scholarly journals Exploring the Operative Strategy for Secondary Mitral Regurgitation: A Systematic Review

2021 ◽  
Vol 2021 ◽  
pp. 1-22
Author(s):  
Francesco Nappi ◽  
Sanjeet Singh Avtaar Singh ◽  
Francesca Bellomo ◽  
Pierluigi Nappi ◽  
Camilla Chello ◽  
...  
Keyword(s):  
Systematic Review ◽  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Papillary Muscle ◽  
Left Ventricular ◽  
Cochrane Library ◽  
Heart Team ◽  
Mitral Annuloplasty ◽  
Observational Series ◽  
Secondary Mitral Regurgitation

Background. Mitral valve disease surgery is an evolving field with multiple possible interventions. There is an increasing body of evidence regarding the optimal strategy in secondary mitral regurgitation where the pathology lies within the ventricle. We conducted a systematic review to identify the benefits and limitations of each surgical option. Methods. A systematic review of the literature was performed to identify pertinent randomized controlled trials (RCTs), propensity-matched observational series, and meta-analyses which were considered initially and followed by unmatched observational series using the MEDLINE, Ovid EMBASE, and Cochrane Library. Results. We identified 6 different strategies for treating secondary mitral valve regurgitation: mitral valve replacement, restrictive mitral annuloplasty, surgical revascularization (with and without mitral annuloplasty), subvalvular procedures (papillary muscle approximation, papillary muscle relocation, ring and string procedure), and procedures directly targeting the mitral valve (edge-to-edge repair and anterior leaflet enlargement) alongside transcatheter heart valve therapy. We also highlighted the role of left ventricular assist devices in the management of this condition. The benefits and limitations of each intervention are highlighted. Conclusion. There is currently no unanimous and shared strategy for the optimal treatment of patients with secondary IMR. The management of patients with secondary mitral regurgitation must be entrusted to a multidisciplinary Heart Team to ensure ideal intervention and patient matching for the best outcomes.

scholarly journals Mid-term results of papillary muscles approximation: a retrospective single-center study

2018 ◽  
Vol 22 (4) ◽  
pp. 54
Author(s):  
V. V. Bazylev ◽  
A. I. Mikulyak ◽  
R. M. Babukov ◽  
V. A. Karnakhin
Keyword(s):  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Papillary Muscle ◽  
Ischemic Cardiomyopathy ◽  
Left Ventricular ◽  
Rank Test ◽  
Mitral Insufficiency ◽  
Papillary Muscles ◽  
Mitral Annuloplasty ◽  
Mid Term Results

<p><strong>Background.</strong> Enlargement of the left ventricular chamber and displacement of papillary muscles in the apical and lateral directions increase the tethering forces. Left ventricular and papillary muscle desynchrony and reduced myocardial contractility reduce the closing forces, thus leading to impaired leaflet coaptation and appearance of mitral regurgitation. Therefore, treatment of mitral insufficiency requires an integrated approach, affecting all aspects of the pathogenesis of mitral regurgitation recurrence. Recent publications show that adjunctive subvalvular repair during mitral annuloplasty for secondary mitral regurgitation is effective in preventing recurrent regurgitation. One of these procedures is papillary muscle approximation. However, the safety and the positive impact of this method are still open to question. <br /><strong>Aim.</strong> This study focused on the assessment of mid-term results of papillary muscles approximation and comparison of the obtained results with those of isolated mitral annuloplasty.<br /><strong>Methods.</strong> Two hundred and twelve patients with ischemic cardiomyopathy and ischemic mitral regurgitation were enrolled in this retrospective single-center study. The patients were randomised to 2 groups by using propensity score matching (a “neighbor” method) according to the following parameters: end diastolic volume, end systolic volume, stroke volume and ejection fraction. The first group included 112 patients with ischemic cardiomyopathy and mitral regurgitation, who underwent coronary artery bypass grafting, mitral annuloplasty and papillary muscle approximation. The second group included 112 patients with ischemic cardiomyopathy who underwent coronary artery bypass grafting and mitral valve annuloplasty. We evaluated early and mid-term results.<br /><strong>Results.</strong> Two patients in group 1 and three patients in group 2 died of heart failure progression during 31.3±10.4 month follow-up. According to the Kaplan-Meier analysis, no statistically significant differences were noted between the groups (log-rank test = 0.8). Approximation of papillary muscles in patients with ischemic mitral regurgitation improved mitral valve leaflet coaptation as evidenced by the values of coaptation depth, coaptation line and tenting area (p&gt;0.05). During follow-up, 3 cases (2.7%) of mitral insufficiency recurrence were recorded in group 1 and 16 (14.3%) in group 2. The Kaplan-Meier analysis of cumulative probability showed a significant difference in freedom from recurrence of mitral regurgitation ≥2 between groups in the mid-term postoperative period (log-rank test = 0.041).<br /><strong>Conclusion.</strong> Adjunctive papillary muscle approximation performed at the time of mitral annuloplasty improves the durability of mitral valve repair.</p><p>Received 18 April 2018. Revised 12 October 2018. Accepted 18 October 2018.</p><p><strong>Funding:</strong> The study did not have sponsorship.</p><p><strong>Conflict of interest:</strong> Authors declare no conflict of interest.</p>

Secondary mitral regurgitation: pathophysiology, proportionality and prognosis

Heart ◽  
2020 ◽  
Vol 106 (10) ◽  
pp. 716-723 ◽  
Author(s):  
Omar Chehab ◽  
Ross Roberts-Thomson ◽  
Clarissa Ng Yin Ling ◽  
Michael Marber ◽  
Bernard D Prendergast ◽  
...  
Keyword(s):  
Heart Failure ◽  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Mitral Valve Repair ◽  
Medical Therapy ◽  
Left Ventricular ◽  
Heart Team ◽  
Valve Repair ◽  
Transcatheter Intervention ◽  
Secondary Mitral Regurgitation

Secondary mitral regurgitation (SMR) occurs as a result of multifactorial left atrioventricular dysfunction and maleficent remodelling. It is the most common and undertreated form of mitral regurgitation (MR) and is associated with a very poor prognosis. Whether SMR is a bystander reflecting the severity of the cardiomyopathy disease process has long been the subject of debate. Studies suggest that SMR is an independent driver of prognosis in patients with an intermediate heart failure (HF) phenotype and not those with advanced HF. There is also no universal agreement regarding the quantitative thresholds defining severe SMR and indeed there are challenges with echocardiographic quantification. Until recently, no surgical or transcatheter intervention for SMR had demonstrated prognostic benefit, in contrast with HF medical therapy and cardiac resynchronisation therapy. In 2018, the first two randomised controlled trials (RCTs) of edge-to-edge transcatheter mitral valve repair versus guideline-directed medical therapy in HF (Percutaneous Repair with the MitraClip Device for Severe (MITRA-FR), Transcather mitral valve repair in patients with heart failure (COAPT)) reported contrasting yet complimentary results. Unlike in MITRA-FR, COAPT demonstrated significant prognostic benefit, largely attributed to the selection of patients with disproportionately severe MR relative to their HF phenotype. Consequently, quantifying the degree of SMR in relation to left ventricular volume may be a useful discriminator in predicting the success of transcatheter intervention. The challenge going forward is the identification and validation of such parameters while in parallel maintaining a heart-team guided holistic approach.

scholarly journals P1320 Percutaneous mitral valve leaflet plication to reduce systolic anterior motion and mitral regurgitation using the transcatheter mitral clip system

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
M Drakopoulou ◽  
S Soulaidopoulos ◽  
G Oikonomou ◽  
K Stathogiannis ◽  
K Aggeli ◽  
...  
Keyword(s):  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Significant Coronary Artery Disease ◽  
Mitral Valve Regurgitation ◽  
Left Ventricular ◽  
Heart Team ◽  
Severe Mitral Regurgitation ◽  
Systolic Anterior Motion ◽  
Anterior Leaflet ◽  
Mitral Valve Leaflet

Abstract A 72-year-old female patient with a past medical history of severe mitral regurgitation, atrial fibrillation and embolic cerebrovascular events was admitted to our institution. The patient was under optimal medical therapy and complained for progressive worsening of activity-related dyspnea with limitation of physical activity (NYHA III). Transthoracic echocardiography showed the presence of severe mitral regurgitation with a central jet. There was prolapse of both mitral valve leaflets and interestingly the anterior leaflet presented systolic anterior motion (SAM) at the same time. There was no significant left ventricular outflow tract obstruction (LVOT). Further evaluation of the regurgitant mitral valve with a transesophageal echocardiography (TOE) confirmed the above findings and the mechanism of MV regurgitation was attributed to prolapse in addition to SAM of an elongated anterior leaflet. Laboratory test showed elevated NT-pro-BNP levels. A coronary angiography was performed and excluded significant coronary artery disease. The findings were assessed by our institution’s HEART TEAM and, in the presence of high surgical risk (LogEuroscore 32,76%), a decision for transcatheter mitral valve repair with a Mitral Clip implantation was taken. The Mitral Clip was succesfully implanted with immediate significant reduction of the regurgitant jet and no signs of stenotic behavior of the repaired valve. There was only mild mitral valve regurgitation. Notably, after the procedure there was elimination of the SAM and no LVOT obstruction (Figure). In accordance to the echocardiography findings, the patient demonstrated a significant clinical improvement and was discharged home 1 day after the procedure. Mitral clip implantation in this case showed improvement of the MR by reducing the SAM of the mitral valve. Abstract P1320 Figure.

scholarly journals Selection of the Optimal Candidate to MitraClip for Secondary Mitral Regurgitation: Beyond Mitral Valve Morphology

2021 ◽  
Vol 8 ◽  
Author(s):  
Tanya Salvatore ◽  
Fabrizio Ricci ◽  
George D. Dangas ◽  
Bushra S. Rana ◽  
Laura Ceriello ◽  
...  
Keyword(s):  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Artery Bypass ◽  
Underlying Disease ◽  
Left Ventricular ◽  
Current Evidence ◽  
Secondary Mitral Regurgitation ◽  
Secondary Mr ◽  
Optimal Candidate ◽  
Selection Of

Secondary mitral regurgitation (MR) occurs despite structurally normal valve apparatus due to an underlying disease of the myocardium leading to disruption of the balance between tethering and closing forces with ensuing failure of leaflet coaptation. In patients with heart failure (HF) and left ventricular dysfunction, secondary MR is independently associated with poor outcome, yet prognostic benefits related to the correction of MR have remained elusive. Surgery is not recommended for the correction of secondary MR outside coronary artery bypass grafting. Percutaneous mitral valve repair (PMVR) with MitraClip implantation has recently evolved as a new transcatheter treatment option of inoperable or high-risk patients with severe MR, with promising results supporting the extension of guideline recommendations. MitraClip is highly effective in reducing secondary MR in HF patients. However, the derived clinical benefit is still controversial as two randomized trials directly comparing PMVR vs. optimal medical therapy in severe secondary MR yielded virtually opposite conclusions. We reviewed current evidence to identify predictors of PMVR-related outcomes in secondary MR useful to improve the timing and the selection of patients who would derive maximal benefit from MitraClip intervention. Beyond mitral valve anatomy, optimal candidate selection should rely on a comprehensive diagnostic workup and a fine-tuned risk stratification process aimed at (i) recognizing the substantial heterogeneity of secondary MR and its complex interaction with the myocardium, (ii) foreseeing hemodynamic consequences of PMVR, (iii) anticipating futility and (iv) improving symptoms, quality of life and overall survival.

scholarly journals Reconstructive operations on subvalvular structures of the mitral valve during remodelling of the left ventricle. Papillary muscle interventions

2020 ◽  
Vol 24 (3) ◽  
pp. 32
Author(s):  
I. I. Skopin ◽  
M. S. Latyshev
Keyword(s):  
Mitral Valve ◽  
Left Ventricle ◽  
Mitral Regurgitation ◽  
Papillary Muscle ◽  
Conflict Of Interest ◽  
Reconstruction Technique ◽  
Type Iiib ◽  
Reconstructive Operations ◽  
Reverse Remodelling ◽  
Secondary Mitral Regurgitation

<p>The optimal treatment strategy for secondary mitral regurgitation of type IIIb (A. Carpentier classification) remains debatable. The use of a standard surgical technique for treating secondary mitral regurgitation and undersized ring annuloplasty demonstrates suboptimal results in several patients (about 30% of the patients exhibit postoperative hemodynamically significant mitral regurgitation with the absence of effective reverse remodelling of the left ventricle). Such suboptimal results are associated with the unification of only the mitral valve reconstruction technique, irrespective of the state of the left ventricle (degree of dysfunction, dilatation, tethering/tenting, and papillary muscle displacement); this is not entirely justified because of the disease complexity (valve and ventricular), and it is crucial to influence both the components of the disease. Particularly, modern researchers are inclined toward the need of using additional reconstructive interventions on the subvalvular structures that contribute to a more effective reverse remodelling of the left ventricle.<br />Here, we present a review of recent studies on the surgical treatment of functional mitral insufficiency of type IIIb (A. Carpentier classification) with effects on the subvalvular structures (pupillary muscle relocation and approximation).</p><p>Revised 19 April 2020. Revised 5 May 2020. Accepted 28 May 2020.</p><p><strong>Funding:</strong> The study did not have sponsorship.</p><p><strong>Conflict of interest:</strong> Authors declare no conflict of interest.</p>

scholarly journals Multimodality Imaging in Secondary Mitral Regurgitation

2020 ◽  
Vol 7 ◽  
Author(s):  
Harish Sharma ◽  
Boyang Liu ◽  
Hani Mahmoud-Elsayed ◽  
Saul G. Myerson ◽  
Richard P. Steeds
Keyword(s):  
Heart Failure ◽  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Multimodality Imaging ◽  
Left Ventricular ◽  
Adverse Outcomes ◽  
Functional Mitral Regurgitation ◽  
Term Survival ◽  
Percutaneous Therapy ◽  
Secondary Mitral Regurgitation

Secondary mitral regurgitation (sMR) is characterized by left ventricular (LV) dilatation or dysfunction, resulting in failure of mitral leaflet coaptation. sMR complicates up to 35% of ischaemic cardiomyopathies (1) and 57% of dilated cardiomyopathies (2). Due to the prevalence of coronary artery disease worldwide, ischaemic cardiomyopathy is the most frequently encountered cause of sMR in clinical practice. Although mortality from cardiovascular disease has gradually fallen in Western countries, severe sMR remains an independent predictor of mortality (3) and hospitalization for heart failure (4). The presence of even mild sMR following acute MI reduces long-term survival free of major adverse events (1). Such adverse outcomes worsen as the severity of sMR increases, due to a cycle in which LV remodeling begets sMR and vice versa. Current guidelines do not recommend invasive treatment of the sMR alone as a first-line approach, due to the paucity of evidence supporting improvement in clinical outcomes. Furthermore, a lack of international consensus on the thresholds that define severe sMR has resulted in confusion amongst clinicians determining whether intervention is warranted (5, 6). The recent Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation (COAPT) trial (7) assessing the effectiveness of transcatheter mitral valve repair is the first study to demonstrate mortality benefit from correction of sMR and has reignited interest in identifying patients who would benefit from mitral valve intervention. Multimodality imaging, including echocardiography and cardiovascular magnetic resonance (CMR), plays a key role in helping to diagnose, quantify, monitor, and risk stratify patients for surgical and transcatheter mitral valve interventions.

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