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MitraClip for Secondary Mitral Regurgitation: Approach to the 2020 ACC/AHA Valvular Heart Disease Guidelines.

ABSTRACT: We describe the case of an 83-year-old man with a history of ischemic cardiomyopathy and severe secondary mitral regurgitation. This case highlights the role of transcatheter edge-to-edge repair with the MitraClip in the management of symptomatic functional mitral regurgitation in a surgically unfavorable patient. (Level of Difficulty: Advanced.).

SUBMITTER: McCauley BD

PROVIDER: S-EPMC8311014 | biostudies-literature | 2021 Mar

REPOSITORIES: biostudies-literature

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MitraClip for Secondary Mitral Regurgitation: Approach to the 2020 ACC/AHA Valvular Heart Disease Guidelines.

McCauley Brian D BD Herrmann Howard C HC Chen Tiffany T Anwaruddin Saif S

JACC. Case reports 20201217 3

We describe the case of an 83-year-old man with a history of ischemic cardiomyopathy and severe secondary mitral regurgitation. This case highlights the role of transcatheter edge-to-edge repair with the MitraClip in the management of symptomatic functional mitral regurgitation in a surgically unfavorable patient. (<b>Level of Difficulty: Advanced.</b>). ...[more]

PMID: 34317537

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Cost-effectiveness of the MitraClip device in German heart failure patients with secondary mitral regurgitation.

Project description:AimTo evaluate the cost-effectiveness of the MitraClip device (MitraClip) in addition to optimal medical therapy (OMT) in patients with heart failure and secondary mitral regurgitation in Germany.Methods and resultsA model-based economic evaluation was performed to estimate the incremental cost per quality-adjusted life-years (QALYs) for patients with a moderate-to-severe or severe secondary mitral regurgitation receiving MitraClip plus OMT compared with OMT alone from the statutory health insurance (SHI) perspective. Transition probabilities, data on survival rates, and hospitalization rates were obtained from the COAPT trial, a randomized-controlled multicenter trial. Data on health utility and costs were taken from published evidence. To assess parameter uncertainty, several deterministic and probabilistic sensitivity analyses were performed. The incremental costs per QALY gained were € 59,728 (costs/incremental life years gained: € 42,360). The results were most sensitive to the transition probabilities and the hospitalization rates. The probabilistic sensitivity analysis showed that the MitraClip strategy was cost-effective with a probability of 80% at a willingness-to-pay threshold of € 67,000/QALY.ConclusionsDepending on the willingness-to-pay threshold, for patients with heart failure and a moderate-to-severe or severe secondary mitral regurgitation the MitraClip can be cost-effective from the perspective of the German SHI.

| S-EPMC10060324 | biostudies-literature

Selection of the Optimal Candidate to MitraClip for Secondary Mitral Regurgitation: Beyond Mitral Valve Morphology.

Project description:Secondary mitral regurgitation (MR) occurs despite structurally normal valve apparatus due to an underlying disease of the myocardium leading to disruption of the balance between tethering and closing forces with ensuing failure of leaflet coaptation. In patients with heart failure (HF) and left ventricular dysfunction, secondary MR is independently associated with poor outcome, yet prognostic benefits related to the correction of MR have remained elusive. Surgery is not recommended for the correction of secondary MR outside coronary artery bypass grafting. Percutaneous mitral valve repair (PMVR) with MitraClip implantation has recently evolved as a new transcatheter treatment option of inoperable or high-risk patients with severe MR, with promising results supporting the extension of guideline recommendations. MitraClip is highly effective in reducing secondary MR in HF patients. However, the derived clinical benefit is still controversial as two randomized trials directly comparing PMVR vs. optimal medical therapy in severe secondary MR yielded virtually opposite conclusions. We reviewed current evidence to identify predictors of PMVR-related outcomes in secondary MR useful to improve the timing and the selection of patients who would derive maximal benefit from MitraClip intervention. Beyond mitral valve anatomy, optimal candidate selection should rely on a comprehensive diagnostic workup and a fine-tuned risk stratification process aimed at (i) recognizing the substantial heterogeneity of secondary MR and its complex interaction with the myocardium, (ii) foreseeing hemodynamic consequences of PMVR, (iii) anticipating futility and (iv) improving symptoms, quality of life and overall survival.

| S-EPMC7887290 | biostudies-literature

Percutaneous treatment of mitral regurgitation with MitraClip device.

Project description:The percutaneous edge-to-edge repair of mitral regurgitation with a MitraClip device has been recently approved in Europe. The results of the randomized EVEREST II study showed a favourable safety profile of the technique. However, the efficacy in terms of regurgitation reduction in a population with predominantly degenerative mitral disease was inferior as compared to the results of conventional open heart surgery. Nevertheless, up to 50% of symptomatic heart failure patients with severe mainly functional mitral regurgitation are not treated surgically because of very high procedural risk. The registry data suggest that the minimally invasive and generally well-tolerated MitraClip procedure reduces symptoms and need for recurrent hospitalization and improves left ventricular function in inoperable subjects. The ongoing randomized clinical trials with clinical endpoints will further define the current role of percutaneous edge-to-edge repair in heart failure patients with mitral regurgitation.

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Performance of 2020 AHA/ACC HCM Guidelines and Incremental Value of Myocardial Strain for Predicting SCD

Project description: Not available

| S-EPMC10782402 | biostudies-literature

MitraClip Procedure in Advanced Heart Failure and Severe Mitral Regurgitation: Case Report and Literature Review.

Project description:Mitral regurgitation (MR) is a common valvular disorder often seen in a severely dilated left ventricle (LV) and reduced LV function. In chronic heart failure (HF), severe functional MR increases preload, wall tension, LV workload, and worsening prognosis. The MitraClip device offers a percutaneous treatment option in HF, although its safety and efficacy in advanced and acute HF remain a gray zone. We present a successful case of the emergent MitraClip intervention in a patient with advanced HF and review the relevant literature.

| S-EPMC11818264 | biostudies-literature

Assessing the applicability of 2017 ACC/AHA hypertension guidelines for secondary stroke prevention in the BOSS study.

Project description:Using data from the Blood Pressure and Clinical Outcome in TIA or Ischemic Stroke (BOSS) study, we aim to test the applicability and feasibility of stroke secondary prevention recommendations from the 2017 American College of Cardiology/American Heart Association guideline. Patients were categorized based on their blood pressure (BP) status at 3 months. The nonhypertension group was defined as those without a diagnosis of hypertension. The other patients were further divided into three subgroups according to office BP measured at 3-month visit (BP <130/80, 130-139/80-89, and ≥140/90 mm Hg). The primary outcome was any stroke within one year. The associations between BP status and 1-year prognosis (recurrent stroke, recurrent stroke/TIA, and poor functional outcome [modified Rankin scale score 3-6]) were estimated. Among 2341 IS/TIA patients, additional 1056 patients were classified as uncontrolled hypertension at the 90-day visit according to the new guidelines. Adjusted hazard/odds ratios (95% confidence intervals [CI]) for recurrent stroke in BP <130/80, 130-139/80-89, and ≥140/90 compared with nonhypertension group were 2.42 (95% CI: 0.87-6.76), and 4.30 (95% CI: 1.73-10.70), respectively. The prevalence of hypertension and uncontrolled BP among BOSS study population was substantially higher based on the new guidelines. BP of 130-139/80-89 did not show the worsened clinical outcomes compared with people without hypertension. Our study adds to the growing uncertainty about secondary prevention BP goal for IS/TIA patients.

| S-EPMC8030308 | biostudies-literature

A Comprehensive Engineering Analysis of Left Heart Dynamics After MitraClip in a Functional Mitral Regurgitation Patient.

Project description:Percutaneous edge-to-edge mitral valve (MV) repair using MitraClip has been recently established as a treatment option for patients with heart failure and functional mitral regurgitation (MR), which significantly expands the number of patients that can be treated with this device. This study aimed to quantify the morphologic, hemodynamic and structural changes, and evaluate the biomechanical interaction between the MitraClip and the left heart (LH) complex of a heart failure patient with functional MR using a fluid-structure interaction (FSI) modeling framework. MitraClip implantation using lateral, central and double clip positions, as well as combined annuloplasty procedures were simulated in a patient-specific LH model that integrates detailed anatomic structures, incorporates age- and gender-matched non-linear elastic material properties, and accounts for mitral chordae tethering. Our results showed that antero-posterior distance, mitral annulus spherecity index, anatomic regurgitant orifice area, and anatomic opening orifice area decreased by up to 28, 39, 52, and 71%, respectively, when compared to the pre-clip model. MitraClip implantation immediately decreased the MR severity and improved the hemodynamic profile, but imposed a non-physiologic configuration and loading on the mitral apparatus, with anterior and posterior leaflet stress significantly increasing up to 210 and 145% during diastole, respectively. For this patient case, while implanting a combined central clip and ring resulted in the highest reduction in the regurgitant volume (46%), this configuration also led to mitral stenosis. Patient-specific computer simulations as used here can be a powerful tool to examine the complex device-host biomechanical interaction, and may be useful to guide device positioning for potential favorable clinical outcomes.

| S-EPMC7221026 | biostudies-literature

Extent and determinants of left ventricular reverse remodeling in patients with secondary mitral regurgitation undergoing MitraClip implantation.

Project description:BackgroundIn secondary MR, data on left ventricular (LV) remodeling after MitraClip procedure are rare, even this information may impact patient selection. This study investigated changes in LV structure and function by cardiovascular magnetic resonance (CMR) following MitraClip implantation for secondary mitral regurgitation (MR) in order to assess extent and predictors of LV reverse remodeling (LVRR).Methods and resultsTwenty-nine patients underwent CMR imaging prior to and six months after MitraClip procedure. LVRR was defined by a decrease of LV end-diastolic volume index (LVEDVi) > 15% compared to baseline. According to the definition of LVRR, 34% of patients displayed LVRR at follow-up CMR. Baseline LV stroke volume index (LVSVi), LV ejection fraction (LVEF), LV circumferential strain and MR volume at baseline were predictors of LVRR at follow-up. At second CMR, we detected an improvement in hemodynamic status as illustrated by an increase in effective LVSVi (28 ± 8 ml/m2 vs. 33 ± 8 ml/m2; p = 0.053) and cardiac index (2.0 ± 0.5 vs. 2.3 ± 0.5 l/min; p = 0.016), while LVEF and LV strain parameters did not change (p > 0.05). Improvements in effective LVSVi were associated with the decrease of MR volume (r = 0.509; p = 0.018) and MR fraction (r = 0.629; p = 0.002) by MitraClip.ConclusionsTogether, MitraClip implantation is associated with LVRR in one third of patients. Baseline LV function and magnitude of MR are important predictors of LVRR. Improvement of hemodynamic status may be assessed by effective stroke volume index and correlates with the reduction of MR by MitraClip implantation, rather than an increase in LV contractility.

| S-EPMC8188052 | biostudies-literature

Predictors of functional improvement in the short term after MitraClip implantation in patients with secondary mitral regurgitation.

Project description:BACKGROUND AND OBJECTIVES:MitraClip implantation is an established therapy for secondary mitral regurgitation (MR) in high-risk patients and has shown to improve several important outcome parameters such as functional capacity. Patient selection is both challenging and crucial for achieving therapeutic success. This study investigated baseline predictors of functional improvement as it was quantified by the six-minute walk distance (6MWD) after transcatheter mitral valve repair. METHODS AND RESULTS:We retrospectively analyzed 79 patients with secondary MR treated with MitraClip implantation at an academic tertiary care center. Before and four weeks after the procedure, all patients underwent comprehensive clinical assessment, six-minute walk tests and echocardiography. 6MWD significantly improved after MitraClip therapy (295 m vs. 265 m, p < 0.001). A linear regression model including seven clinical baseline variables significantly predicted the change in 6MWD (p = 0.002, R2 = 0.387). Female gender, diabetes mellitus and arterial hypertension were found to be significant negative predictors of 6MWD improvement. At baseline, female patients had significant higher left ventricular ejection fraction (49% vs. 42%, p = 0.019) and lower 6MWD (240 m vs. 288 m, p = 0.034) than male patients. CONCLUSION:MitraClip implantation in secondary MR significantly improves functional capacity in high-risk patients even in the short term of four weeks after the procedure. Female gender, diabetes mellitus and arterial hypertension are baseline predictors of a less favourable functional outcome. While further validation in a larger cohort is recommended, these parameters may improve patient selection for MitraClip therapy.

| S-EPMC7255600 | biostudies-literature

Successful MitraClip for severe rheumatic mitral regurgitation: a case report.

Project description:BackgroundAnatomical exclusion criteria for the MitraClip procedure have included rheumatic heart disease (RHD) involving the mitral valve. This was primarily because RHD is typically associated with mitral stenosis (MS).Case summaryWe report the case of an 85-year-old male who had recurrent heart failure admissions from severe rheumatic mitral regurgitation (MR). This was successfully treated with the MitraClip system.DiscussionOur case demonstrated the possibility of rheumatic MR being treated by the MitraClip system in appropriately selected patients. Careful examination of the mechanism of MR to determine suitability for MitraClip must be done as well as exclusion of significant MS.

| S-EPMC6764582 | biostudies-literature

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