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Competing Interests: Funding Support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Objectives: Mitral valve (MV) clip procedure requires interatrial trans-septal puncture to access the left atrium (LA). Iatrogenic atrial septal defect (iASD) is not uncommon and may remain for a while. However, haemodynamic and echocardiographic determinants of persistent iASD are not well investigated. We sought to find haemodynamic and echocardiographic determinants of iASD after MV clip., Methods: A total of 131 patients with grades 3 to 4+ mitral regurgitation who underwent MitraClip and completed invasive haemodynamic measurement, baseline, 1 month and approximately 12 months of transthoracic echocardiography (TTE) follow-up were retrospectively reviewed., Results: TTE at 1 month showed persistent iASD in 57% (1M-iASD). Mean LA pressure after clip was significantly higher in patients with 1M-iASD than patients without 1M-iASD (17±6 mm Hg vs 15±5 mm Hg, p=0.01). Among patients with 1M-iASD, 24 patients (35%) had persistent iASD at 12 months (12M-iASD). Mean LA pressure after clip was significantly higher in patients with 12M-iASD than patients without 12M-iASD (19±6 mm Hg vs 16±6 mm Hg, p=0.04). Patients with 12M-iASD did not significantly differ from patients without 12M-iASD in terms of right heart enlargement, estimated systolic pulmonary artery pressure, New York Heart Association functional class and brain natriuretic peptide at 12 months. Logistic regression analysis, however, showed that mean LA pressure after clip was significantly associated with persistent iASD at 12 months in patients with 1M-iASD even after adjustment for cardiac index after clip and the prevalence of mitral regurgitation ≥3+ at 12 months (OR 1.10 per 1 mm Hg, 95% CI 1.01 to 1.21, p=0.04)., Conclusions: Elevated LA pressure after MV clip was associated with persistent iASD., Competing Interests: Competing interests: TS and RJS are speakers for Philips Ultrasound, and SK received consulting fees from Abbott Vascular. FR is a consultant of MyoKardia., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: Percutaneous edge-to-edge repair alters mitral valve (MV) geometry in functional mitral regurgitation (FMR). We sought to characterize MV morphology in patients with central and eccentric FMR, compare the geometrical effect of MitraClip therapy, and elucidate different mechanisms of MR improvement according to FMR subtypes., Methods and Results: Seventy-six symptomatic patients with Grade 3 to 4+ FMR (central, n = 39; eccentric, n = 37) underwent three-dimensional transoesophageal echocardiography during MitraClip implantation. We defined procedural success as a reduction of MR by ≥1 grade with having a residual mitral regurgitation (MR) of ≤ grade 2+. Procedural success rate was similar between central and eccentric FMR (77% vs. 78%, P = 0.55). After MitraClip, the reduction in anterior-posterior diameter did not differ between FMR subtypes, but patients with eccentric FMR had a greater reduction in the averaged tethering angle difference (P < 0.001) with less reduction in tenting volume and height (both P < 0.001) than did patients with central FMR. On multivariable analysis, in central FMR, MR reduction post-clip was associated with shortening in anterior-posterior diameter [coefficient 0.388, 95% confidence interval (CI) 0.216-0.561; P < 0.001] and an increase in coaptation area (coefficient 0.117, 95% CI 0.039-0.194; P = 0.004), whereas in eccentric FMR MR reduction was mainly associated with a decrease in the averaged tethering angle difference (coefficient 0.050, 95% CI 0.021-0.078; P = 0.001)., Conclusion: MV geometrical effect and its association with MR improvement after MitraClip therapy differ according to FMR subtypes. Our results indicate the MR jet direction and the leaflet tethering pattern may be considered in the strategy for percutaneous treatment for FMR., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2018. For permissions, please email: journals.permissions@oup.com.)

Objectives: The aim of this study was to determine the prognostic value of pulmonary venous (PV) flow during MitraClip implantation., Background: The clinical significance of PV flow information during MitraClip implantation is unknown., Methods: A total of 300 patients who underwent MitraClip implantation and in whom the measurement of PV flow was completed using intraprocedural transesophageal echocardiography were retrospectively reviewed. The optimal threshold of the ratio of systolic velocity-time integral (Svti) to diastolic velocity-time integral (Dvti) ratio after MitraClip placement for major adverse cardiovascular events (all-cause death, redo MitraClip implantation, mitral valve surgery, and heart transplantation) during 12 months was assessed. The best cutoff ratio was 0.72. Patients were divided into 2 groups using this cutoff ratio (low Svti/Dvti, n = 91; high Svti/Dvti, n = 209)., Results: Following mitral regurgitation reduction by MitraClip placement, Svti increased in the both groups. The frequency of mitral regurgitation 3/4+ immediately after MitraClip implantation, at 1-month follow-up, and at 12-month follow-up was significantly higher in patients with low Svti/Dvti ratios than in those with high Svti/Dvti ratios (after MitraClip placement, 5.5% vs. 0%; p < 0.001; at 1 month; 26% vs. 5.2%; p < 0.001; at 12 months, 18% vs. 5.3%; p = 0.006). Major adverse cardiovascular events during 12 months were significantly higher in patients with low Svti/Dvti ratios than in those with high Svti/Dvti ratios (23% vs. 6.2%; p < 0.001). Multivariate analysis demonstrated that low Svti/Dvti ratio was significantly associated with major adverse cardiovascular events during 12 months after adjustment for age, baseline renal function, and mean transmitral pressure gradient (adjusted hazard ratio: 4.00; 95% confidence interval: 2.02 to 8.23; p < 0.001)., Conclusions: PV flow information in the catheterization laboratory immediately after MitraClip implantation predicted recurrent mitral regurgitation and worse long-term outcomes., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Left ventricular diastolic dysfunction is a sensitive and early sign of myocardial ischemia. We assessed whether mitral annular velocity reflected the severity of myocardial ischemia evaluated by single-photon emission computed tomography in patients with suspected coronary artery disease (CAD) and preserved ejection fraction., Methods and Results: The study population consisted of 125 patients with suspected CAD who underwent both single-photon emission computed tomography and transthoracic echocardiography. There were 68 patients with no ischemia, 42 patients with mild ischemia, and 15 patients with severe ischemia. With increasing severity of myocardial ischemia, septal e' decreased. Compared with patients with no ischemia, septal e' was significantly lower even in patients with mild ischemia (6.6 ± 1.4 vs. 6.1 ± 1.4 cm/s, P < 0.05). Septal E/e' (9.9 ± 2.6 vs. 13.6 ± 4.0, P < 0.01) and lateral E/e' (7.7 ± 2.3 vs. 10.3 ± 3.6, P < 0.01) were significantly higher finally in patients with severe ischemia. Multivariate logistic regression analyses showed that BMI [odds ratio (OR) 1.13, 95% confidence interval (CI) 1.01-1.29; P = 0.03] and septal e' (OR 0.71, 95% CI 0.53-0.94; P = 0.02) were independent predictors of any myocardial ischemia and that diabetes (OR 5.78, 95% CI 1.58-23.0; P = 0.008) and septal E/e' (OR 1.38, 95% CI 1.13-1.76; P = 0.001) were independent predictors of severe myocardial ischemia., Conclusion: Our data suggested that decreased e' was useful in detecting mild myocardial ischemia and increased E/e' was useful in detecting severe myocardial ischemia in patients with suspected CAD and preserved ejection fraction.

Background: Left ventricular (LV) outflow tract (LVOT) obstruction increases mortality in patients undergoing transcatheter mitral valve implantation (TMVI) in degenerated bioprostheses, annuloplasty rings, and native mitral valves. We aimed to evaluate the LVOT area after TMVI using 3‐dimensional (3D) transesophageal echocardiography (TEE) and to investigate the preprocedural cardiac geometry that affects the LVOT area after TMVI. Methods: We retrospectively reviewed echocardiography data in 43 patients who had TMVI. A change in pressure gradient across LVOT from before to after TMVI (∆PG) and postprocedure 3D LVOT cross‐sectional area at the level of the most distal portion of the mitral valve stent that was closest to the LV apex were assessed as evidence of LVOT narrowing. Results: Transcatheter mitral valve implantation with the use of balloon‐expandable valve system was performed for 24 bioprostheses, 7 annuloplasty rings, and 12 native valves. Compared to patients without increase in LVOT gradient (∆PG <10 mm Hg; n = 33), patients with increase in LVOT gradient (∆PG ≥10 mm Hg; n = 10) had smaller LV end‐systolic volume (LVESV), greater LV ejection fraction (LVEF), and smaller aorto‐mitral (AM) angle. The LVOT area at the valve stent distal edge showed strong association with ∆PG (r = −.68, P <.0001). Only a small AM angle was associated with a small LVOT area at the valve stent distal edge on multivariable analysis, independent of LVESV and LVEF. Conclusion: Small LV size, preserved LVEF, and small AM angle were associated with LVOT narrowing. 3D‐derived AM angle might be independently associated with LVOT narrowing in patients undergoing transcatheter mitral valve‐in‐valve, valve‐in‐ring, and valve‐in‐native valve implantation, independent of LVESV and LVEF. [ABSTRACT FROM AUTHOR]

Aims We sought to find the morphological mechanisms of recurrent mitral regurgitation (MR) after MitraClip procedure using 3D transoesophageal echocardiography (TOE). Methods and results Of 478 consecutive patients treated with the initial MitraClip procedure, 41 patients who underwent repeat mitral valve (MV) transcatheter or surgical intervention for recurrent MR were retrospectively reviewed. Using 3D-TOE, we investigated morphological changes of MV leading to repeat MV intervention. Aetiology of MR at the index intervention was primary in 24 (59%) and secondary in 17 (41%) patients. In the primary MR group, worsening leaflet prolapse at the clip site caused recurrent MR in 12 (50%) patients, while 7 (29%) patients had a leaflet tear at the clip site. Acute single leaflet device detachment was seen in four patients and one patient had recurrent MR between the plug and the clip. In secondary MR, left ventricular (LV)/left atrial dilation caused recurrent MR in 13 (76%) patients. Significant increase in the LV end-diastolic volume and tenting height were observed from post-index procedure to repeat intervention (LV end-diastolic volume; from 205 to 237 ml, P  <   0.001, tenting height; from 0.8 to 1.3 cm, P  <   0.001). New emergent leaflet prolapse/flail was seen in 3 (18%) patients, suggesting iatrogenic MR. Conclusion Mechanisms of recurrent MR after MitraClip procedure varied and depended on the underlying MV pathology: in primary MR, worsening mitral leaflet prolapse and in secondary MR, progressive LV dilation with worsening tenting were the main causes of recurrent MR. [ABSTRACT FROM AUTHOR]

Objectives: Mitral valve (MV) clip procedure requires interatrial trans-septal puncture to access the left atrium (LA). Iatrogenic atrial septal defect (iASD) is not uncommon and may remain for a while. However, haemodynamic and echocardiographic determinants of persistent iASD are not well investigated. We sought to find haemodynamic and echocardiographic determinants of iASD after MV clip.Methods: A total of 131 patients with grades 3 to 4+ mitral regurgitation who underwent MitraClip and completed invasive haemodynamic measurement, baseline, 1 month and approximately 12 months of transthoracic echocardiography (TTE) follow-up were retrospectively reviewed.Results: TTE at 1 month showed persistent iASD in 57% (1M-iASD). Mean LA pressure after clip was significantly higher in patients with 1M-iASD than patients without 1M-iASD (17±6 mm Hg vs 15±5 mm Hg, p=0.01). Among patients with 1M-iASD, 24 patients (35%) had persistent iASD at 12 months (12M-iASD). Mean LA pressure after clip was significantly higher in patients with 12M-iASD than patients without 12M-iASD (19±6 mm Hg vs 16±6 mm Hg, p=0.04). Patients with 12M-iASD did not significantly differ from patients without 12M-iASD in terms of right heart enlargement, estimated systolic pulmonary artery pressure, New York Heart Association functional class and brain natriuretic peptide at 12 months. Logistic regression analysis, however, showed that mean LA pressure after clip was significantly associated with persistent iASD at 12 months in patients with 1M-iASD even after adjustment for cardiac index after clip and the prevalence of mitral regurgitation ≥3+ at 12 months (OR 1.10 per 1 mm Hg, 95% CI 1.01 to 1.21, p=0.04).Conclusions: Elevated LA pressure after MV clip was associated with persistent iASD. [ABSTRACT FROM AUTHOR]

Aims Percutaneous edge-to-edge repair alters mitral valve (MV) geometry in functional mitral regurgitation (FMR). We sought to characterize MV morphology in patients with central and eccentric FMR, compare the geometrical effect of MitraClip therapy, and elucidate different mechanisms of MR improvement according to FMR subtypes. Methods and results Seventy-six symptomatic patients with Grade 3 to 4+ FMR (central, n  = 39; eccentric, n  = 37) underwent three-dimensional transoesophageal echocardiography during MitraClip implantation. We defined procedural success as a reduction of MR by ≥1 grade with having a residual mitral regurgitation (MR) of ≤ grade 2+. Procedural success rate was similar between central and eccentric FMR (77% vs. 78%, P  =   0.55). After MitraClip, the reduction in anterior-posterior diameter did not differ between FMR subtypes, but patients with eccentric FMR had a greater reduction in the averaged tethering angle difference (P  <   0.001) with less reduction in tenting volume and height (both P  <   0.001) than did patients with central FMR. On multivariable analysis, in central FMR, MR reduction post-clip was associated with shortening in anterior-posterior diameter [coefficient 0.388, 95% confidence interval (CI) 0.216–0.561; P  <   0.001] and an increase in coaptation area (coefficient 0.117, 95% CI 0.039–0.194; P  =   0.004), whereas in eccentric FMR MR reduction was mainly associated with a decrease in the averaged tethering angle difference (coefficient 0.050, 95% CI 0.021–0.078; P  =   0.001). Conclusion MV geometrical effect and its association with MR improvement after MitraClip therapy differ according to FMR subtypes. Our results indicate the MR jet direction and the leaflet tethering pattern may be considered in the strategy for percutaneous treatment for FMR. [ABSTRACT FROM AUTHOR]

Background: Mitral valve (MV) tethering plays a central role in the development of functional mitral regurgitation (FMR). However, patients with FMR without MV tethering were encountered in clinical setting. Left atrial dilatation due to chronic atrial fibrillation has been known to cause FMR. Therefore, we aimed to identify the cause of FMR without MV tethering in patients with sinus rhythm using 3D transesophageal echocardiography. Methods: We studied 31 FMR patients with sinus rhythm and LV dysfunction (LVEF <50%) but without significant MV tethering, defined as a tenting height ≤7.7 mm. Control subjects with normal MV (n = 26) had tenting of 5.1 ± 1.3 mm. The value of 7.7 mm was derived from the mean plus 2 standard deviation. From 3D datasets, the mitral valve was divided into 11 equidistant antero-posterior planes at mid-systole. In each plane, the entire leaflet length and straight distance from annular point to coaptation point were measured (Figure 1). The entire leaflet area was obtained as the product of inter-slice distance and the sum of the entire leaflet lengths. The theoretically minimum leaflet area was also obtained by the same calculating formula with the straight distance. The ratio of leaflet areas was then obtained, which represented abnormal leaflet remodeling. Regurgitant orifice area (ROA) was measured assuming elliptical shape of the flow convergence zone by 2D color Doppler. Results: Compared to controls, FMR had larger LV volumes, MV annular area, and tenting volume (P <0.01). MV leaflet area was correlated with MV annular area and tethering (P <0.001). A wide range of ROA (0.02 to 1.02 cm2) was observed, unrelated to LV volumes, MV annular area, and MV tethering. The ratio of leaflet areas was the only determinant of ERO (R = 0.75, P <0.0001). Conclusion: MV leaflets become enlarged in response to annular dilatation and MV tethering. However, abnormal leaflet remodeling may lead to significant FMR in patients without MV tethering or atrial fibrillation. [ABSTRACT FROM AUTHOR]