Artificial intelligence-derived risk score for mortality in secondary mitral regurgitation treated by transcatheter edge-to-edge repair: the EuroSMR risk score.

BACKGROUND AND AIMS: Risk stratification for mitral valve transcatheter edge-to-edge repair (M-TEER) is paramount in the decision-making process to appropriately select patients with severe secondary mitral regurgitation (SMR). This study sought to develop and validate an artificial intelligence-derived risk score (EuroSMR score) to predict 1-year outcomes (survival or survival + clinical improvement) in patients with SMR undergoing M-TEER. METHODS: An artificial intelligence-derived risk score was developed from the EuroSMR cohort (4172 and 428 patients treated with M-TEER in the derivation and validation cohorts, respectively). The EuroSMR score was validated and compared with established risk models. RESULTS: The EuroSMR risk score, which is based on 18 clinical, echocardiographic, laboratory, and medication parameters, allowed for an improved discrimination of surviving and non-surviving patients (hazard ratio 4.3, 95% confidence interval 3.7-5.0; P < .001), and outperformed established risk scores in the validation cohort. Prediction for 1-year mortality (area under the curve: 0.789, 95% confidence interval 0.737-0.842) ranged from <5% to >70%, including the identification of an extreme-risk population (2.6% of the entire cohort), which had a very high probability for not surviving beyond 1 year (hazard ratio 6.5, 95% confidence interval 3.0-14; P < .001). The top 5% of patients with the highest EuroSMR risk scores showed event rates of 72.7% for mortality and 83.2% for mortality or lack of clinical improvement at 1-year follow-up. CONCLUSIONS: The EuroSMR risk score may allow for improved prognostication in heart failure patients with severe SMR, who are considered for a M-TEER procedure. The score is expected to facilitate the shared decision-making process with heart team members and patients.

Secondary Mitral Regurgitation: Updated Review with Focus on Percutaneous Interventional Management.

Secondary mitral regurgitation (SMR) is associated with increased mortality and heart failure hospitalizations. The management of heart failure patients with SMR is complex and requires a multidisciplinary Heart Team approach. Guideline-directed medical therapies remain fundamental, yet in a proportion of patients SMR persists. In the past decade, transcatheter edge-to-edge repair (TEER) has been shown to improve survival in patients with SMR who remain symptomatic despite medical therapy. Technical advancements across newer generations of devices, improved imaging, and greater operator expertise have collectively contributed to the increased safety and efficacy of this procedure over time. Various emerging transcatheter mitral valve repair and replacement devices are currently under investigation and may offer superior, complementary or synergistic treatment options in patients ineligible for TEER. This review provides a state-of-the-art overview regarding the diagnosis of SMR, and currently available transcatheter mitral valve interventions and describes a contemporary approach to the management of SMR.

Prevalence and prognostic significance of malnutrition in patients with secondary mitral regurgitation undergoing transcatheter edge-to-edge repair.

BACKGROUND: Malnutrition is associated with poor prognosis in several cardiovascular diseases; however, its role in patients with secondary mitral regurgitation (SMR) is poorly known. AIMS: To evaluate the impact of nutritional status, assessed using different scores, on clinical outcomes in patients with SMR undergoing transcatheter edge-to-edge repair (TEER) in a real-world setting. METHODS: A total of 658 patients with SMR and complete nutritional data were identified from the MIVNUT registry. Nutritional status has been assessed using controlling nutritional status index (CONUT), prognostic nutritional index (PNI), and geriatric nutritional risk index (GNRI) scores. Outcomes of interest were all-cause mortality and all-cause mortality or heart failure (HF) hospitalization. RESULTS: Any malnutrition grade was observed in 79.4%, 16.7%, and 47.9% of patients by using CONUT, PNI, and GNRI, respectively, while moderate to severe malnutrition was noted in 24.7%, 16.7%, and 25.6% of patients, respectively. At a median follow-up of 2.2 years, 212 patients (32.2%) died. Moderate-severe malnutrition was associated with a higher rate of all-cause mortality (HR: 2.46 [95% CI: 1.69-3.58], HR: 2.18 [95% CI: 1.46-3.26], HR: 1.97 [95% CI: 1.41-2.74] for CONUT, PNI, and GNRI scores, respectively). The combined secondary endpoint of all-cause mortality and HF rehospitalization occurred in 306 patients (46.5%). Patients with moderate-severe malnutrition had a higher risk of the composite endpoint (HR: 1.56 [95% CI: 1.20-2.28], HR: 1.55 [95% CI: 1.01-2.19], HR: 1.36 [95% CI: 1.02-1.80] for CONUT, PNI, and GNRI scores, respectively). After adjustment for multiple confounders, moderate-severe malnutrition remained independently associated with clinical outcomes. CONCLUSIONS: Moderate-severe malnutrition was common in patients with SMR undergoing TEER. It was independently associated with poor prognosis regardless of the different scores used.

Impact of the MitraClip G4 System on Routine Practice and Outcomes in Patients With Secondary Mitral Regurgitation.

BACKGROUND: The MitraClip G4 system is a new iteration of the transcatheter edge-to-edge repair system. We assessed the impact of the G4 system on routine practice and outcomes in secondary mitral regurgitation (2°MR).Methods and Results: Consecutive patients with 2°MR treated with either the MitraClip G2 (n=89) or G4 (n=63) system between 2018 and 2021 were included. Baseline characteristics, procedures, and outcomes were compared. Inverse probability of treatment weighting and Cox regression were used to adjust for baseline differences. Baseline characteristics were similar, except for a lower surgical risk in the G4 group (Society of Thoracic Surgeons Predicted Risk of Mortality ≥8: 38.1% vs. 56.2%; P=0.03). In the G4 group, more patients had short (≤2 mm) coaptation length (83.7% vs. 54.0%; P<0.001) and fewer clips were used (17.5% vs. 36.0%; P=0.02). Acceptable MR reduction was observed in nearly all patients, with no difference between the G4 and G2 groups (100% vs. 97.8%, respectively; P=0.51). The G4 group had fewer patients with high transmitral gradients (>5mmHg; 3.3% vs. 13.6%; P=0.03). At 1 year, there was no significant difference between groups in the composite endpoint (death or heart failure rehospitalization) after baseline adjustment (10.5% vs. 20.2%; hazard ratio 0.39; 95% confidence interval 0.11-1.32; P=0.13). CONCLUSIONS: The G4 system achieved comparable device outcomes to the early-generation G2, despite treating more challenging 2°MR with fewer clips.

Secondary Mitral Regurgitation and Transcatheter Mitral Valve Therapies: Do They Have a Role in Advanced Heart Failure with Reduced Ejection Fraction?

Transcatheter mitral valve repair should be considered for patients with severe secondary mitral regurgitation with symptomatic heart failure with reduced ejection fraction for symptom improvement and survival benefit. Patients with a higher severity of secondary mitral regurgitation relative to the degree of left ventricular dilation are more likely to benefit from transcatheter mitral valve repair. A multidisciplinary Heart Team should participate in patient selection for transcatheter mitral valve therapy.

Prognostic value of left ventricular global longitudinal strain in mitral regurgitation: a systematic review.

Conventional echocardiographic assessment may overestimate the left ventricular (LV) function in mitral regurgitation (MR). LV global longitudinal strain (GLS) is more sensitive marker to detect subclinical LV dysfunction. Multiple studies have investigated the prognostic value of LV-GLS in MR to examine its potential to determine the timing and indication of intervention. This systematic review aimed to assess the prognostic value of LV-GLS in patients with mitral regurgitation (MR) to define its clinical applicability. PUBMED and EMBASE were queried through July 2021 to identify studies investigating the prognostic value of LV-GLS in MR. A total of 24 observational studies with 5267 patients were identified. Sixteen studies investigated for primary MR, 7 studies for secondary MR, and 1 study for both. Most studies included patients who underwent intervention. There was significant heterogeneity in patient population, intervention status, follow-up period, LV-GLS cutoff value, outcomes, and statistical methods among the studies. Meta-analysis was not performed considering the significant variability. With exception to 1 study, all studies demonstrated significant association between impaired LV-GLS and worse clinical and echocardiographic outcomes in primary MR. Prognostic value of LV-GLS in secondary MR was less certain due to inconsistent findings and limited reporting. LV-GLS is a promising parameter of prognostication in primary MR and can be considered as alternative to determine the timing of intervention. However, the optimal cutoff value remains unclear. The prognostic value of LV-GLS in secondary MR is less clear. Further large-scale prospective study is warranted before its routine clinical application.

The Prognostic Significance of Secondary Mitral Regurgitation in Heart Failure Patients with Varying Estimated Pulmonary Artery Systolic Pressure.

Background: Limited research has been conducted to investigate the impact of secondary mitral regurgitation (MR) in heart failure (HF) patients with different levels of estimated pulmonary artery systolic pressure (ePASP). Methods: A total of 468 patients suffering from HF and secondary MR were enrolled and categorized into non-severe and severe MR groups based on the degree of MR. The primary endpoint of the study was a composite of cardiovascular death and a first-heart-failure hospitalization. The secondary endpoints were the primary outcomes, individually. The outcomes of the two groups were compared. Patients were further classified based on whether their ePASP was ≥ 50 mmHg or < 50 mmHg. Subsequently, the outcomes of the non-severe and severe MR groups were compared within each ePASP category. Results: In a median (SD) follow-up of 694 (410) days, severe MR was associated with higher risk for primary endpoints in patients with heart failure, especially in those with ePASP ≥ 50 mmHg. In patients with ePASP < 50 mmHg, the prognostic value of severe MR was diminished. Conclusions: Assessment of the severity of MR can identify heart failure patients who are at greater risks for poor clinical outcomes. Additionally, the prognostic value of secondary MR was more pronounced in patients with elevated ePASP.

Usefulness of Vena Contracta for Identifying Severe Secondary Mitral Regurgitation: A Three-Dimensional Transesophageal Echocardiography Study.

Background: In secondary mitral regurgitation (SMR), effective regurgitant orifice area by the proximal isovelocity surface area method ( EROA PISA ) evaluation might cause an underestimation of regurgitant orifice area because of its ellipticity compared with vena contracta area (VCA). We aimed to reassess the SMR severity using VCA-related parameters and EROA PISA . Methods: The three-dimensional transesophageal echocardiography data of 128 patients with SMR were retrospectively analyzed; the following parameters were evaluated: EROA PISA , anteroposterior and mediolateral vena contracta widths (VCWs) of VCA (i.e., VCW AP and VCW ML ), VCW Average calculated as ( VCW AP + VCW ML )/2, and VCA Ellipse calculated as π × ( VCW AP /2) × ( VCW ML /2). Severe SMR was defined as ≥ 0.39 cm 2 . Results: The mean age of the patients was 77.0 ± 8.9 years, and 78 (60.9%) were males. Compared with EROA PISA (r = 0.801), VCW Average (r = 0.940) and VCA Ellipse (r = 0.980) were strongly correlated with VCA. On receiver-operating characteristic curve analysis, VCW Average and VCA Ellipse had C-statistics of 0.981 (95% confidence interval [CI], 0.963-1.000) and 0.985 (95% CI, 0.970-1.000), respectively; these were significantly higher than 0.910 (95% CI, 0.859-0.961) in EROA PISA (p = 0.007 and p = 0.003, respectively). The best cutoff values for severe SMR of VCW Average and VCA Ellipse were 0.78 cm and 0.42 cm 2 , respectively. The prevalence of severe SMR significantly increased with an increase in EROA PISA (38 of 88 [43.2%] patients with EROA PISA < 0.30 cm 2 , 21 of 24 [87.5%] patients with EROA PISA = 0.30-0.40 cm 2 , and 16 of 16 [100%] patients with EROA PISA ≥ 0.40 cm 2 [Cochran-Armitage test; p < 0.001]). Among patients with EROA PISA < 0.30 cm 2 , SMR severity based on VCA was accurately reclassified using VCW Average (McNemar's test; p = 0.505) and VCA Ellipse (p = 0.182). Conclusions: Among patients who had SMR with EROA PISA of < 0.30 cm 2 , suggestive of moderate or less SMR according to current guidelines, > 40% had discordantly severe SMR based on VCA. VCW Average and VCA Ellipse values were useful for identifying severe SMR based on VCA in these patients.

Perspectives on Secondary Mitral Regurgitation in Heart Failure.

PURPOSE OF THE REVIEW: This review focuses on broader perspectives of mitral regurgitation (MR) in patients with heart failure. RECENT FINDINGS: The ratio of regurgitant volume to end-diastolic volume appears to help identify patients who may benefit from valve interventions. Secondary MR is not only attributed to geometric changes of the LV but also related to the structural changes in the mitral valve that include fibrosis of the mitral leaflets and changes in the extracellular matrix. The transition from mild to severe secondary MR can occur at different rates, from a slow LV remodeling process to a more abrupt process precipitated by an inciting event such as atrial fibrillation. Septal flash and apical rocking, two new visual markers of LV mechanical dyssynchrony, appear to be predictive of MR reduction following cardiac resynchronization therapy. Optimal guideline-directed medical therapy has been shown to decrease the severity of secondary MR effectively. A theoretical framework to characterize secondary MR as it relates to the onset of MR is proposed. Type A: Early onset of MR contemporaneous with myocardial injury. The maladaptive LV remodeling occurs in parallel with MR. Type B: LV remodeling proceeds without significant MR until the LV is moderately dilated, which coincides with or without inciting factors such as atrial fibrillation. Type C: LV remodeling proceeds after myocardial injury without significant MR until the LV is severely dilated. MR is a late manifestation of LV remodeling.

Transcatheter edge to edge repair using the ease-of-use valve clamp system for functional mitral regurgitation: a primary report.

PURPOSE: The ValveClamp system is a novel edge-to-edge mitral valve repair system designed for the ease of operation. We report the outcomes of our initial experience of treating functional mitral regurgitation (MR) with the ValveClamp system. METHODS: The subjects of this study were patients with symptomatic functional MR despite standard medical therapy, who were treated with transapical ValveClamp implantation. The patients were divided into an atrial functional mitral regurgitation (AFMR) group and a ventricular functional mitral regurgitation (VFMR) group. Clinical and echocardiographic outcomes were evaluated at baseline and then at the 3-month follow up. RESULTS: Twelve patients, with a median age of 71 years (range 65-78 years), were assigned to the AFMR group (n = 5) or the VFMR group (n = 7). The device implantation rate was 100%, and 10 (83.3%) patients required implantation of only one clamp. The catheter time was less than 10 min in half of the patients, the fastest time being 5 min. There were no procedure-related complications. At the 3-month follow up, all patients were free from all-cause mortality, surgery, and rehospitalization. MR improved to ≤ 2 + in all 12 patients with MR grade 3 + or 4 + at baseline, (100%) and to ≤ 1 + in 9 of these patients (75%), with a low-pressure gradient. The left atrial diameter and the left ventricular end diastolic diameter decreased significantly in both the AFMR and VFMR groups. The left ventricular eject fraction at the 3-month follow up showed a rising trend in both the AFMR and VFMR groups, whereas PASP decreased remarkably. All 12 patients with baseline NYHA functional class III/IV (100%) showed improvement of at least 1 class, and 2 of these patients (16.7%) showed improvement of at least 2 classes. CONCLUSIONS: The ValveClamp system is simple and effective for transapical transcatheter edge to edge repair in patients with functional MR.

Secondary Mitral Regurgitation and Heart Failure: Current Advances in Diagnosis and Management.

The causes of mitral regurgitation (MR) can be broadly divided into primary and secondary causes. Although primary MR is caused by degenerative alterations of the mitral valve and the mitral valve apparatus, secondary (functional) MR is multifactorial and related to dilation of the left ventricle and/or mitral annulus commonly resulting in concomitant restriction of the leaflets. Therefore, the treatment of secondary MR (SMR) is complex and includes guideline directed heart failure therapy along with surgical and transcatheter approaches that have shown effectiveness in certain subgroups. This review aims to provide insight into current advances in diagnosis and management of SMR.

Association between triglyceride glucose index and worsening heart failure in significant secondary mitral regurgitation following percutaneous coronary intervention.

BACKGROUND: The triglyceride glucose (TyG) index is an alternative to insulin resistance (IR) as an early indicator of worsening heart failure (HF). Patients with secondary mitral regurgitation (sMR) often experience progressive deterioration of cardiac function. This study aimed to investigate the relationship between the TyG index and worsening of HF in significant sMR (grade ≥ 2) following percutaneous coronary intervention (PCI). METHODS: This study enrolled participants with significant sMR following PCI from a multicenter cohort study. The patients were divided into the following 3 groups according to tertiles of TyG index: T1, TyG ≤ 8.51; T2, TyG > 8.51 to ≤ 8.98; and T3, TyG > 8.98. The main clinical outcome was worsening HF including unplanned rehospitalization or unscheduled physician office/emergency department visit due to HF and unplanned mitral valve surgery. RESULTS: A total of 922 patients (mean ± SD age, 64.1 ± 11.0 years; 79.6% male) were enrolled. The incidence of worsening HF was 15.5% in T1, 15.7% in T2, and 26.4% in T3. In the multivariable model, the highest TyG tertile (T3 group) was more strongly correlated with worsening HF than the lowest tertile (T1 group) after adjusting for confounders (adjusted hazard ratio, 2.44; 95% confidence interval, 1.59-3.72; P < 0.001). The addition of TyG to risk factors such as N-terminal pro brain natriuretic peptide and clinical models improved the predictive ability of TyG for worsening HF. CONCLUSIONS: Elevated preprocedural TyG index is a significant and independent risk factor for worsening HF in sMR following PCI that can be used for risk stratification.

The role of surgery for secondary mitral regurgitation and heart failure in the era of transcatheter mitral valve therapies.

The approach to the management of mitral valve (MV) disease and heart failure (HF) has dramatically changed over the last decades. It is well recognized that severe mitral regurgitation secondary to ischemic or non-ischemic cardiomyopathy is associated with an excess risk of mortality. Understanding the impact of the surgical treatment modality on mortality outcomes has been difficult due to the broad spectrum of secondary mitral regurgitation (SMR) phenotypes and lack of randomized surgical clinical trials. Over the last 30 years, surgeons have failed to provide compelling evidence to convince the medical community of the need to treat SMR in patients with severe HF. Therefore, the surgical treatment of SMR has never gained uniform acceptance as a significant option among patients suffering from SMR. Recent evidence from randomized trials in a non-surgical eligible patients treated with transcatheter therapies, has provided a new perspective on SMR treatment. Recently published European and American guidelines confirm the key role of percutaneous treatment of SMR and in parallel, these guidelines reinforce the role of mitral valve surgery in patients who require surgical revascularization. Complex mitral valve repair combining subvalvular apparatus repair along with annuloplasty seems to be a promising approach in selected patients in selected centers. Meanwhile, mitral valve replacement has become the preferred surgical strategy in most patients with advanced heart failure and severe LV remodeling or high risk of recurrent mitral regurgitation. In this comprehensive review, we aimed to discuss the role of mitral surgery for SMR in patients with heart failure in the contemporary era and to provide a practical approach for its surgical management.

Learning from Controversy and Revisiting the Randomized Trials of Secondary Mitral Regurgitation.

Until recently, conventional mitral valve surgery has been the treatment of choice even in secondary mitral regurgitation. Recent evidence, however, advocates the use of transcatheter edge-to-edge mitral valve repair (TEER) of the mitral valve. This has been reflected by the change in guidelines of the American College of Cardiology/American Heart Association. We reviewed the literature to shed light on the risks and benefits of all interventions, surgical, transcatheter and guideline-directed medical therapy. Secondary mitral regurgitation occurs due to an imbalance between closing forces and tethering forces. Given the pathology extends beyond the valve alone, treatment should be directed at restoring the geometrical shape of the left ventricle alongside the valve. Myocardial revascularization plays a pivotal role in preventing recurrence. The role of papillary muscle approximation in addition to restrictive mitral annuloplasty should be considered in a select group of patients. We also reviewed the current literature on TEERs from the COAPT and Mitra-FR trials while highlighting the concept of proportionate/disproportionate MR which may help identify which patients benefit from mitral valve restoration. Treatment of this condition will require robust randomized trials alongside the use of state-of-the-art imaging technologies available with the full complement of the multidisciplinary team to ensure the best outcomes for each patient.

Insight from International Guidelines: do We Have Satisfactory Recommendations for Secondary Mitral Regurgitation?

Both the European Society of Cardiology (ESC) and the American College of Cardiology (ACC/AHA) have recently released guidelines on the management of patients with secondary mitral regurgitation. This includes defining, classifying, and assessing the severity of secondary mitral regurgitation. These guidelines are also the first to incorporate the use of transcatheter edge-to-edge repair in decision-making based on recent studies. The review highlights the strengths and shortcomings of these studies and the applicability and generalisability of these results to assist in decision-making for the heart time. It also emphasises the importance of shared decision-making via the heart team. Echocardiography plays an important role in the assessment of these patients although these may be specifically for primary mitral insufficiency. The optimal guideline-directed medical therapy should be the first line of treatment followed by mechanical intervention. The choice of intervention is best directed by a specialist multidisciplinary team. Concomitant revascularization should be performed in a subgroup of patients with severe secondary mitral regurgitation given the role of adverse LV remodelling in propagation of the dynamic secondary MR. The guidelines need further confirmation from high-quality studies in the near future to decision-making towards either TEER, mitral valve replacement, or mitral valve repair with or without a subvalvular procedure.

Survival and readmission among patients with advanced cardiomyopathy undergoing transcatheter edge-to-edge mitral valve repair: Are we applying COAPT findings too broadly?

OBJECTIVE: Transcathether edge-to-edge mitral valve repair (TEER) has been shown to be an effective treatment for secondary mitral regurgitation (MR). However, the outcomes of TEER in patients with severe cardiomyopathy is less clear. The objective of this study is to determine the outcomes of such patients who underwent TEER at our institution. METHODS: A retrospective review of patients with severe cardiomyopathy, defined as ejection fraction ≤30% or the requirement of inotropic support preoperatively, undergoing TEER for secondary MR at our institution from 11/2016 to 11/2020 was performed. Univariate analysis associating preoperative characteristics with our primary endpoint of 1-year death or orthotopic heart transplant (OHT) was performed. Kaplan-Meier analysis was conducted for the composite outcome of death or OHT, as well as for heart failure-related readmission. Finally, an assessment of changes in MR severity from the preoperative, to immediate postoperative period, to 30-day postoperative period was conducted. RESULTS: There were 48 patients identified. Median age was 74.5 years (IQR 65.5-79.5), median ejection fraction was 21.5% (IQR 16.0-27.5), and 81.4% of patients had severe or torrential mitral regurgitation preoperatively. The composite endpoint of 1-year mortality or OHT occurred in 15 of 48 patients (31.3%, 14 deaths and 1 OHT). One-year heart failure readmission rate was 47.9%. Mortality or OHT at 2 years occurred in 45.8%. CONCLUSION: Patients at extremes of heart failure who underwent TEER had poor outcomes when assessed at 1-year. Our study may suggest that the results of cardiovascular outcomes assessment of the mitraclip percutaneous therapy for heart failure patients with secondary mitral regurgitation may not be applicable to patients with severe cardiomyopathy.

A morphofunctional analysis of the regurgitant mitral valve as a guide to repair: Another point of view.

Based on Carpentier's classification and principles, the techniques for mitral valve repair continue to evolve. We herein report our experience with the morphofunctional echocardiographic analysis of single mitral leaflets, as different anatomic features, even if conflicting, may coexist not only in the two leaflets but in the same leaflet as well. A classification is proposed, based on the length (normal, short, or long) and mobility (normal, restricted, or excessive) of mitral leaflets. The surgical techniques adopted for mitral valve repair are the direct consequence of this analysis.

Update on surgical repair in functional mitral regurgitation.

BACKGROUND: Functional mitral regurgitation (FMR) is common in patients with myocardial infarction or dilated cardiomyopathy, and portends a poor prognosis despite guideline-directed medical therapy (GDMT). Surgical or transcatheter mitral repair for FMR from recent randomized clinical trials showed disappointing or conflicting results. AIMS: To provide an update on the role of surgical repair in the management of FMR. MATERIALS AND METHODS: A literature search was conducted utilizing PubMed, Ovid, Web of Science, Embase, and Cochrane Library. The search terms included secondary/FMR, ischemic mitral regurgitation, mitral repair, mitral replacement, mitral annuloplasty, transcatheter mitral repair, and percutaneous mitral repair. Randomized clinical trials over the past decade were the particular focus of the current review. RESULTS: Recent data underlined the complexity and poor prognosis of FMR. GDMT and cardiac resynchronization, when indicated, should always be applied. Accurate assessment of the interplay between ventricular geometry and mitral valve function is essential to differentiate proportionate FMR from the disproportionate subgroup, which could be helpful in selecting appropriate transcatheter intervention strategies. Surgical repair, most commonly performed with an undersized ring annuloplasty, remains controversial. Adjunctive valvular or subvalvular repair techniques are evolving and may produce improved results in selected FMR patients. CONCLUSION: FMR resulted from complex valve-ventricular interaction and remodeling. Distinguishing proportionate FMR from disproportionate FMR is important in exploring their underlying mechanisms and to guide medical treatment with surgical or transcatheter interventions. Further studies are warranted to confirm the clinical benefit of appropriate surgical repair in selected FMR patients.

Fate of moderate secondary mitral regurgitation in patients undergoing aortic valve replacement for severe aortic regurgitation.

OBJECTIVES: Moderate secondary mitral regurgitation is common in patients with severe aortic regurgitation, but whether it has to be addressed at the time of aortic valve surgery remains unclear. With this study, we evaluated the long-term fate of moderate secondary mitral regurgitation in this specific scenario. METHODS: Between January 2004 and January 2018, in 154 patients admitted to our institution for treatment of severe aortic regurgitation, a moderate secondary mitral regurgitation was diagnosed. Ninety-four patients underwent isolated aortic valve replacement (group 1) and 60 patients underwent also concomitant mitral valve annuloplasty (group 2). RESULTS: One death (1.1%) occurred in group 1, whereas two deaths (3.3%) occurred in group 2 (p = .561). At 11 years, the cumulative incidence function of cardiac death, with noncardiac death as a competing risk was 11.5 ± 5.11% in group 1 and 8.3 ± 5.15% in group 2 (p = .731). The cumulative incidence function of mitral valve reintervention, with death as a competing risk, was 3.7 ± 2.61% in group 1 and 4.5 ± 4.35% in group 2 (p = .620) at 11 years. Secondary mitral regurgitation improved to ≤mild in 66% and 76% of the survivors of group 1 and group 2, respectively (p = .67). CONCLUSIONS: In our experience, in patients with moderate secondary mitral regurgitation undergoing aortic valve replacement for severe aortic regurgitation, concomitant mitral valve annuloplasty did not improve the long-term survival, the incidence of cardiac death and mitral valve reoperation or the evolution of the mitral valve disease.

The management of secondary mitral regurgitation in patients with heart failure: a joint position statement from the Heart Failure Association (HFA), European Association of Cardiovascular Imaging (EACVI), European Heart Rhythm Association (EHRA), and European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC.

Secondary (or functional) mitral regurgitation (SMR) occurs frequently in chronic heart failure (HF) with reduced left ventricular (LV) ejection fraction, resulting from LV remodelling that prevents coaptation of the valve leaflets. Secondary mitral regurgitation contributes to progression of the symptoms and signs of HF and confers worse prognosis. The management of HF patients with SMR is complex and requires timely referral to a multidisciplinary Heart Team. Optimization of pharmacological and device therapy according to guideline recommendations is crucial. Further management requires careful clinical and imaging assessment, addressing the anatomical and functional features of the mitral valve and left ventricle, overall HF status, and relevant comorbidities. Evidence concerning surgical correction of SMR is sparse and it is doubtful whether this approach improves prognosis. Transcatheter repair has emerged as a promising alternative, but the conflicting results of current randomized trials require careful interpretation. This collaborative position statement, developed by four key associations of the European Society of Cardiology-the Heart Failure Association (HFA), European Association of Percutaneous Cardiovascular Interventions (EAPCI), European Association of Cardiovascular Imaging (EACVI), and European Heart Rhythm Association (EHRA)-presents an updated practical approach to the evaluation and management of patients with HF and SMR based upon a Heart Team approach.