Outcome and undertreatment of mitral regurgitation: a community cohort study

Dziadzko, Volha; Clavel, Marie‐Annick; Dziadzko, Mikhail; Medina‐Inojosa, José R.; Michelena, Héctor I.; Maalouf, Joseph F.; Nkomo, Vuyisile T.; Thapa, Prabin; Enríquez-Sarano, Maurice

doi:10.1016/s0140-6736(18)30473-2

Cited by 291 publications

(192 citation statements)

References 42 publications

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“…In another study, Cortés and colleagues also did not find a link between MR improvement of 1 degree and 6-months mortality, however, reported-similar to our results-a trend towards increased cardiac mortality in patients with remaining MR ≥ 3 + at only 6-months of follow-up (24.4% vs. 15.7%; P = 0.151) [17]. Thus, MR improvement itself seems not to be necessarily related to better outcomes, but rather the absolute degree of MR following TAVR [19]. Two recent studies reported improved survival in patients with MR regression to none/mild MR following TAVR [18,20].…”

Section: Discussionsupporting

confidence: 87%

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Prognosis of persistent mitral regurgitation in patients undergoing transcatheter aortic valve replacement

et al. 2020

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Objective The objective of this study was to assess imaging predictors of mitral regurgitation (MR) improvement and to evaluate the impact of MR regression on long-term outcome in patients undergoing transcatheter aortic valve replacement (TAVR). Background Concomitant MR is a frequent finding in patients with severe aortic stenosis but usually left untreated at the time of TAVR. Methods Mitral regurgitation was graded by transthoracic echocardiography before and after TAVR in 677 consecutive patients with severe aortic stenosis. 2-year mortality was related to the degree of baseline and discharge MR. Morphological echo analysis was performed to determine predictors of MR improvement. Results 15.2% of patients presented with baseline MR ≥ 3 +, which was associated with a significantly decreased 2-year survival (57.7% vs. 74.4%, P < 0.001). MR improved in 50% of patients following TAVR, with 44% regressing to MR ≤ 2 +. MR improvement to ≤ 2 + was associated with significantly better survival compared to patients with persistent MR ≥ 3 +. Baseline parameters including non-severe baseline MR, the extent of mitral annular calcification and large annular dimension (≥ 32 mm) predicted the likelihood of an improvement to MR ≤ 2 +. A score based on these parameters selected groups with differing probability of MR ≤ 2 + post TAVR ranging from 10.5 to 94.4% (AUC 0.816; P < 0.001), and was predictive for 2-year mortality. Conclusion Unresolved severe MR is a critical determinant of long term mortality following TAVR. Persistence of severe MR following TAVR can be predicted using selected parameters derived from TTE-imaging. These data call for close follow up and additional mitral valve treatment in this subgroup.Matti Adam and Henrik ten Freyhaus contributed equally.Matti Adam and Henrik ten Freyhaus share jointly co-directed this work and share the last authorship of this work. Electronic supplementary materialThe online version of this article (https ://doi. Graphic abstractFactors associated with MR persistence or regression after TAVR

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Section: Discussionsupporting

confidence: 87%

“…Patient characteristics are presented in 19.5% mild to moderate MR), and 9.3% MR ≥ 3 + (6.6% moderate to severe MR, 2.7% severe MR; P < 0.001; Fig. 1).…”

Section: Patient Populationmentioning

confidence: 99%

Prognosis of persistent mitral regurgitation in patients undergoing transcatheter aortic valve replacement

et al. 2020

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“…At present, surgical treatment of isolated FMR remains uncommon because patients with FMR are often at high surgical risk due to LV dysfunction, older age and co‐morbidities . In addition, evidence on the prognostic benefit of MV surgery in patients with severe FMR who do not require CABG is limited and mostly restricted to patients with ischaemic FMR …”

Section: Functional Mitral Regurgitation: Everything We Need To Knowmentioning

confidence: 99%

Treatment of functional mitral regurgitation in chronic heart failure: can we get a ‘proof of concept’ from the MITRA‐FR and COAPT trials?

Senni

Adamo

Metra

et al. 2019

European J of Heart Fail

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Functional mitral regurgitation (FMR) is associated with poor outcomes in patients with heart failure (HF). However, it is not clear whether FMR is just a consequence of left ventricular (LV) remodelling or a factor contributing to cardiomyopathy progression. There will be more clarity about this controversy when the effects of FMR correction on outcomes will be shown. FMR correction can be performed surgically or, more often, percutaneously with the MitraClip procedure. MitraClip is the most widely used device with more than 70 000 implants performed to date. Observational studies suggest that MitraClip treatment of FMR is safe and associated with improved symptoms, quality of life and functional status in HF patients. Two recently randomized controlled clinical trials have investigated the impact of MitraClip on the outcomes of HF patients: Percutaneous Repair with the MitraClip Device for Severe Functional/Secondary Mitral Regurgitation (MITRA‐FR) and Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation (COAPT). Both trials randomized patients to MitraClip plus guideline‐directed medical therapy (GDMT) or GDMT alone. No reduction in the primary endpoint of all‐cause mortality or HF hospitalizations was shown in MITRA‐FR, whereas a significant reduction in HF hospitalizations (primary endpoint) as well as in mortality alone were shown in COAPT. The aim of this review is to summarize the pathophysiology, prevalence, prognostic role and management of FMR, focusing on the differences between MITRA‐FR and COAPT and trying to provide possible explanations for the diverging results. We speculate that the two trials should be interpreted as complementary rather than opposite. Patients with severe FMR (effective regurgitant orifice area > 30 mm2) despite maximum tolerated GDMT (including cardiac resynchronization therapy), and without too advanced cardiomyopathy seem to be the best candidates for MitraClip treatment. MITRA‐FR and COAPT provide us a long awaited ‘proof of concept’: FMR may be considered a leading actor in cardiomyopathy progression rather than a mere marker of severity.

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“…However, prior studies estimated that nearly 30-50% of patients with severe VHD who met guideline criteria for intervention were not appropriately recognized or referred, [8][9][10][11] even in highly resourced environments. 7,12 There are an increasing number of treatment options available to patients with VHD; yet, not all patients are aware of or have access to the full spectrum of interventions. For most patients with severe primary MR, for example, it is well-recognized that mitral valve repair is superior to mitral valve replacement.…”

Section: Statement Of the Problemmentioning

confidence: 99%

“…It is now recognized that the longstanding effects of VHD can lead to irreversible changes in left ventricular (LV) function, repeated hospitalizations, patient morbidity (e.g., atrial fibrillation, heart failure, endocarditis), reduced quality of life (QOL), and premature mortality, which can often be prevented by earlier treatment. However, prior studies estimated that nearly 30–50% of patients with severe VHD who met guideline criteria for intervention were not appropriately recognized or referred, even in highly resourced environments …”

Section: Introductionmentioning

confidence: 99%

2019 AATS/ACC/ASE/SCAI/STS expert consensus systems of care document: A proposal to optimize care for patients with valvular heart disease

Nishimura

O’Gara

Bavaria

et al. 2019

Cathet Cardio Intervent

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Outcome and undertreatment of mitral regurgitation: a community cohort study

Abstract: Mayo Clinic Foundation.

Cited by 291 publications

References 42 publications

Prognosis of persistent mitral regurgitation in patients undergoing transcatheter aortic valve replacement

Prognosis of persistent mitral regurgitation in patients undergoing transcatheter aortic valve replacement

Treatment of functional mitral regurgitation in chronic heart failure: can we get a ‘proof of concept’ from the MITRA‐FR and COAPT trials?

2019 AATS/ACC/ASE/SCAI/STS expert consensus systems of care document: A proposal to optimize care for patients with valvular heart disease

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