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Copyright of Die Kardiologie is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Herz is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Primary mitral regurgitation (MR) is a heterogeneous clinical disease requiring integration of echocardiographic parameters using guideline-driven recommendations to identify severe disease. The purpose of this preliminary study was to explore novel data-driven approaches to delineate phenotypes of MR severity that benefit from surgery. The authors used unsupervised and supervised machine learning and explainable artificial intelligence (AI) to integrate 24 echocardiographic parameters in 400 primary MR subjects from France (n = 243; development cohort) and Canada (n = 157; validation cohort) followed up during a median time of 3.2 years (IQR: 1.3-5.3 years) and 6.8 (IQR: 4.0-8.5 years), respectively. The authors compared the phenogroups' incremental prognostic value over conventional MR profiles and for the primary endpoint of all-cause mortality incorporating time-to-mitral valve repair/replacement surgery as a covariate for survival analysis (time-dependent exposure). High-severity (HS) phenogroups from the French cohort (HS: n = 117; low-severity [LS]: n = 126) and the Canadian cohort (HS: n = 87; LS: n = 70) showed improved event-free survival in surgical HS subjects over nonsurgical subjects (P = 0.047 and P = 0.020, respectively). A similar benefit of surgery was not seen in the LS phenogroup in both cohorts (P = 0.70 and P = 0.50, respectively). Phenogrouping showed incremental prognostic value in conventionally severe or moderate-severe MR subjects (Harrell C statistic improvement; P = 0.480; and categorical net reclassification improvement; P = 0.002). Explainable AI specified how each echocardiographic parameter contributed to phenogroup distribution. Novel data-driven phenogrouping and explainable AI aided in improved integration of echocardiographic data to identify patients with primary MR and improved event-free survival after mitral valve repair/replacement surgery. [Display omitted] [ABSTRACT FROM AUTHOR]

Purpose of Review: The purpose of this paper is to review the selection of candidates for percutaneous mitral interventions using multimodality cardiovascular imaging. Recent Findings: Transcatheter mitral valve interventions are increasing in frequency. This has led to a paradigm shift in managing mitral valve disease in patients who are at high surgical risk. Summary: Here, we review different cases of mitral valve pathology with a percutaneous approach of mitral valve intervention. The first case reviews patient selection for transcatheter edge-to-edge repair of the native mitral valve with severe mitral regurgitation. The second case reviews flail bioprosthetic leaflet with severe mitral regurgitation and a valve-in-valve approach of intervention. The third case reviews senile calcific mitral valve stenosis with a percutaneous approach of valve in mitral annular calcification. [ABSTRACT FROM AUTHOR]

Before the development of transcatheter interventions, patients with mitral regurgitation (MR) and high surgical risk were often conservatively treated and subject to poor prognoses. We aimed to assess the therapeutic approaches and outcomes in the contemporary era. The study participants were consecutive high-risk MR patients from April 2019 to October 2021. Among the 305 patients analyzed, 274 (89.8%) underwent mitral valve interventions, whereas 31 (10.2%) received medical therapy alone. Of the interventions, transcatheter edge-to-edge mitral repair (TEER) was the most frequent (82.0% of overall), followed by transcatheter mitral valve replacement (TMVR) (4.6%). In patients treated with medical therapy alone, non-optimal morphologies for TEER and TMVR were shown in 87.1% and 65.0%, respectively. Patients undergoing mitral valve interventions experienced less frequent heart failure (HF) rehospitalization compared to those with medical therapy alone (18.2% vs. 42.0%, p < 0.01). Mitral valve intervention was associated with a lower risk of HF rehospitalization (HR 0.36 [0.18–0.74]) and an improved New York Heart Association class (p < 0.01). Most high-risk MR patients can be treated with mitral valve interventions. However, approximately 10% remained on medical therapy alone and were considered as unsuitable for current transcatheter technologies. Mitral valve intervention was associated with a lower risk of HF rehospitalization and improved functional status. [ABSTRACT FROM AUTHOR]

Mitral annular calcification (MAC) is a common chronic degenerative process of the mitral valve fibrous support ring. MAC increases the risk of mitral valve dysfunction, all-cause and cardiovascular mortality, and worse outcomes in cardiac interventions. Echocardiography represents the first imaging modality for MAC assessment, but it has low specificity compared to cardiac CT in terms of distinguishing between calcium and dense collagen. Novel three-dimensional transesophageal maximal intensity projection (MIP) mapping allows for the real-time MAC distribution and depth visualization of the cardiac anatomy and represents a useful and promising tool for pre-procedural assessment and intra-procedural guidance of cardiac interventions. [ABSTRACT FROM AUTHOR]

Before the development of transcatheter interventions, patients with mitral regurgitation (MR) and high surgical risk were often conservatively treated and subject to poor prognoses. We aimed to assess the therapeutic approaches and outcomes in the contemporary era. The study participants were consecutive high-risk MR patients from April 2019 to October 2021. Among the 305 patients analyzed, 274 (89.8%) underwent mitral valve interventions, whereas 31 (10.2%) received medical therapy alone. Of the interventions, transcatheter edge-to-edge mitral repair (TEER) was the most frequent (82.0% of overall), followed by transcatheter mitral valve replacement (TMVR) (4.6%). In patients treated with medical therapy alone, non-optimal morphologies for TEER and TMVR were shown in 87.1% and 65.0%, respectively. Patients undergoing mitral valve interventions experienced less frequent heart failure (HF) rehospitalization compared to those with medical therapy alone (18.2% vs. 42.0%, p < 0.01). Mitral valve intervention was associated with a lower risk of HF rehospitalization (HR 0.36 [0.18–0.74]) and an improved New York Heart Association class (p < 0.01). Most high-risk MR patients can be treated with mitral valve interventions. However, approximately 10% remained on medical therapy alone and were considered as unsuitable for current transcatheter technologies. Mitral valve intervention was associated with a lower risk of HF rehospitalization and improved functional status.

Background: Optimal timing for intervention remains uncertain in asymptomatic patients with primary mitral regurgitation (MR). We aimed to assess the prognostic value of a new cardiac damage staging classification in patients with asymptomatic moderate or severe primary MR. Methods: Clinical, Doppler-echocardiographic, and outcome data prospectively collected in 338 asymptomatic patients (64 ± 15 years, 68% men) with at least moderate primary MR were retrospectively analyzed. Patients were hierarchically classified as per the following staging classification: no cardiac damage (stage 0), mild left ventricular or left atrial damage (stage 1), moderate or severe left ventricular or left atrial damage (stage 2), pulmonary vasculature or tricuspid valve damage (stage 3), or right ventricular damage (stage 4). Results: There was a stepwise increase in 10-year mortality rates as per cardiac damage stage: 20.0% in stage 0, 25.6% in stage 1, 31.5% in stage 2, and 61.3% in stage 3-4 (p < 0.001). The staging classification was significantly associated with increased risk of mortality (hazard ratio = 1.41 per one-stage increase, 95% confidence interval: 1.07-1.85, p = 0.015) and the composite of cardiovascular mortality or hospitalization (hazard ratio = 1.51 per one-stage increase, 95% confidence interval: 1.07-2.15, p = 0.020) in multivariable analysis adjusted for EuroSCORE II, mitral valve intervention as a time-dependent variable, and other risk factors. The proposed scheme showed incremental value over several clinical variables (net reclassification index = 0.40, p = 0.03). Conclusions: The new staging classification provides independent and incremental prognostic value in patients with asymptomatic moderate or severe MR.

Mitral annular calcification (MAC) is a common chronic degenerative process of the mitral valve fibrous support ring. MAC increases the risk of mitral valve dysfunction, all-cause and cardiovascular mortality, and worse outcomes in cardiac interventions. Echocardiography represents the first imaging modality for MAC assessment, but it has low specificity compared to cardiac CT in terms of distinguishing between calcium and dense collagen. Novel three-dimensional transesophageal maximal intensity projection (MIP) mapping allows for the real-time MAC distribution and depth visualization of the cardiac anatomy and represents a useful and promising tool for pre-procedural assessment and intra-procedural guidance of cardiac interventions.

The aim of this work was the development of an isolated heart setup to delineate the interactions between intraventricular flow features, hemodynamic parameters and mechano-energetics after certain mitral valve therapies. Five porcine hearts were explanted and prepared for (i) edge-to-edge mitral valve repair, (ii) implantation of a rotatable biscupid mechanical valve prosthesis. Flow structures were visualized using echocardiography while hemodynamics was recorded in terms of pressures, flow rates and ventricular volume. Hemodynamic and cardiac mechano-energetics implied a marginal effect (

In 2020 in Germany, 21,753 patients were hospitalized with the main diagnosis of mitral valve regurgitation (MR), whereby 6050 isolated mitral valve (MV) operations, 4977 combined MV operations and 6011 transcatheter MV interventions were performed. In the last 10 years there was a nearly linear increase of MR-related hospitalizations and transcatheter MV interventions, whereas the numbers of isolated MV operations remained stable and the number of combined MV operations decreased. Due to demographic change and age distribution of MR patients, an increased need for minimally invasive transcatheter MV procedures can be expected in the future. In 2020 the 6011 transcatheter MV interventions were performed at approximately 180 centers in Germany. According to a retrospective analysis of diagnosis-related groups (DRG) hospital data up to 2017, two thirds of all 158 centers which provided transcatheter MV repair in Germany at that time carried out no more than 25 procedures per year. A significant correlation between hospital intervention volume and intrahospital mortality has not yet been found for transcatheter MV repair; however, registry data from Germany, Italy and the USA consistently confirm that centers with a high intervention volume achieve a better reduction of mitral regurgitation, which could directly translate into long-term survival. Thresholds of 20 or 50 procedures per year were suggested as predictive for a better procedural result in terms of MR reduction. Such analyses should be implemented in considerations regarding the appropriate number of transcatheter MV centers for Germany., (© 2023. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

OBJECTIVES: Surgical strategies to treat drug refractory left ventricular outflow tract obstruction (LVOTO) in hypertrophic cardiomyopathy include septal myectomy (SM) and, less frequently, mitral valve (MV) repair or replacement. The primary aim of this study was to report the surgical technique and management outcomes in a consecutive group of patients with variable phenotypes of hypertrophic cardiomyopathy in a broad national specialist practice. METHODS: A total of 203 consecutive patients, 132 men (mean age 48.6 ± 14.6 years) underwent surgery for the management of LVOTO. Surgical approaches included SM (n = 159), SM with MV repair (n = 25), SM with MV replacement (n = 9) and MV replacement alone (n = 10). Specific surgical approaches were performed based on the underlying mechanism of obstruction. Eleven (5.4%) patients had previous alcohol septal ablation for the management of LVOTO. Concomitant non-mitral cardiac procedures were carried out in 22 (10.8%) patients. RESULTS: Operative survival rate was 99.0% with 2 deaths within 30 days. The mean bypass time was 92.9 ± 47.8min, with a mean length of hospital stay of 10.5 ± 7.8 days. Surgical complications included 3 ventricular septal defects requiring repair (1.5%), 1 Gerbode defect surgically repaired, 2 aortic valve repairs (1.0%), 2 transient ischaemic attacks (1.0%) and 4 strokes (2.0%). Thirty-nine (19.2%) patients had perioperative new-onset atrial fibrillation and 8 (3.9%) patients had unexpected atrioventricular block requiring a permanent pacemaker. Mean resting left ventricular outflow tract gradient improved from 70.6 ± 40.3mmHg preoperatively to 11.0 ± 10.5mmHg at 1 year postoperatively (P < 0.001). Mean New York Heart Association class improved from 2.6 ± 0.5 preoperatively to 1.6 ± 0.6 at 1 year after the procedure. CONCLUSIONS: In variable phenotypes of LVOTO in hypertrophic cardiomyopathy, an individualized surgical approach provided effective reductions in left ventricular outflow tract gradients and good symptomatic relief with acceptable mortality and morbidity. [ABSTRACT FROM AUTHOR]

Shone's syndrome (SS) has a varied anatomic spectrum without consensus on need and timing for mitral valve intervention (MVI). We sought to (1) characterize the anatomic spectrum and treatment pathways; (2) describe long-term outcomes and their determinants; and (3) define the impact of MVI timing on survival. In total, 121 patients with SS who underwent operation at Cleveland Clinic between 1956 and 2021 were reviewed. Multivariable parametric hazard analyses including time-varying covariables, and modulated renewal to account for repeated events, were performed. End points included time-related survival and reintervention. Median follow-up was 9.9 years. Mitral stenosis (MS) (98%), coarctation (80%), and aortic stenosis (70%) predominated. The most common combination was MS + aortic stenosis + coarctation (26%). Median initial mean mitral and aortic gradients were 3.6 (15th/85th percentiles: 2.0/6.8) and 9.0 (2.1/46) mm Hg, respectively. Median initial surgery age was 0.041 (0.011/3.2) years. Initial surgeries included coarctation repair (43%), arch repair (18%), and staged biventricular repair (18%). Overall survival was 92% at 20 years. Freedom from reoperation was 66% and 24% at 1 and 20 years. Patients with no MVI or initial MVI (N = 7) tended to be associated with better early survival compared with those with MVI at subsequent operation (N = 29) (P =.06). Risk factors for early reintervention included initial Norwood operation, with younger age and arch hypoplasia increasing later reintervention. Despite excellent long-term survival, reoperation in SS is frequent and occurs most commonly on left ventricular outflow tract and mitral valve. Although MS is present in most, few require MVI. Delaying MVI may compromise early survival. [Display omitted] [ABSTRACT FROM AUTHOR]

OBJECTIVES Transcatheter-based treatment of valvular heart disease has increasingly been implemented for the treatment of high-risk patients. The impact of these new treatment modalities on surgical valve programmes is unclear at present. We sought to evaluate the impact of an interventional mitral valve programme on surgical mitral valve activity and to assess the risk profiles of the respective patient populations. METHODS Between 2007 and 2011, 1112 patients underwent mitral valve surgery for isolated or combined procedures. An interventional mitral valve programme was initiated in 2008, with 270 patients treated from 2008 to 2011. Data were prospectively entered into a database and retrospectively analysed. RESULTS From 2007 to 2011, surgical mitral valve activity increased by 29.9% compared with a 9.8% increase nationwide (P = 0.09). Compared with the year before the introduction of a MitraClip programme, mean logistic EuroSCORE I of surgical patients was similar in 2011 (2007: 9.4 ± 10.4 vs 2011: 9.5 ± 10.5; P = 0.92), while overall 30-day mortality decreased from 7.2 to 4.4% (P = 0.22). The risk profile of surgical patients decreased significantly regarding several parameters. For isolated mitral valve repair, 30-day mortality was 1.5% (6 of 406) in all patients during the study period. Mean logistic EuroSCORE I of transcatheter patients was significantly higher when compared with that of surgical patients (28.8 ± 18.8 vs 9.5 ± 10.5%; P < 0.01). CONCLUSIONS Since the implementation of an interventional mitral valve programme, surgical mitral valve activity has increased over the following years. The risk profile of surgical patients decreased regarding several important parameters, although the overall logistic EuroSCORE I remained unchanged. An integrated approach to mitral valve disease with complementary surgical and non-surgical treatment options may possibly help in relieving the undertreatment of patients with severe mitral regurgitation. [ABSTRACT FROM AUTHOR]

Background: Optimal timing for intervention remains uncertain in asymptomatic patients with primary mitral regurgitation (MR). We aimed to assess the prognostic value of a new cardiac damage staging classification in patients with asymptomatic moderate or severe primary MR., Methods: Clinical, Doppler-echocardiographic, and outcome data prospectively collected in 338 asymptomatic patients (64 ± 15 years, 68% men) with at least moderate primary MR were retrospectively analyzed. Patients were hierarchically classified as per the following staging classification: no cardiac damage (stage 0), mild left ventricular or left atrial damage (stage 1), moderate or severe left ventricular or left atrial damage (stage 2), pulmonary vasculature or tricuspid valve damage (stage 3), or right ventricular damage (stage 4)., Results: There was a stepwise increase in 10-year mortality rates as per cardiac damage stage: 20.0% in stage 0, 25.6% in stage 1, 31.5% in stage 2, and 61.3% in stage 3-4 ( p < 0.001). The staging classification was significantly associated with increased risk of mortality (hazard ratio = 1.41 per one-stage increase, 95% confidence interval: 1.07-1.85, p = 0.015) and the composite of cardiovascular mortality or hospitalization (hazard ratio = 1.51 per one-stage increase, 95% confidence interval: 1.07-2.15, p = 0.020) in multivariable analysis adjusted for EuroSCORE II, mitral valve intervention as a time-dependent variable, and other risk factors. The proposed scheme showed incremental value over several clinical variables (net reclassification index = 0.40, p = 0.03)., Conclusions: The new staging classification provides independent and incremental prognostic value in patients with asymptomatic moderate or severe MR., Competing Interests: Dr Pibarot received funding from 10.13039/100006520Edwards Lifesciences and 10.13039/100004374Medtronic for echocardiography core laboratory analyses in the field of transcatheter aortic valve replacement with no direct personal compensation. Dr Clavel received funding from 10.13039/100006520Edwards Lifesciences for computed tomography core laboratory analyses in the field of surgical aortic valve prosthesis with no direct personal compensation and research grant from 10.13039/100004374Medtronic. All other authors reported no conflict of interest to disclose., (© 2022 The Authors.)

Background: The indication for a mitral valve intervention is an important patient-relevant parameter for the assessment of process quality and the comparison of healthcare providers. In this article, we describe the development of a corresponding quality indicator for an external hospital quality assurance (QA) procedure in Germany., Methods: An expert panel was set up by the aQua Institute to assist with the development of a QA procedure for mitral valve interventions and the associated quality indicators. In a comprehensive, systematic literature and evidence research, the American and European guidelines were identified as the best evidence available. Especially the more current American guideline formed the basis on which a quality indicator dealing with the correct indication for a mitral valve intervention was developed., Results: The developed quality indicator assesses the proportion of patients for whom an indication for a mitral valve intervention was determined in compliance with guideline recommendations. The indicator differentiates between surgical and catheter-based procedures. To determine whether or not the indication was correct, different medical parameters are included, such as, for example, type of mitral valve defect, etiology of the disease, severity of symptoms, valve morphology (e. g., mitral valve area), valve hemodynamics and comorbidity, which healthcare providers have to document., Conclusion: The documentation for the developed quality indicator is considerable. Nonetheless, its relevance is undeniable because it allows the user to determine whether a surgical or catheter-based mitral valve intervention was necessary and performed according to guideline recommendations. In the first year of its implementation, this indicator should be evaluated for further improvement and simplification of assessment., (Copyright © 2017. Published by Elsevier GmbH.)