P < 0.001, and 13.9% versus 4.9%, P = 0.043, respectively) and had worse cumulative survival (χ 2 = 4.259, log-rank P = 0.039).Patients suffering from moderate chronic IMR secondary to prior MI (rather than chronic ischemia) with anterior wall motion abnormalities (rather than inferior-posterior wall motion abnormalities) may not be good candidates for CABG alone, and may have a poor prognosis after CABG alone.

The benefits of concomitant mitral valve procedure (MVP) for treating moderate chronic ischemic mitral regurgitation (IMR) during coronary artery bypass grafting (CABG) have not been clearly established. This study aimed to determine the incidence of moderate or more residual mitral regurgitation (MR) following CABG plus MVP for moderate chronic IMR, and to evaluate the impacts of concomitant MVP vs. CABG alone on clinical outcomes based on propensity-matched data.All eligible patients were entered into either the MVP group (CABG plus MVP, n = 184) or CABG group (CABG alone, n = 162). Moderate or more residual MR rate was investigated, and in-hospital and follow-up outcomes between the groups were compared after matching.Moderate or more residual MR rate was 11.4% at 1 year and 22.9% at 2 years after CABG plus MVP, respectively. Patients in the MVP group as compared with the CABG group had significantly lower moderate or more residual MR rates at various postoperative time points (all P < 0.001). Grouping was not an independent risk factor for in-hospital adverse events in multivariate logistic regression analysis. Also, grouping was a significant variable related to moderate or more residual MR rate and NYHA class III-IV at the latest follow-up in Cox regression analysis (HR = 0.391, 95% CI 0.114-0.628; HR = 0.419, 95% CI 0.233-0.819, respectively).Concomitant MVP as compared with CABG alone for treating moderate chronic IMR was associated with a reduction in moderate or more residual MR rate and an improvement in NYHA functional status, with no increase in in-hospital adverse events or follow-up death.