Reduction of sleep-disordered breathing following effective percutaneous mitral valve repair with the MitraClip system

  • Jens Spiesshoefer
  • Maximilian Spieker
  • Simon Klose
  • Stefanie Keymel
  • Matthias Boentert
  • Stefan Krüger
  • Patrick Horn
  • Malte Kelm
  • Ralf WestenfeldEmail author
Sleep Breathing Physiology and Disorders • Original Article



This study tested the hypothesis that a reduction of pulmonary congestion achieved by a reduction of mitral regurgitation (MR) severity in heart failure (HF) patients is associated with reduced event lengths of sleep-disordered breathing (SDB).


We prospectively enrolled 20 consecutive HF patients who underwent MitraClip implantation. Patients underwent cardiorespiratory polygraphic recording prior to and after percutaneous mitral valve repair (PMVR). Beyond routinely established indicators of apneas and hypopneas per hour (respiratory event index), we manually analyzed apnea event lengths.


MitraClip implantation led to marked reduction of MR severity and a reduction in left atrial pressure. These hemodynamic changes were accompanied by changes in SDB: the subtype of SDB switched from CSA to OSA in 4 patients. Likewise, quantitative indicators of SDB were altered in both forms of SDB with a reduction in circulatory delay (CSA 38 ± 14 vs. 33 ± 15 s.; p = 0.002 and OSA 34 ± 9 vs. 28 ± 6 s.; p = 0.02) and a corresponding reduction in ventilation lengths in CSA patients (42 ± 15 vs. 37 ± 13 s.; p = 0.05).


A reduction of pulmonary congestion as achieved by a decrease of left atrial pressure through successful MitraClip implantation is associated with a reduction in respiratory event lengths, further pointing towards a relation between SDB and HF.


Percutaneous mitral valve repair MitraClip Sleep-disordered breathing Respiratory physiology 



Respiratory event index


Apnea length


Circulatory delay


Cycle length


Central sleep apnea


Cheyne-Stokes respiration


Effective regurgitant orifice area


Heart failure


Left ventricular ejection fraction


Mitral regurgitation


New York Heart Association


Obstructive sleep apnea


Proximal isovelocity surface area


Polygraphic recording


Percutaneous mitral valve repair


Regurgitation volume


Sleep-disordered breathing


Right ventricular end-diastolic diameter




Ventilation length



We gratefully acknowledge Miss Cettolines’ technical help in collecting our data and Mister Perez’ help in analyzing the sleep studies.


JS has been supported by the ‘Else-Kröner-Fresenius Stiftung’ (Grant A109) and by ‘Kommission für Innovative Medizinische Forschung an der Medizinischen Fakultät Muenster’ (IMF Grant SP 11 18 15) outside this work. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. This does not alter our adherence to Journal policies on sharing data and materials.

Compliance with ethical standards

Conflict of interest

JS has been supported by the ‘Else-Kröner-Fresenius Stiftung’ (Grant A109) and by ‘Kommission für Innovative Medizinische Forschung an der Medizinischen Fakultät Muenster’ (IMF Grant SP 11 18 15) outside this work.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the local Ethics Committee of the University of Düsseldorf.

Informed consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Kasai T, Floras JS, Bradley TD (2012) Sleep apnea and cardiovascular disease: a bidirectional relationship. Circulation 126:1495–1510. CrossRefGoogle Scholar
  2. 2.
    Oldenburg O, Lamp B, Faber L, Teschler H, Horstkotte D, Töpfer V (2007) Sleep-disordered breathing in patients with symptomatic heart failure. A contemporary study of prevalence in and characteristics of 700 patients. Eur J Heart Fail 9:251–257. CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Bradley TD, Floras JS (2003) Sleep apnea and heart failure—part II: central sleep apnea. Circulation 107:1822–1826. CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Harada D, Joho S, Oda Y, Hirai T, Asanoi H, Inoue H (2011) Autonomic neuroscience : basic and clinical short term effect of adaptive servo-ventilation on muscle sympathetic nerve activity in patients with heart failure. Auton Neurosci Basic Clin 161:95–102. CrossRefGoogle Scholar
  5. 5.
    Cowie MR, Woehrle H, Wegscheider K, Angermann C, d'Ortho MP, Erdmann E, Levy P, Simonds A, Somers VK, Zannad F, Teschler H (2013) Rationale and design of the SERVE-HF study: treatment of sleep-disordered breathing with predominant central sleep apnoea with adaptive servo-ventilation in patients with chronic heart failure. Eur J Heart Fail 15:937–943. CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Efken C, Bitter T, Prib N, Horstkotte D, Oldenburg O (2013) Obstructive sleep apnoea: longer respiratory event lengths in patients with heart failure. Eur Respir J 41:1340–1346. CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Baumgartner H, Falk V, Bax JJ, de Bonis M, Hamm C, Holm PJ, Iung B, Lancellotti P, Lansac E, Rodriguez Muñoz D, Rosenhek R, Sjögren J, Tornos Mas P, Vahanian A, Walther T, Wendler O, Windecker S, Zamorano JL, ESC Scientific Document Group, Roffi M, Alfieri O, Agewall S, Ahlsson A, Barbato E, Bueno H, Collet JP, Coman IM, Czerny M, Delgado V, Fitzsimons D, Folliguet T, Gaemperli O, Habib G, Harringer W, Haude M, Hindricks G, Katus HA, Knuuti J, Kolh P, Leclercq C, McDonagh TA, Piepoli MF, Pierard LA, Ponikowski P, Rosano GMC, Ruschitzka F, Shlyakhto E, Simpson IA, Sousa-Uva M, Stepinska J, Tarantini G, Tchétché D, Aboyans V, Windecker S, Aboyans V, Agewall S, Barbato E, Bueno H, Coca A, Collet JP, Coman IM, Dean V, Delgado V, Fitzsimons D, Gaemperli O, Hindricks G, Iung B, Jüni P, Katus HA, Knuuti J, Lancellotti P, Leclercq C, McDonagh T, Piepoli MF, Ponikowski P, Richter DJ, Roffi M, Shlyakhto E, Simpson IA, Zamorano JL, Kzhdryan HK, Mascherbauer J, Samadov F, Shumavets V, Camp GV, Lončar D, Lovric D, Georgiou GM, Linhartova K, Ihlemann N, Abdelhamid M, Pern T, Turpeinen A, Srbinovska-Kostovska E, Cohen A, Bakhutashvili Z, Ince H, Vavuranakis M, Temesvári A, Gudnason T, Mylotte D, Kuperstein R, Indolfi C, Pya Y, Bajraktari G, Kerimkulova A, Rudzitis A, Mizariene V, Lebrun F, Demarco DC, Oukerraj L, Bouma BJ, Steigen TK, Komar M, de Moura Branco LM, Popescu BA, Uspenskiy V, Foscoli M, Jovovic L, Simkova I, Bunc M, de Prada JAV, Stagmo M, Kaufmann BA, Mahdhaoui A, Bozkurt E, Nesukay E, Brecker SJD (2017) 2017 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J 38:2739–2786. CrossRefPubMedGoogle Scholar
  8. 8.
    Wedewardt J, Bitter T, Prinz C, Faber L, Horstkotte D, Oldenburg O (2010) Cheyne-Stokes respiration in heart failure: cycle length is dependent on left ventricular ejection fraction. Sleep Med 11:137–142. CrossRefPubMedGoogle Scholar
  9. 9.
    Bradley TD, Floras JS (2009) Obstructive sleep apnoea and its cardiovascular consequences. Lancet 373:82–93. CrossRefPubMedGoogle Scholar
  10. 10.
    Lang RM, Badano LP, Mor-avi V et al (2015) Recommendations for cardiac chamber quantification by echocardiography in adults : an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 28:1–39.e14. CrossRefPubMedGoogle Scholar
  11. 11.
    Berry RB, Brooks R, Gamaldo CE et al (2013) The AASM manual for the scoring of sleep and associated events. Am Acad Sleep Med 53:1689–1699. CrossRefGoogle Scholar
  12. 12.
    Berry RB, Budhiraja R, Gottlieb DJ, Gozal D, Iber C, Kapur VK, Marcus CL, Mehra R, Parthasarathy S, Quan SF, Redline S, Strohl KP, Ward SLD, Tangredi MM (2012) Rules for scoring respiratory events in sleep: update of the 2007 AASM manual for the scoring of sleep and associated events. J Clin Sleep Med.
  13. 13.
    Collop NA, Tracy SL, Kapur V, Mehra R, Kuhlmann D, Fleishman SA, Ojile JM (2011) Obstructive sleep apnea devices for out-of-center (OOC) testing: technology evaluation. J Clin Sleep Med 7(5):531–548PubMedPubMedCentralGoogle Scholar
  14. 14.
    Muza RT (2015) Central sleep apnoea—a clinical review. J Thorac Dis 7:930–937. CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Ryan CM, Bradley TD (2005) Periodicity of obstructive sleep apnea in patients with and without heart failure. Chest 127(2):536–542CrossRefPubMedGoogle Scholar
  16. 16.
    Kasai T, Motwani SS, Yumino D, Mak S, Newton GE, Bradley TD (2012) Differing relationship of nocturnal fluid shifts to sleep apnea in men and women with heart failure. Circ Hear Fail 5:467–474. CrossRefGoogle Scholar
  17. 17.
    Fox H, Bitter T, Horstkotte D, Oldenburg O (2016) Cardioversion of atrial fibrillation or atrial flutter into sinus rhythm reduces nocturnal central respiratory events and unmasks obstructive sleep apnoea. Clin Res Cardiol 105:451–459. CrossRefPubMedGoogle Scholar
  18. 18.
    Bitter T, Horstkotte D, Basic K et al (2016) Improvements of central respiratory events , Cheyne e Stokes respiration and oxygenation in patients hospitalized for acute decompensated heart failure. Sleep Med 28:15–19. CrossRefGoogle Scholar
  19. 19.
    Vazir A, Hastings PC, Morrell MJ, Pepper J, Henein MY, Westaby S, Poole-Wilson PA, Cowie MR, Simonds AK (2010) Resolution of central sleep apnoea following implantation of a left ventricular assist device. Int J Cardiol 138:317–319. CrossRefPubMedGoogle Scholar
  20. 20.
    Fox H, Bitter T, Horstkotte D, Oldenburg O (2017) Resolution of cheyne-stokes respiration after treatment of heart failure with sacubitril/valsartan: a first case report. Cardiol 137:96–99. CrossRefGoogle Scholar
  21. 21.
    Fox H, Puehler T, Schulz U, Bitter T, Horstkotte D, Oldenburg O (2014) Delayed recovery from Cheyne-Stokes respiration in heart failure after successful cardiac transplantation: a case report. Transplant Proc 46:2462–2463. CrossRefPubMedGoogle Scholar
  22. 22.
    Takahashi M, Kasai T, Dohi T, Maeno KI, Kasagi S, Kawana F, Ishiwata S, Narui K (2011) Conversion from predominant central sleep apnea to obstructive sleep apnea following valvuloplasty in a patient with mitral regurgitation. J Clin Sleep Med 7:523–525. CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Yasuma F, Hayashi H, Noda S et al (1995) A case of mitral regurgitation whose nocturnal periodic breathing was improved after mitral valve replacement. Jpn Heart J 36:267–272CrossRefPubMedGoogle Scholar
  24. 24.
    Lorenzi-Filho G, Dajani HR, Leung RS, Floras JS, Bradley TD (1999) Entrainment of blood pressure and heart rate oscillations by periodic breathing. Am J Respir Crit Care Med 159(4 Pt 1):1147–1154CrossRefPubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  • Jens Spiesshoefer
    • 1
    • 2
  • Maximilian Spieker
    • 2
  • Simon Klose
    • 2
  • Stefanie Keymel
    • 2
  • Matthias Boentert
    • 1
  • Stefan Krüger
    • 2
    • 3
  • Patrick Horn
    • 2
  • Malte Kelm
    • 2
    • 4
  • Ralf Westenfeld
    • 2
    Email author
  1. 1.Institute for Sleep Medicine and Neuromuscular DisordersUniversity Hospital of MuensterMuensterGermany
  2. 2.Division of Cardiology, Pulmonology and Vascular MedicineHeinrich-Heine University Medical Center DuesseldorfDüsseldorfGermany
  3. 3.Clinic for Pulmonology, Cardiology and Intensive Care MedicineFlorence-Nightingale-HospitalDuesseldorfGermany
  4. 4.CARID Cardiovascular Research Institute DuesseldorfDüsseldorfGermany

Personalised recommendations