Impact of left-heart myopathy on mitral valve stenosis assessment and interventional outcomes: an in-silico trial

Abstract

Aims The shift in mitral stenosis (MS) aetiology from rheumatic to calcific valve disease complicates distinguishing valve-related from myocardial-driven haemodynamic abnormalities. This study examines how left-heart myopathy influences flow velocity-based echocardiographic MS severity assessment and evaluates haemodynamic changes following mitral valve (MV) intervention at rest and during exercise.Methods and results The CircAdapt biophysical model was used to create a virtual cohort with varying MS severity, left ventricular (LV) compliance, and left atrial (LA) function. Mean gradient (MG) was evaluated alongside left-heart pressures at rest and during exercise. To study acute haemodynamic effects of MV intervention, the mitral valve's effective orifice area was restored to 5.9 cm(2). MG showed variation of 1 mmHg attributable to left-heart myopathy. Following virtual MV intervention for clinically significant MS, mean left atrial pressure (mLAP) decreased by 50% in patients with preserved myocardial function but remained elevated in those with LV and LA dysfunction due to persistently elevated LV end-diastolic pressure, resulting in persistently impaired exercise capacity.Conclusion Virtual patient cohorts suggest that MV intervention reduces MG but may not normalize mLAP in patients with impaired LV and LA function. Persistent myocardial dysfunction may limit both symptomatic and exercise capacity improvement, despite successful intervention. As percutaneous treatment options expand, distinguishing myocardial from valve-driven abnormalities is essential for accurate assessment, patient selection, and optimizing outcomes.