MitraClip for secondary mitral regurgitation: Patient selection.

Mitral regurgitation (MR) is one of the common valvular heart diseases and can be broadly categorized as primary or secondary. Primary MR occurs due to abnormalities of the valvular apparatus where surgical repair offers excellent outcomes. In contrast, the underlying degree of left ventricular dysfunction plays a major role in the development of secondary MR. Recently, two randomized controlled trials, the Percutaneous Repair with the MitraClip Device for Severe Functional/ Secondary Mitral Regurgitation (MITRA-FR) and the Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation (COAPT), evaluated the role of transcatheter edge-to-edge repair (TEER) using MitraClip device among heart failure patients with secondary MR and observed contradictory results; this has created a considerable dilemma among clinicians for an appropriate patient selection for the transcatheter mitral valve (MV) therapies. In this review, we highlight several important differences in patient characteristics between the COAPT and MITRA-FR trials that may help explain the differences observed in outcomes. We also reviewed several key clinical, echocardiographic, and procedural characteristics that may guide clinicians in improving patient selection for transcatheter MV therapies for better outcomes.

Characterisation of aortic stenosis severity: a retrospective analysis of echocardiography reports in a clinical laboratory.

OBJECTIVE: To evaluate how common echocardiographic metrics of aortic stenosis (AS) influence the proportion of patients who may be categorised as having severe stenosis and therefore considered for valve replacement. METHODS: Retrospective analysis was performed of all echocardiograms with aortic valve area (AVA) ≤1.2 cm2 and peak jet velocity (Vmax) ≥3 m/s from 1 December 2014 through 30 October 2017 at a single academic medical centre. Echocardiographic indices collected include AVA, Vmax, left ventricular ejection fraction, stroke volume and annotated aortic stenosis severity. RESULTS: Among 807 patients with AVA ≤1.2 cm2 and Vmax ≥3 m/s (44.0% female, median age 74 years (IQR: 66-81)), 45.6% had Vmax ≥4 m/s, while 75.8% had AVA ≤1 cm2. 40.0% of patients had concordant indices (Vmax ≥4 m/s and AVA ≤1 cm2), and 35.8% had discordant indices (Vmax <4 m/s and AVA ≤1 cm2) of severe AS. Compared with those with concordant indices, patients with discordant indices were more commonly female (54.0% vs 44.3%, p<0.05) and less commonly characterised as severe (42.6% vs 93.8%, p<0.001). Patients with paradoxical low-flow, low-gradient severe AS by echocardiography were disproportionately female (61.5% vs 41.8%, p<0.001), and their disease was characterised as severe only 49.5% of the time. CONCLUSIONS: Patients with discordant indices, who are disproportionately female, are commonly described in clinical echocardiography reports as having less than severe AS. Given the potential benefit of AVR in patients with AVA ≤1 cm2 regardless of Vmax, this could have important clinical implications.