MitraClip and left ventricular reverse remodelling: a strain imaging study

Abstract

Aims The purpose of this study is to identify echocardiography predictors of clinical response and reverse left ventricular (LV) remodelling in patients with functional mitral regurgitation (FMR) treated with MitraClip. Method and results We retrospectively analysed 86 high surgical risk patients with severe FMR; of those, 58 were implanted a MitraClip, and 28 received medical treatment and served as controls. At baseline and at 1-year follow-up, we performed clinical and echocardiography evaluation to assess global longitudinal strain (GLS) and myocardial work [global work index (GWI), global constructive work (GCW), global wasted work (GWW), global work efficiency (GWE)]. Mitral regurgitation was significantly reduced after MitraClip implantation (3.7 ± 0.4 vs. 1.7 ± 0.8, P < 0.001), and the procedure was associated with improvement in brain natriuretic peptide levels (980 ± 1027 vs. 420 ± 338 pg/mL, P < 0.001), New York Heart Association class status (3.2 ± 0.55 vs. 2.0 ± 0.6, P < 0.001), 6-min walking test (233 ± 154 vs. 286 ± 114 m, P = 0.01) at follow-up and reduction of left ventricle end-systolic (LVESV) and left ventricle end-diastolic volumes (LVEDV) (152 ± 68 vs. 136 ± 43 mL, P = 0.004 & 219 ± 74 vs. 193 ± 66 mL, P = 0.001, respectively). MitraClip procedure was associated with improvement of LV performance and significant increase of GWI (607 ± 282 vs. 650 ± 260 mmHg%, P = 0.045) and GCW (854 ± 288 vs. 949 ± 325 mmHg%, P < 0.001). Baseline ejection fraction (EF), GLS, GWI, GCW, and effective regurgitant orifice area were the variables that were associated with reduction of LVEDV 1 year after intervention (P < 0.05 for all) and baseline GCW of the LV was the only variable associated with reduction of LVESV (P = 0.002). Receiver operating characteristic curve analysis identified that a GLS cutoff value of À8.65% (AUC 0.815, P = 0.007) was associated with a 20% reduction of the LVEDV with a sensitivity and specificity of 72% and 70%, respectively, and that a GCW cutoff value of 846 mmHg% (AUC 0.759, P = 0.007) was associated with a 10% reduction of LVESV with sensitivity and specificity 79% and 74%, respectively. Conclusions Mitral valve repair with MitraClip has positive clinical and echocardiographic impact in patients with FMR 1 year after implantation. Preserved GLS and GCW values appear to be associated with LV reverse remodelling post intervention.

Myocardial Work: Methodology and Clinical Applications

“…MW has also been evaluated in HFrEF patients with concomitant severe functional mitral regurgitation (MR) treated with MitraClip [ 50 ]. The baseline GCW was the only statistically significant predictor of LV reverse remodeling one year after MitraClip implantation.…”

“…However, when ΔLVESV was evaluated, as the true indicator of reverse remodeling, GCW was the only parameter that predicted reverse remodeling. A cut-off value of GCW > 846 mmHg% was associated with 10% LVESV reduction with a sensitivity and specificity of 79 and 74%, respectively [ 50 ]. Again, as the sample of the study was small, MW cannot be applied in daily practice in such patients except for research purposes.…”

The non-invasive assessment of myocardial work by pressure-strain analysis: clinical applications

“…Another interesting outlook is related to the field of trans-catheter valve repair. Papadopoulos et al conducted a retrospective case–control study to evaluate left ventricular global longitudinal strain and myocardial work indices in patients with heart failure and mitral regurgitation 1 year after transcatheter mitral-valve repair compared to patients treated with optimal medical treatment [ 102 ]. Preserved baseline GLS and GCW appeared to be able to predict reduction in LVEDV and LVESV, respectively, after successful MV repair proving to be potential new markers of positive LV remodeling, which could allow better patients’ selection for this procedure [ 102 ].…”

“…Papadopoulos et al conducted a retrospective case–control study to evaluate left ventricular global longitudinal strain and myocardial work indices in patients with heart failure and mitral regurgitation 1 year after transcatheter mitral-valve repair compared to patients treated with optimal medical treatment [ 102 ]. Preserved baseline GLS and GCW appeared to be able to predict reduction in LVEDV and LVESV, respectively, after successful MV repair proving to be potential new markers of positive LV remodeling, which could allow better patients’ selection for this procedure [ 102 ]. In addition, patients who were treated with a MitraClip® showed stable GWE as well as improved GCW and GWI at follow-up, reflecting better cardiac energetics in contrast to patients treated with optical medical treatment [ 102 ].…”

Multimodality imaging for preprocedural planning of percutaneous mitral valve repair: a comprehensive review

“…Speckle tracking imaging represents a more sensitive tool to assess LV dysfunction than ejection fraction and may improve the selection of candidates for the procedure. Recently, baseline GLS value <-9% has been demonstrated to be an independent predictor of LV reverse remodeling and clinical outcomes in patients with secondary MR treated with MitraClip [7] .…”