Brief reports

Prevalence and severity of mitral regurgitation in chronic systolic heart failure

Patients with heart failure (HF) and symptomatic secondary mitral regurgitation (SMR) have a poor prognosis, with morbidity and mortality directly correlated with MR severity. Correction of isolated SMR with surgery is not well established in this population, and medical management remains the preferred approach in most patients. The Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation (COAPT) trial was designed to determine whether transcatheter mitral valve (MV) repair with the MitraClip device is safe and effective in patients with symptomatic HF and clinically significant SMR.

The COAPT trial is a prospective, randomized, parallel-controlled, open-label multicenter study of the MitraClip device for the treatment of moderate-to-severe (3+) or severe (4+) SMR (as verified by an independent echocardiographic core laboratory) in patients with New York Heart Association class II-IVa HF despite treatment with maximally tolerated guideline-directed medical therapy (GDMT) who have been determined by the site’s local heart team as not appropriate for MV surgery. A total of 614 eligible subjects were randomized in a 1:1 ratio to MV repair with the MitraClip plus GDMT versus GDMT alone. The primary effectiveness end point is recurrent HF hospitalizations through 24 months, analyzed when the last subject completes 12-month follow-up, powered to demonstrate superiority of MitraClip therapy. The primary safety end point is a composite of device-related complications at 12 months compared to a performance goal. Follow-up is ongoing, and the principal results are expected in late 2018.

HF patients with clinically significant SMR who continue to be symptomatic despite optimal GDMT have limited treatment options and a poor prognosis. The randomized COAPT trial was designed to determine the safety and effectiveness of transcatheter MV repair with the MitraClip in symptomatic HF patients with moderate-to-severe or severe SMR.

Functional mitral regurgitation (MR) caused by reduced left ventricular ejection fraction (EF) and tethering, termed ventricular functional MR (VFMR), is associated with worse outcomes. Atrial functional MR (AFMR) caused by left atrial enlargement and annular dilatation was also recently described in patients with atrial fibrillation (AF). However, the clinical profiles of AFMR in hospitalized heart failure (HF) patients are unclear. We investigated the prevalence, clinical characteristics, and prognosis of AFMR in hospitalized HF patients with AF.

We analyzed 189 hospitalized HF patients with AF. The prevalence, clinical characteristics, and prognosis were compared between 4 groups: patients with EF ≥50% and no/mild MR (pEFnoMR), patients with EF <50% and no/mild MR (rEFnoMR), patients with EF ≥50% and moderate/severe MR (AFMR), and patients with EF <50% and moderate/severe MR (VFMR).

The prevalence of AFMR was 15.9% in hospitalized HF patients with AF. AFMR patients were older and more likely to have an enlarged left atrium, lower tenting height, and moderate/severe tricuspid regurgitation than VFMR patients. There were no differences in all-cause death after discharge among pEFnoMR, rEFnoMR, and AFMR patients. AFMR patients were associated with a higher rate of a composite of cardiac death and readmission for HF compared with pEFnoMR and rEFnoMR patients (log-rank p = 0.046 and p = 0.004). There were no differences in composite endpoints between AFMR and VFMR patients (log-rank p = 0.507).

AFMR was present in a proportion of elderly hospitalized HF patients with AF, and was a condition requiring attention because of readmission for HF in a hospitalized HF cohort.

The prognostic value of secondary mitral regurgitation (MR) at baseline versus immediately after and several months after cardiac resynchronization therapy (CRT), beyond left ventricular (LV) reverse remodelling, has yet to be investigated.

To evaluate the clinical significance of secondary MR before and at two timepoints after CRT in a large cohort of consecutive patients with heart failure (HF) and reduced LV ejection fraction.

A total of 198 patients were recruited prospectively into a registry, and underwent echocardiography at baseline and immediately after CRT (on the day of hospital discharge). Echocardiography was also performed 9 months after CRT in 172 patients. The impact of significant secondary MR (≥ moderate) on all-cause death, cardiovascular death and hospitalization for HF was studied at each stage.

The frequency of significant secondary MR decreased from 23% (n = 45) to 8% (n = 16) immediately after CRT. Among the 172 patients who underwent echocardiography 9 months after CRT, 17 (10%) had significant secondary MR. During a median follow-up of 48 months, 49 patients died and 36 were hospitalized for HF. Patients with significant secondary MR immediately after or 9 months after CRT had an increased risk of all-cause death, cardiovascular death and hospitalization for HF during follow-up (P < 0.05 for all endpoints). After adjustment for LV reverse remodelling, significant secondary MR 9 months after CRT remained associated with an increased risk of all-cause death (adjusted hazard ratio [HR] 3.77; P = 0.014), cardiovascular death (adjusted HR 5.36; P = 0.037), and hospitalization for HF (adjusted HR 7.33; P = 0.001).

Significant secondary MR despite CRT provides important prognostic information beyond LV reverse remodelling. Further studies are needed to evaluate the potential role of new percutaneous procedures for mitral valve repair in improving outcome in these very high-risk patients.

La valeur pronostique de l’insuffisance mitrale (IM) secondaire en base versus immédiatement après et plusieurs mois après resynchronisation cardiaque, au-delà du remodelage inverse du ventricule gauche, n’a pas encore été évaluée.

Le but de cette étude était d’évaluer la signification clinique de l’insuffisance mitrale secondaire avant, précocement et tardivement après resynchronisation cardiaque dans une large cohorte de patients consécutifs insuffisants cardiaques avec dysfonction systolique du ventricule gauche.

Cent quatre-vingt dix-huit patients recrutés prospectivement dans un registre ont bénéficié d’une échocardiographie avant et juste après l’implantation d’un stimulateur cardiaque biventriculaire. Une échocardiographie tardive était réalisée 9 mois après l’implantation chez 172 patients. L’impact de l’IM secondaire significative (≥ grade 2) sur la mortalité totale et cardiovasculaire et sur les hospitalisations pour insuffisance cardiaque était étudié à chaque stade.

La fréquence de l’IM secondaire significative diminuait de 23 % (n = 45) en pré-implantation à 8 % (n = 16) immédiatement après l’implantation. Parmi les 172 patients qui ont bénéficié d’une échocardiographie tardive, 17 patients (10 %) avaient une IM secondaire significative. Pendant un suivi médian de 48 mois, 49 patients sont décédés et 36 ont été hospitalisés pour insuffisance cardiaque. Les patients avec une IM secondaire significative précocement ou tardivement après resynchronisation biventriculaire présentaient un risque accru de mortalité, de mortalité cardiovasculaire et d’hospitalisation pour insuffisance cardiaque dans le suivi (p < 0,05 pour tous les critères de jugement). Après ajustement sur la survenue d’un remodelage inverse dans le suivi, l’IM secondaire tardivement après resynchronisation biventriculaire restait associée avec un risque accru de mortalité (HR ajusté 3,77 ; p = 0,014), de mortalité cardiovasculaire (HR ajusté 5,36 ; p = 0,037) et d’hospitalisation pour insuffisance cardiaque dans le suivi (HR ajusté 7,33 ; p = 0,001).

La présence d’une IM secondaire significative malgré une resynchronisation cardiaque apporte une information pronostique importante au-delà du remodelage inverse post-resynchronisation. D’autres études seront nécessaires pour évaluer le rôle des nouvelles procédures percutanées de réparation valvulaire mitrale pour améliorer le pronostic de ces patients à haut risque.

Objectives: Optimal management of significant mitral regurgitation (SMR) during left ventricular assist device (LVAD) placement remains uncertain. This study evaluates the effect of untreated preop SMR on outcomes following LVAD implant. Methods: Adults undergoing primary LVAD placement from April 2004 to May 2017 were included. Most recent preop transthoracic echocardiogram (TTE) was used to divide patients into an SMR group with moderate or greater regurgitation, and a group without SMR. Patients underwent LVAD implant without correction of SMR. Primary endpoint was 3-year postoperative survival, with secondary endpoints of length of stay (LOS), resolution of SMR following LVAD on postdischarge (30 day) TTE, and 1-year TTE. Results: LVAD placement was performed in 270 patients, 172 (63.7%) without SMR and 98 (36.3%) with SMR. There were no differences in comorbidities including diabetes, hypertension, and renal disease. Preop ejection fraction was similar, but a higher pulmonary vascular resistance was recorded in the SMR group (3.6 vs 3.0 Wood Units, P = 0.048). There was no difference in 3-year mortality between the 2 cohorts (log-rank P = 0.0.803). The SMR group had decreased LOS (median 19.5 vs 22 days, P = 0.009). Of the 98 SMR patients, 91 (92.9%) had resolution of SMR to less than moderate at 30 days. At 1 year, 15% of those with preoperative SMR had recurrent SMR. Conclusions: Patients undergoing LVAD placement with preop SMR experience no differences in mortality, and a majority experience resolution of MR after implant. Longer-term SMR recurrence and need for mitral intervention with LVAD implant warrant further investigation.