Early improvement in congestive heart failure after correction of secondary mitral regurgitation in end-stage cardiomyopathy

doi:10.1016/0002-8703(95)90399-2

American Heart Journal

Volume 129, Issue 6, June 1995, Pages 1165-1170

https://doi.org/10.1016/0002-8703(95)90399-2 Get rights and content

Abstract

Mitral regurgitation frequently complicates dilated cardiomyopathy, aggravates volume overload of the left ventricle, and contributes to symptoms of congestive heart failure. This study was performed to assess the impact of mitral valve reconstruction in nine consecutive patients with severe mitral regurgitation resulting from end-stage dilated cardiomyopathy. Clinical and echocardiographic follow-up were obtained 17 ± 5 and 16 ± 6 weeks after surgery, respectively. There were no operative or early deaths. All patients noted symptomatic improvement postoperatively, and there was a decrease of at least one New York Heart Association functional class (3.9 ± 0.3 to 1.7 ± 0.5, p < 0.001). Quantitative echocardiography/Doppler demonstrated a small but significant decrease in left ventricular end-diastolic volume (317 ± 111 ml to 291 ± 105 ml, p = 0.04) and increases in ejection fraction (18 ± 5% to 24 ± 9%, p = 0.02) and forward cardiac output (3.1 ± 1.0 to 4.6 ± 0.8 Umin, p < 0.01) on follow-up. Mitral valve reconstruction for the correction of mitral regurgitation in patients with end-stage dilated cardiomyopathy results in improved symptomatic status on early follow-up accompanied by evidence of improvement in left ventricular performance. (Ann HEART J 1995;129:1165-70.)

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Citation Excerpt :
Along the same line, patients with progressive residual MR during follow-up had similarly impaired functional status compared with patients with procedural failure. LV reverse remodeling has been documented both after isolated and concomitant MV surgery.17-19,31 Conversely, an ongoing LV dilatation was observed in the COAPT trial in both groups during the study period that was significantly worse in the GDMT group.32
To compare the efficacy and clinical outcomes of transcatheter edge-to-edge mitral valve repair (TMVr) and surgical mitral valve repair (SMVr) among patients with secondary mitral regurgitation (SMR).
Consecutive patients with SMR treated using either TMVr (n = 199) or SMVr (n = 222) at 2 centers were included and retrospectively analyzed. To account for differences in patient demographic characteristics, 1:1 propensity score matching was performed. The primary endpoint was all-cause death within 2 years after the procedure.
The study population consisted of 202 matched patients. At 2 years, all-cause mortality was 24.3% for TMVr and 23.0% for SMVr (hazard ratio, 0.97; 95% confidence interval, 0.55-1.71; P = .909). Severe heart failure symptoms at 2 years were less prevalent after SMVr (New York Heart Association functional class III or IV: 13.5% vs 29.5%; P = .032) than after TMVr. A higher proportion of the SMVr patients had SMR reduction to none or mild at discharge (90.8% vs 72.0%; P < .001) and 2 years (86.5% vs 59.6%; P < .001). Among patients who achieved none or mild MR at discharge, 7 patients (10.1%) in the SMVr group and 15 (34.9%) in the TMVr group had progression to moderate or greater MR at 2 years (P = .003). Left ventricular ejection fraction (LVEF) significantly improved (+10.1% ± 11.1%; P < .001) after SMVr (LVEF at 2 years: 45.7% ± 12.8%), whereas it remained unchanged (–1.3% ± 8.9%; P = .260) after TMVr (LVEF at 2 years: 34.0% ± 13.2%).
In this propensity score-matched analysis, there was no significant difference in 2-year survival between TMVr and SMVr, despite greater and more durable SMR reduction, as well as LVEF improvement in the surgical group.
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Transcatheter mitral valve repair is beneficial in patients with mitral regurgitation (MR), left ventricular dysfunction, and persistent symptoms despite maximally tolerated medical therapy.
The aim of this study was to evaluate the safety and feasibility of transcatheter mitral cerclage ventriculoplasty in patients with MR and either heart failure with reduced ejection fraction or preserved ejection fraction and in subjects with prior edge-to-edge repair but persistent or recurrent symptomatic MR.
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Nineteen subjects consented and underwent cerclage, 63% with heart failure with reduced ejection fraction and 37% with heart failure with preserved ejection fraction, with ischemic cardiomyopathy in 26% and nonischemic cardiomyopathy in 74%. There were no procedural deaths, strokes, or transient ischemic attacks or other major cardiovascular adverse events. The primary endpoint was met in 17 subjects. Cerclage induced sustained reductions in mitral regurgitant volume (−41%) and effective orifice area (−33%) after a median of 337 days. Cerclage resulted in improvements in 6-minute walking distance (+78 m) and Kansas City Cardiomyopathy Questionnaire Overall Summary Score (+22 points) at 30 days that were maintained after a median of 265 days. New complete heart block developed in 6 of 17 subjects. Three deaths occurred on postprocedural days 79, 159, and 756, unrelated to cerclage.
Transcatheter mitral cerclage ventriculoplasty resulted in significant and sustained improvements in mitral regurgitation and in heart failure quality-of-life assessments.
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This report describes the 12-month outcomes of the a prospective, multicenter, nonrandomized post-approval study of the MitraClip therapy in Europe (ACCESS-EU postapproval study of MitraClip therapy) with respect to preprocedural left ventricular ejection fraction (LVEF). Transcatheter deployment of the MitraClip device may be considered for patients who are not suitable for conventional surgery. A total of 567 patients with significant mitral regurgitation (MR) underwent MitraClip therapy. Of those, 393 had functional MR (FMR) and were subdivided by preprocedural LVEF (A: 10% to 20%, B: >20% to 30%, C: >30% to 40%, D: >40%). Procedural safety and efficacy and treatment outcomes including MR grade, New York Heart Association (NYHA) functional class, 6-minute walk test, and the Minnesota Living with Heart Failure Questionnaire were analyzed at baseline, 30 days, and 12 months. Baseline mean logistic EuroSCORE was 25 ± 19; 87% of patients were in NYHA classes III or IV (A: 96%, B: 83%, C: 90%, D: 86%). There was no incidence of death or stroke intraprocedurally. Eleven patients died within 30 days with no differences among subgroups. Kaplan–Meier survival at 12 months was 81.8% (A: 71%, B: 79%, C: 87%, D: 86%). There was a significant improvement in MR severity at 30 days and 12 months (p <0.0001). At 12 months, all subgroups experienced similar improvements in NYHA class, 6-minute walk test, and Minnesota Living with Heart Failure Questionnaire. This real-world registry reports promising results of MitraClip therapy in patients with FMR. In conclusion, the low rates of hospital mortality and adverse events in patients with FMR—even in patients with severely reduced LVEF—provide additional evidence of substantial benefits after MitraClip implantation.
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Clinical investigationEarly improvement in congestive heart failure after correction of secondary mitral regurgitation in end-stage cardiomyopathy

Abstract

J Am Coll Cardiol

J Thorac Cardiovasc Surg

J Am Coll Cardiol

Am J Cardiol

J Thorac Cardiovasc Surg

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Quantitative echocardiography of the mitral complex in dilated cardiomyopathy: the mechanism of functional mitral regurgitation

Circulation

Mechanism of mitral regurgitation in patients with myocardial infarction: a study using real-time two-dimensional Doppler flow imaging and echocardiography

Circulation

Dynamics of acute experimental mitral regurgitation

Clinical investigation
Early improvement in congestive heart failure after correction of secondary mitral regurgitation in end-stage cardiomyopathy