Mitral Regurgitation After Percutaneous Mitral Valvuloplasty: Insights Into Mechanisms and Impact on Clinical Outcomes

Maria Carmo P Nunes; Robert A Levine; Renato Braulio; Marcelo A Pascoal-Xavier; Sammy Elmariah; Nayana F A Gomes; Juliana R Soares; William A M Esteves; Xin Zeng; Jacob P Dal-Bianco; Livia S A Passos; Luiz G Passaglia; Victor T Ribeiro; Cláudio L Gelape; Paulo H N Costa; Lucas Lodi-Junqueira; Walderez Dutra; Timothy C Tan; Elena Aikawa; Judy Hung

doi:10.1016/j.jcmg.2020.07.020

Mitral Regurgitation After Percutaneous Mitral Valvuloplasty: Insights Into Mechanisms and Impact on Clinical Outcomes

JACC Cardiovasc Imaging. 2020 Dec;13(12):2513-2526. doi: 10.1016/j.jcmg.2020.07.020. Epub 2020 Sep 16.

Authors

Maria Carmo P Nunes¹, Robert A Levine², Renato Braulio³, Marcelo A Pascoal-Xavier⁴, Sammy Elmariah⁵, Nayana F A Gomes⁶, Juliana R Soares³, William A M Esteves³, Xin Zeng², Jacob P Dal-Bianco², Livia S A Passos⁷, Luiz G Passaglia³, Victor T Ribeiro³, Cláudio L Gelape³, Paulo H N Costa³, Lucas Lodi-Junqueira³, Walderez Dutra⁸, Timothy C Tan⁹, Elena Aikawa¹⁰, Judy Hung²

Affiliations

¹ Hospital das Clinicas, School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil. Electronic address: mcarmo@waymail.com.br.
² Cardiac Ultrasound Lab, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
³ Hospital das Clinicas, School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
⁴ Laboratory of Molecular Pathology, Department of Pathological Anatomy and Legal Medicine, School of Medicine of the Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
⁵ Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
⁶ Hospital das Clinicas, School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil; Laboratory of Molecular Pathology, Department of Pathological Anatomy and Legal Medicine, School of Medicine of the Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
⁷ Department of Morphology, Institute of Biological Sciences, Federal University of Minas Gerais, and National Institutes for Science and Technology, Belo Horizonte, Minas Gerais, Brazil; The Center for Excellence in Vascular Biology, Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
⁸ Department of Morphology, Institute of Biological Sciences, Federal University of Minas Gerais, and National Institutes for Science and Technology, Belo Horizonte, Minas Gerais, Brazil.
⁹ Department of Cardiology, Blacktown Hospital, University of Western Sydney, New South Wales, Australia.
¹⁰ The Center for Excellence in Vascular Biology, Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Abstract

Objectives: The aim of this study was to assess the incidence, mechanisms, and outcomes of mitral regurgitation (MR) after percutaneous mitral valvuloplasty (PMV).

Background: Significant MR continues to be a major complication of PMV, with a wide range in clinical presentation and prognosis.

Methods: Consecutive patients with mitral stenosis undergoing PMV were prospectively enrolled. MR severity was evaluated by using quantitative echocardiographic criteria, and its mechanism was characterized by 3-dimensional transesophageal echocardiography, divided broadly into 4 categories based on the features contributing to the valve damage. B-type natriuretic peptide levels were obtained before and 24 h after the procedure. Endpoints estimated cardiovascular death or mitral valve (MV) replacement due to predominant MR.

Results: A total of 344 patients, ages 45.1 ± 12.1 years, of whom 293 (85%) were women, were enrolled. Significant MR after PMV was found in 64 patients (18.6%). The most frequent mechanism of MR was commissural, which occurred in 22 (34.4%) patients, followed by commissural with posterior leaflet in 16 (25.0%), leaflets at central scallop or subvalvular damage in 15 (23.4%), and central MR in 11 (17.2%). During the mean follow-up period of 3 years (range 1 day to 10.6 years), 60 patients reached the endpoint. The event-free survival rates were similar among patients with mild or commissural MR, whereas patients with damaged central leaflet scallop or subvalvular apparatus had the worst outcome, with an event-free survival rate at 1 year of only 7%. Long-term outcome was predicted by net atrioventricular compliance (C_n) at baseline and post-procedural variables, including valve area, mean gradient, and magnitude of decrease in B-type natriuretic peptide levels, adjusted for the mechanism of MR.

Conclusions: Significant MR following PMV is a frequent event, mainly related to commissural splitting, with favorable clinical outcome. Parameters that express the relief of valve obstruction and the mechanism by which MR develops were predictors of long-term outcomes.

Keywords: mitral regurgitation; mitral stenosis; outcomes; percutaneous mitral valvuloplasty.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Adult
Female
Follow-Up Studies
Humans
Male
Middle Aged
Mitral Valve
Mitral Valve Insufficiency*
Mitral Valve Stenosis*
Predictive Value of Tests
Stroke Volume
Treatment Outcome
Ventricular Function, Left

Abstract

Publication types

MeSH terms

Grants and funding