51
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Rossi A, Dandale R, Nistri S, Faggiano P, Cicoira M, Benfari G, Onorati F, Santini F, Messika-Zeitoun D, Enriquez-Sarano M, Vassanelli C. Functional mitral regurgitation in patients with aortic stenosis: prevalence, clinical correlates and pathophysiological determinants: a quantitative prospective study. Eur Heart J Cardiovasc Imaging 2014; 15:631-636. [DOI: 10.1093/ehjci/jet269] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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52
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Intraoperative Transesophageal Echocardiography for Surgical Repair of Mitral Regurgitation. J Am Soc Echocardiogr 2014; 27:345-66. [DOI: 10.1016/j.echo.2014.01.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Indexed: 12/14/2022]
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53
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Golba K, Mokrzycki K, Drozdz J, Cherniavsky A, Wrobel K, Roberts BJ, Haddad H, Maurer G, Yii M, Asch FM, Handschumacher MD, Holly TA, Przybylski R, Kron I, Schaff H, Aston S, Horton J, Lee KL, Velazquez EJ, Grayburn PA. Mechanisms of functional mitral regurgitation in ischemic cardiomyopathy determined by transesophageal echocardiography (from the Surgical Treatment for Ischemic Heart Failure Trial). Am J Cardiol 2013; 112:1812-8. [PMID: 24035166 DOI: 10.1016/j.amjcard.2013.07.047] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 07/24/2013] [Accepted: 07/24/2013] [Indexed: 11/27/2022]
Abstract
The mechanisms underlying functional mitral regurgitation (MR) and the relation between mechanism and severity of MR have not been evaluated in a large, multicenter, randomized controlled trial. Transesophageal echocardiography (TEE) was performed in 215 patients at 17 centers in the Surgical Treatment for Ischemic Heart Failure (STICH) trial. Both 2-dimensional (n = 215) and 3-dimensional (n = 81) TEEs were used to assess multiple quantitative measurements of the mechanism and severity of MR. By 2-dimensional TEE, leaflet tenting area, anterior and posterior leaflet angles, mitral annulus diameter, left ventricular (LV) end-systolic volume index, LV ejection fraction (LVEF), and sphericity index (p <0.05 for all) were significantly different across MR grades. By 3-dimensional TEE, mitral annulus area, leaflet tenting area, LV end-systolic volume index, LVEF, and sphericity index (p <0.05 for all) were significantly different across MR grades. A multivariate analysis showed a trend for annulus area (p = 0.069) and LV end-systolic volume index (p = 0.071) to predict effective regurgitant orifice area and for annulus area (p = 0.018) and LV end-systolic volume index (p = 0.073) to predict vena contracta area. In the STICH trial, multiple quantitative parameters of the mechanism of functional MR are related to MR severity. The mechanism of functional MR in ischemic cardiomyopathy is heterogeneous, but no single variable stands out as a strong predictor of quantitative severity of MR.
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54
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Uretsky S, Chaudhry FA, Gillam L, Gurram S, Bonda SLK, Ponnam H, Bader E, Thota N, Cohen R, Supariwala A, Wolff SD. A novel technique to quantify the instantaneous mitral regurgitant rate. J Cardiovasc Magn Reson 2013; 15:74. [PMID: 24119924 PMCID: PMC3766041 DOI: 10.1186/1532-429x-15-74] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Accepted: 08/22/2013] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The systolic variation of mitral regurgitation (MR) is a pitfall in its quantification. Current recommendations advocate using quantitative echocardiographic techniques that account for this systolic variation. While prior studies have qualitatively described patterns of systolic variation no study has quantified this variation. METHODS This study includes 41 patients who underwent cardiovascular magnetic resonance (CMR) evaluation for the assessment of MR. Systole was divided into 3 equal parts: early, mid, and late. The MR jets were categorized as holosystolic, early, or late based on the portions of systole the jet was visible. The aortic flow and left ventricular stroke volume (LVSV) acquired by CMR were plotted against time. The instantaneous regurgitant rate was calculated for each third of systole as the difference between the LVSV and the aortic flow. RESULTS The regurgitant rate varied widely with a 1.9-fold, 3.4-fold, and 1.6-fold difference between the lowest and highest rate in patients with early, late, and holosystolic jets respectively. There was overlap of peak regurgitant rates among patients with mild, moderate and severe MR. The greatest variation of regurgitant rate was seen among patients with mild MR. CONCLUSION CMR can quantify the systolic temporal variation of MR. There is significant variation of the mitral regurgitant rate even among patients with holosystolic MR jets. These findings highlight the need to use quantitative measures of MR severity that take into consideration the temporal variation of MR.
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Affiliation(s)
- Seth Uretsky
- Department of Medicine, Division of Cardiology, St. Luke’s-Roosevelt Hospital Center, 1111 Amsterdam Ave, Cardiology 3rd Floor, New York, NY 10025, USA
| | - Farooq A Chaudhry
- Department of Cardiology, Mount Sinai School of Medicine, New York, NY USA
| | - Linda Gillam
- Department of Cardiovascular Medicine, Morristown Medical Center, Morristown, NJ USA
| | - Srinivasa Gurram
- Department of Medicine, Division of Cardiology, St. Luke’s-Roosevelt Hospital Center, 1111 Amsterdam Ave, Cardiology 3rd Floor, New York, NY 10025, USA
| | - Sri Lakshmi Kala Bonda
- Department of Medicine, Division of Cardiology, St. Luke’s-Roosevelt Hospital Center, 1111 Amsterdam Ave, Cardiology 3rd Floor, New York, NY 10025, USA
| | - Harikrishna Ponnam
- Department of Medicine, Division of Cardiology, St. Luke’s-Roosevelt Hospital Center, 1111 Amsterdam Ave, Cardiology 3rd Floor, New York, NY 10025, USA
| | - Eric Bader
- Department of Medicine, Division of Cardiology, St. Luke’s-Roosevelt Hospital Center, 1111 Amsterdam Ave, Cardiology 3rd Floor, New York, NY 10025, USA
| | - Naganath Thota
- Department of Medicine, Division of Cardiology, St. Luke’s-Roosevelt Hospital Center, 1111 Amsterdam Ave, Cardiology 3rd Floor, New York, NY 10025, USA
| | - Randy Cohen
- Department of Medicine, Division of Cardiology, St. Luke’s-Roosevelt Hospital Center, 1111 Amsterdam Ave, Cardiology 3rd Floor, New York, NY 10025, USA
| | - Azhar Supariwala
- Department of Medicine, Division of Cardiology, St. Luke’s-Roosevelt Hospital Center, 1111 Amsterdam Ave, Cardiology 3rd Floor, New York, NY 10025, USA
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55
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Konstantinou DM, Papadopoulou K, Giannakoulas G, Kamperidis V, Dalamanga EG, Damvopoulou E, Parcharidou DG, Karamitsos TD, Karvounis HI. Determinants of functional mitral regurgitation severity in patients with ischemic cardiomyopathy versus nonischemic dilated cardiomyopathy. Echocardiography 2013; 31:21-8. [PMID: 23930844 DOI: 10.1111/echo.12304] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
AIMS Functional mitral regurgitation (MR) is prevalent among patients with left ventricular (LV) dysfunction and is associated with a poorer prognosis. Our aim was to assess the primary determinants of MR severity in patients with ischemic cardiomyopathy (ICM) and nonischemic dilated cardiomyopathy (DCM). METHODS AND RESULTS Patients with functional MR secondary to ICM (n = 55) and DCM (n = 48) were prospectively enrolled. Effective regurgitant orifice (ERO) area, global LV remodeling, regional wall-motion abnormalities, and mitral apparatus deformity indices were assessed utilizing conventional and tissue Doppler echocardiography. ICM patients had more severe MR compared with DCM patients despite similar ejection fraction and functional status (ERO = 0.16 ± 0.08 cm(2) vs. ERO = 0.12 ± 0.70 cm(2) , respectively, P = 0.002). Regional myocardial systolic velocities in mid-inferior and mid-lateral wall were negatively correlated with ERO in ICM and DCM patients, respectively. Multivariate analysis identified coaptation height as the only independent determinant of ERO in both groups. In a subset of ICM patients (n = 9) with relatively high ERO despite low coaptation height, a higher prevalence of left bundle branch block was detected (88.9% vs. 46.7%, P = 0.02). CONCLUSIONS Functional MR severity was chiefly determined by the extent of mitral apparatus deformity, and coaptation height can provide a rapid estimation of MR severity in heart failure patients. Additional contributory mechanisms in ICM patients include depressed myocardial systolic velocities in posteromedial papillary muscle attaching site and evidence of global LV dyssynchrony.
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Affiliation(s)
- Dimitrios M Konstantinou
- First Department of Cardiology, AHEPA University Hospital, Aristotle University Medical School, Thessaloniki, Greece; Heart Failure Care Group, Royal Brompton Hospital, London, United Kingdom
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56
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Beaudoin J, Thai WE, Wai B, Handschumacher MD, Levine RA, Truong QA. Assessment of mitral valve adaptation with gated cardiac computed tomography: validation with three-dimensional echocardiography and mechanistic insight to functional mitral regurgitation. Circ Cardiovasc Imaging 2013; 6:784-9. [PMID: 23873402 DOI: 10.1161/circimaging.113.000561] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Mitral valve (MV) enlargement is a compensatory mechanism capable of preventing functional mitral regurgitation (FMR) in dilated ventricles. Total leaflet area and its relation with closure area measured by 3-dimensional (3D) echocardiography have been related to FMR. Whether these parameters can be assessed with other imaging modalities is not known. Our objectives are to compare cardiac computed tomography (CT)-based measurements of MV leaflets with 3D echocardiography and determine the relationship of these metrics to the presence of FMR. METHODS AND RESULTS We used 2 cohorts of patients who had cardiac CT to measure MV total leaflet, closure, and annulus areas. In cohort 1 (26 patients), we validated these CT metrics to 3D echocardiography. In cohort 2 (66 patients), we assessed the relation of MV size with the presence of FMR in 3 populations: heart failure with FMR, heart failure without FMR, and normal controls. Cardiac CT and 3D echocardiography produced similar results for total leaflet (R(2)=0.97), closure (R(2)=0.89), and annulus areas (R(2)=0.84). MV size was the largest in heart failure without FMR compared with controls and patients with FMR (9.1 ± 1.7 versus 7.5 ± 1.0 versus 8.1 ± 0.9 cm(2)/m(2); P<0.01). Patients with FMR had reduced ratios of total leaflet to closure areas and total leaflet to annulus areas when compared with patients without FMR (P<0.01). CONCLUSIONS MV size measured by CT is comparable with 3D echocardiography. MV enlargement in cardiomyopathy suggests leaflet adaptation. Patients with FMR have inadequate adaptation as reflected by decreased ratios of leaflet area and areas determined by ventricle size (annulus and closure areas). These measurements provide additional insight into the mechanism of FMR.
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Affiliation(s)
- Jonathan Beaudoin
- Cardiac MR PET CT Program and Cardiac Ultrasound Laboratory, Division of Cardiology, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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57
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Yap CH, Thiele K, Wei Q, Santhanakrishnan A, Khiabani R, Cardinale M, Salgo IS, Yoganathan AP. Novel method of measuring valvular regurgitation using three-dimensional nonlinear curve fitting of Doppler signals within the flow convergence zone. IEEE TRANSACTIONS ON ULTRASONICS, FERROELECTRICS, AND FREQUENCY CONTROL 2013; 60:1295-1311. [PMID: 25004499 DOI: 10.1109/tuffc.2013.2704] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Mitral valve regurgitation (MR) is among the most prevalent and significant valve problems in the Western world. Echocardiography plays a significant role in the diagnosis of degenerative valve disease. However, a simple and accurate means of quantifying MR has eluded both the technical and clinical ultrasound communities. Perhaps the best clinically accepted method used today is the 2-D proximal isovelocity surface area (PISA) method. In this study, a new quantification method using 3-D color Doppler ultrasound, called the field optimization method (FOM), is described. For each 3-D color flow volume, this method iterates on a simple fluid dynamics model that, when processed by a model of ultrasound physics, attempts to agree with the observed velocities in a least-squares sense. The output of this model is an estimate of the regurgitant flow and the location of its associated orifice. To validate the new method, in vitro experiments were performed using a pulsatile flow loop and different geometric orifices. Measurements from the FOM and from 2-D PISA were compared with measurements made with a calibrated ultrasonic flow probe. Results show that the new method has a higher correlation to the truth data and has lower inter- and intra-observer variability than the 2-D PISA method.
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58
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Abstract
Echocardiography is undoubtedly one of the main tools used in assessment of mitral regurgitation (MR) because it allows characterization of valvular morphology, assessment of the severity of the regurgitation, and its secondary effects. In this article we present an overview of the echocardiographic assessment of MR.
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59
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Topilsky Y, Vaturi O, Watanabe N, Bichara V, Nkomo VT, Michelena H, Le Tourneau T, Mankad SV, Park S, Capps MA, Suri R, Pislaru SV, Maalouf J, Yoshida K, Enriquez-Sarano M. Real-time 3-dimensional dynamics of functional mitral regurgitation: a prospective quantitative and mechanistic study. J Am Heart Assoc 2013; 2:e000039. [PMID: 23727698 PMCID: PMC3698758 DOI: 10.1161/jaha.113.000039] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background Three‐dimensional transthoracic echocardiography (3D‐TTE) with dedicated software permits quantification of mitral annulus dynamics and papillary muscle motion throughout the cardiac cycle. Methods and Results Mitral apparatus 3D‐TTE was acquired in controls (n=42), patients with left ventricle dysfunction and functional mitral regurgitation (LVD‐FMR; n=43) or without FMR (LVD‐noMR, n=35). Annulus in both normal and LVD‐noMR subjects displayed saddle shape accentuation in early‐systole (ratio of height to intercommissural diameter, 10.6±3.7 to 13.5±4.0 in normal and 9.1±4.3 to 12.6±3.6 in LVD‐noMR; P<0.001 for diastole to early‐systole motion, P=NS between those groups). In contrast, saddle shape was unchanged from diastole in FMR patients (10.0±6.4 to 8.0±5.2; P=NS, P<0.05 compared to both other groups). Papillary tips moved symmetrically towards to the midanterior annulus in control and LVD‐noMR subjects, maintaining constant ratio of the distances between both tips to midannulus (PtAR) throughout systole. In LVD‐FMR patients midsystolic posterior papillary tip to anterior annulus distance was increased, resulting in higher PtAR (P=0.05 compared to both other groups). Mechanisms of early‐ and midsystolic FMR differed between different etiologies of LV dysfunction. In patients with anterior MI and global dysfunction annular function and dilatation were the dominant parameters, while papillary muscle motion was the predominant determinant of FMR in patients with inferior MI. Conclusions Inadequate early‐systolic annular contraction and saddle‐shape accentuation in patients with impaired LV contribute to early–mitral incompetency. Asymmetric papillary tip movement towards the midanterior annulus is a major determinant of mid‐ and late‐systolic functional mitral regurgitation.
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Affiliation(s)
- Yan Topilsky
- Division of Cardiovascular Diseases, Tel Aviv Medical Center, Rochester, MN 55905, USA
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60
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Thavendiranathan P, Liu S, Datta S, Rajagopalan S, Ryan T, Igo SR, Jackson MS, Little SH, De Michelis N, Vannan MA. Quantification of Chronic Functional Mitral Regurgitation by Automated 3-Dimensional Peak and Integrated Proximal Isovelocity Surface Area and Stroke Volume Techniques Using Real-Time 3-Dimensional Volume Color Doppler Echocardiography. Circ Cardiovasc Imaging 2013; 6:125-33. [DOI: 10.1161/circimaging.112.980383] [Citation(s) in RCA: 100] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The aim of this study was to test the accuracy of an automated 3-dimensional (3D) proximal isovelocity surface area (PISA) (in vitro and patients) and stroke volume technique (patients) to assess mitral regurgitation (MR) severity using real-time volume color flow Doppler transthoracic echocardiography.
Methods and Results—
Using an in vitro model of MR, the effective regurgitant orifice area and regurgitant volume (RVol) were measured by the PISA technique using 2-dimensional (2D) and 3D (automated true 3D PISA) transthoracic echocardiography. The mean anatomic regurgitant orifice area (0.35±0.10 cm
2
) was underestimated to a greater degree by the 2D (0.12±0.05 cm
2
) than the 3D method (0.25±0.10 cm
2
;
P
<0.001 for both). Compared with the flowmeter (40±14 mL), the RVol by 2D PISA (20±19 mL) was underestimated (
P
<0.001), but the 3D peak (43±16 mL) and integrated PISA-based (38±14 mL) RVol were comparable (
P
>0.05 for both). In patients (n=30, functional MR), 3D effective regurgitant orifice area correlated well with cardiac magnetic resonance imaging RVol
r
=0.84 and regurgitant fraction
r
=0.80. Compared with cardiac magnetic resonance imaging RVol (33±22 mL), the integrated PISA RVol (34±26 mL;
P
=0.42) was not significantly different; however, the peak PISA RVol was higher (48±27 mL;
P
<0.001). In addition, RVol calculated as the difference in automated mitral and aortic stroke volumes by real-time 3D volume color flow Doppler echocardiography was not significantly different from cardiac magnetic resonance imaging (34±21 versus 33±22 mL;
P
=0.33).
Conclusions—
Automated real-time 3D volume color flow Doppler based 3D PISA is more accurate than the 2D PISA method to quantify MR. In patients with functional MR, the 3D RVol by integrated PISA is more accurate than a peak PISA technique. Automated 3D stroke volume measurement can also be used as an adjunctive method to quantify MR severity.
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Affiliation(s)
- Paaladinesh Thavendiranathan
- From the Ohio State University, Columbus, OH (P.T., S.L., S.R., T.R., M.A.V.); Siemens Medical Solutions USA Inc, Mountain View, CA (S.D.); The Methodist DeBakey Heart and Vascular Center, Houston, TX (S.R.I., M.S.J., S.H.L); and University of California Irvine, Orange, CA (N.D.M.)
| | - Shizhen Liu
- From the Ohio State University, Columbus, OH (P.T., S.L., S.R., T.R., M.A.V.); Siemens Medical Solutions USA Inc, Mountain View, CA (S.D.); The Methodist DeBakey Heart and Vascular Center, Houston, TX (S.R.I., M.S.J., S.H.L); and University of California Irvine, Orange, CA (N.D.M.)
| | - Saurabh Datta
- From the Ohio State University, Columbus, OH (P.T., S.L., S.R., T.R., M.A.V.); Siemens Medical Solutions USA Inc, Mountain View, CA (S.D.); The Methodist DeBakey Heart and Vascular Center, Houston, TX (S.R.I., M.S.J., S.H.L); and University of California Irvine, Orange, CA (N.D.M.)
| | - Sanjay Rajagopalan
- From the Ohio State University, Columbus, OH (P.T., S.L., S.R., T.R., M.A.V.); Siemens Medical Solutions USA Inc, Mountain View, CA (S.D.); The Methodist DeBakey Heart and Vascular Center, Houston, TX (S.R.I., M.S.J., S.H.L); and University of California Irvine, Orange, CA (N.D.M.)
| | - Thomas Ryan
- From the Ohio State University, Columbus, OH (P.T., S.L., S.R., T.R., M.A.V.); Siemens Medical Solutions USA Inc, Mountain View, CA (S.D.); The Methodist DeBakey Heart and Vascular Center, Houston, TX (S.R.I., M.S.J., S.H.L); and University of California Irvine, Orange, CA (N.D.M.)
| | - Stephen R. Igo
- From the Ohio State University, Columbus, OH (P.T., S.L., S.R., T.R., M.A.V.); Siemens Medical Solutions USA Inc, Mountain View, CA (S.D.); The Methodist DeBakey Heart and Vascular Center, Houston, TX (S.R.I., M.S.J., S.H.L); and University of California Irvine, Orange, CA (N.D.M.)
| | - Matthew S. Jackson
- From the Ohio State University, Columbus, OH (P.T., S.L., S.R., T.R., M.A.V.); Siemens Medical Solutions USA Inc, Mountain View, CA (S.D.); The Methodist DeBakey Heart and Vascular Center, Houston, TX (S.R.I., M.S.J., S.H.L); and University of California Irvine, Orange, CA (N.D.M.)
| | - Stephen H. Little
- From the Ohio State University, Columbus, OH (P.T., S.L., S.R., T.R., M.A.V.); Siemens Medical Solutions USA Inc, Mountain View, CA (S.D.); The Methodist DeBakey Heart and Vascular Center, Houston, TX (S.R.I., M.S.J., S.H.L); and University of California Irvine, Orange, CA (N.D.M.)
| | - Nathalie De Michelis
- From the Ohio State University, Columbus, OH (P.T., S.L., S.R., T.R., M.A.V.); Siemens Medical Solutions USA Inc, Mountain View, CA (S.D.); The Methodist DeBakey Heart and Vascular Center, Houston, TX (S.R.I., M.S.J., S.H.L); and University of California Irvine, Orange, CA (N.D.M.)
| | - Mani A. Vannan
- From the Ohio State University, Columbus, OH (P.T., S.L., S.R., T.R., M.A.V.); Siemens Medical Solutions USA Inc, Mountain View, CA (S.D.); The Methodist DeBakey Heart and Vascular Center, Houston, TX (S.R.I., M.S.J., S.H.L); and University of California Irvine, Orange, CA (N.D.M.)
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61
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Ennezat PV, Maréchaux S, Pibarot P, Le Jemtel TH. Secondary Mitral Regurgitation in Heart Failure with Reduced or Preserved Left Ventricular Ejection Fraction. Cardiology 2013; 125:110-117. [DOI: 10.1159/000350356] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Secondary mitral regurgitation (MR) has been extensively studied in heart failure due to reduced ejection fraction. In contrast, the occurrence and the pathogenesis of secondary MR are much less known in heart failure with preserved ejection fraction (HFpEF). The present review aimed at describing this common but ignored feature of HFpEF.
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62
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Affiliation(s)
- Paul A Grayburn
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX 75226, USA.
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63
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Moraldo M, Cecaro F, Shun-Shin M, Pabari PA, Davies JE, Xu XY, Hughes AD, Manisty C, Francis DP. Evidence-based recommendations for PISA measurements in mitral regurgitation: systematic review, clinical and in-vitro study. Int J Cardiol 2012; 168:1220-8. [PMID: 23245796 PMCID: PMC3819991 DOI: 10.1016/j.ijcard.2012.11.059] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Revised: 09/06/2012] [Accepted: 11/11/2012] [Indexed: 11/05/2022]
Abstract
Background Guidelines for quantifying mitral regurgitation (MR) using “proximal isovelocity surface area” (PISA) instruct operators to measure the PISA radius from valve orifice to Doppler flow convergence “hemisphere”. Using clinical data and a physically-constructed MR model we (A) analyse the actually-observed colour Doppler PISA shape and (B) test whether instructions to measure a “hemisphere” are helpful. Methods and results In part A, the true shape of PISA shells was investigated using three separate approaches. First, a systematic review of published examples consistently showed non-hemispherical, “urchinoid” shapes. Second, our clinical data confirmed that the Doppler-visualized surface is non-hemispherical. Third, in-vitro experiments showed that round orifices never produce a colour Doppler hemisphere. In part B, six observers were instructed to measure hemisphere radius rh and (on a second viewing) urchinoid distance (du) in 11 clinical PISA datasets; 6 established experts also measured PISA distance as the gold standard. rh measurements, generated using the hemisphere instruction significantly underestimated expert values (− 28%, p < 0.0005), meaning rh2 was underestimated by approximately 2-fold. du measurements, generated using the non-hemisphere instruction were less biased (+ 7%, p = 0.03). Finally, frame-to-frame variability in PISA distance was found to have a coefficient of variation (CV) of 25% in patients and 9% in in-vitro data. Beat-to-beat variability had a CV of 15% in patients. Conclusions Doppler-visualized PISA shells are not hemispherical: we should avoid advising observers to measure a hemispherical radius because it encourages underestimation of orifice area by approximately two-fold. If precision is needed (e.g. to detect changes reliably) multi-frame averaging is essential.
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Affiliation(s)
- Michela Moraldo
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, 59-61 North Wharf Road, London W21LA, UK.
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64
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Thavendiranathan P, Phelan D, Collier P, Thomas JD, Flamm SD, Marwick TH. Quantitative Assessment of Mitral Regurgitation. JACC Cardiovasc Imaging 2012; 5:1161-75. [DOI: 10.1016/j.jcmg.2012.07.013] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Revised: 07/12/2012] [Accepted: 07/23/2012] [Indexed: 11/28/2022]
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65
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Thavendiranathan P, Phelan D, Thomas JD, Flamm SD, Marwick TH. Quantitative Assessment of Mitral Regurgitation. J Am Coll Cardiol 2012; 60:1470-83. [DOI: 10.1016/j.jacc.2012.05.048] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 05/07/2012] [Accepted: 05/10/2012] [Indexed: 11/28/2022]
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66
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Liang YJ, Zhang Q, Fang F, Lee APW, Liu M, Yan BPY, Lam YY, Chan GCP, Yu CM. Incremental value of global systolic dyssynchrony in determining the occurrence of functional mitral regurgitation in patients with left ventricular systolic dysfunction. Eur Heart J 2012; 34:767-74. [PMID: 22613344 DOI: 10.1093/eurheartj/ehs078] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
AIMS The aim of this study was to assess the contribution of left ventricular (LV) systolic dyssynchrony to functional mitral regurgitation (MR). METHODS AND RESULTS Patients (n = 136) with LV systolic dysfunction (ejection fraction <50%) and at least mild MR were prospectively recruited. The effective regurgitant orifice area (EROA) was assessed by the proximal isovelocity surface area method. Left ventricular global systolic dyssynchrony [the maximal difference in time to peak systolic velocity among the 12 LV segments (Ts-Dif)] and regional systolic dyssynchrony (the delay between the anterolateral and posteromedial papillary muscle attaching sites) were assessed by tissue Doppler imaging. Left ventricular global and regional remodelling, systolic function, indices of mitral valvular and annular deformation were also measured. The size of the EROA correlated with the degrees of mitral deformation, LV remodelling, systolic function, and systolic dyssynchrony. By multivariate logistic regression analysis, the mitral valve tenting area (OR = 1.020, P < 0.001) and the Ts-Dif (OR = 1.011, P = 0.034) were independent determinants of significant functional MR (defined by EROA ≥20 mm(2)). From the receiver-operating characteristic curve, the tenting area of 2.7 cm(2) (sensitivity 83%, specificity 82%, AUC 0.86, P < 0.001) and the Ts-Dif of 85 ms (sensitivity 66%, specificity 72%, AUC 0.74, P < 0.001) were associated with significant functional MR. The assessment of Ts-Dif showed an incremental value over the mitral valve tenting area for determining functional MR (χ(2) = 53.92 vs.49.11, P = 0.028). CONCLUSION This cross-sectional study showed that LV global, but not regional systolic dyssynchrony, is a determinant of significant functional MR in patients with LV systolic dysfunction, and is incremental to the tenting area that is otherwise the strongest factor for mitral valve deformation.
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Affiliation(s)
- Yu-Jia Liang
- Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong SAR, Peoples' Republic of China
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67
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Matsumoto K, Tanaka H, Okajima K, Hayashi T, Kajiya T, Kawai H, Hirata KI. Relation between left ventricular morphology and reduction in functional mitral regurgitation by cardiac resynchronization therapy in patients with idiopathic dilated cardiomyopathy. Am J Cardiol 2011; 108:1327-34. [PMID: 21864818 DOI: 10.1016/j.amjcard.2011.06.052] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Revised: 06/27/2011] [Accepted: 06/27/2011] [Indexed: 11/30/2022]
Abstract
The presence of functional mitral regurgitation (MR) is considered a significant risk factor for poor clinical prognosis in patients with idiopathic dilated cardiomyopathy (IDC). The objectives of this study were to test the hypothesis that not only global but also local left ventricular (LV) remodeling, including the position of the papillary muscles, may contribute to the development of MR in patients with IDC and wide QRS durations and can be reversed with cardiac resynchronization therapy (CRT). Eighty-four subjects were studied, 44 patients with IDC who underwent CRT and 40 age- and gender-matched controls. The position of the posteromedial papillary muscle was similar in the 2 groups, whereas the position of the anterolateral papillary muscle in patients with IDC was displaced more posteriorly than in controls. Multivariate analysis revealed that reduction in coaptation height (β = 0.44, p <0.001) and LV dyssynchrony by speckle-tracking radial strain (β = 0.303, p <0.01) were independent determinants of reduction in MR 5 ± 2 days after CRT; in contrast, restoration of the position of the posteriorly displaced anterolateral papillary muscle (β = 0.50, p <0.001) and the increase in sphericity index (β = 0.440, p <0.001) were identified as independent determinants of reduction in MR 6 ± 1 months after CRT. In conclusion, asymmetric local LV remodeling was observed at baseline, and asymmetric local LV reverse remodeling was observed at long-term follow-up after CRT in patients with IDC. Furthermore, different parameters contribute to the reduction in MR observed at short- and long-term follow-up after CRT.
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Affiliation(s)
- Kensuke Matsumoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
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68
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Paiva RMP, Garcia-Guasch L, Manubens J, Montoya-Alonso JA. Proximal isovelocity surface area variability during systole in dogs with mitral valve prolapse. J Vet Cardiol 2011; 13:267-70. [PMID: 22036803 DOI: 10.1016/j.jvc.2011.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2011] [Revised: 08/02/2011] [Accepted: 08/20/2011] [Indexed: 11/19/2022]
Abstract
The proximal isovelocity surface area (PISA) principles and methodology have been described in human and veterinary medicine with special emphasis given to the ease and speed for the quantification of mitral regurgitation. Although limitations have been described in both human and veterinary medicine, in the case of veterinary medicine, clinical examples have not been well defined and in some cases have not been individually presented. The objective of this paper is to illustrate in a qualitative manner the echocardiographic existence of the dynamic behavior and variability of mitral regurgitation in dogs with mitral valve prolapse, a factor to be taken into consideration as a limitation inherent to the PISA technique.
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69
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Yared K, Lam KMT, Hung J. The use of exercise echocardiography in the evaluation of mitral regurgitation. Curr Cardiol Rev 2011; 5:312-22. [PMID: 21037848 PMCID: PMC2842963 DOI: 10.2174/157340309789317841] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2008] [Revised: 01/21/2009] [Accepted: 01/23/2009] [Indexed: 12/18/2022] Open
Abstract
Mitral regurgitation (MR) is the second most common valvular disease in western countries after aortic stenosis. Optimal management of patients with MR depends on the etiology of the regurgitation and is based predominantly on left ventricular function and functional status. Recent outcome studies report high risk subsets of asymptomatic patients with MR, and practice guidelines underscore the importance of a well-established estimation of exercise tolerance and recommend exercise testing to objectively assess functional status and hemodynamic factors.
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Affiliation(s)
- Kibar Yared
- Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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70
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Mechanistic Insights into Ischemic Mitral Regurgitation: Echocardiographic and Surgical Implications. J Am Soc Echocardiogr 2011; 24:707-19. [DOI: 10.1016/j.echo.2011.04.001] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2010] [Indexed: 11/24/2022]
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71
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Different Determinants of Improvement of Early and Late Systolic Mitral Regurgitation Contributed after Cardiac Resynchronization Therapy. J Am Soc Echocardiogr 2010; 23:1160-7. [DOI: 10.1016/j.echo.2010.07.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2010] [Indexed: 11/17/2022]
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72
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73
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Poglajen G, Harlander M, Geršak B. Ex Vivo Study of Altered Mitral Apparatus Geometry in Functional Mitral Regurgitation. Heart Surg Forum 2010; 13:E172-6. [DOI: 10.1532/hsf98.20091148] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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74
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Solis J, McCarty D, Levine RA, Handschumacher MD, Fernandez-Friera L, Chen-Tournoux A, Mont L, Vidal B, Singh JP, Brugada J, Picard MH, Sitges M, Hung J. Mechanism of decrease in mitral regurgitation after cardiac resynchronization therapy: optimization of the force-balance relationship. Circ Cardiovasc Imaging 2009; 2:444-50. [PMID: 19920042 PMCID: PMC2821680 DOI: 10.1161/circimaging.108.823732] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) has been shown to reduce functional mitral regurgitation (MR). It has been proposed that the mechanism of MR reduction relates to geometric change or, alternatively, changes in left ventricular (LV) contractile function. Normal mitral valve (MV) function relies on a balance between tethering and closing forces on the MV leaflets. Functional MR results from a derangement of this force-balance relationship, and CRT may be an important modulator of MV function by its ability to enhance the force-balance relationship on the MV. We hypothesized that CRT improves the comprehensive force balance acting on the valve, including favorable changes in both geometry and LV contractile function. METHODS AND RESULTS We examined the effect of CRT on 34 patients with functional MR before and after CRT (209+/-81 days). MR regurgitant volume, closing forces on MV (derived from Doppler transmitral pressure gradients), including dP/dt and a factor (closing pressure ratio) expressing how long the peak closing gradient is maintained over systole (closing pressure ratio=velocity time integral/MR peak velocityxmitral regurgitation time), and dyssynchrony by tissue Doppler were measured. End-diastolic volume, end-systolic volume, mitral valve annular area (MAA) and contraction (percent change in MAA from end-diastole to midsystole), leaflet closing area (leaflet area during valve closure), and tenting volume (volume under leaflets to annular plane) were measured by 3D echocardiography. After CRT, end-diastolic volume (253+/-111 versus 221+/-110 mL, P<0.001) and end-systolic volume (206+/-97 versus 167+/-91 mL, P<0.001) decreased and ejection fraction (19+/-6 versus 27+/-9%, P<0.001) increased. MR regurgitant volume decreased from 35+/-17 to 23+/-14 mL (P<0.001), MAA from 11.6+/-3.5 to 10.5+/-3.1 cm(2) (P<0.001), leaflet closing area from 15.4+/-5 to 13.7+/-3.8 cm(2) (P<0.001), and tenting volume from 5.7+/-2.6 to 4.6+/-2.2 mL (P<0.001). Peak velocity (and therefore transmitral closing pressure) was more sustained throughout systole, as reflected by the increase in the closing pressure ratio (0.77+/-0.1 versus 0.84+/-0.1 before CRT versus after CRT, P=0.01); dP/dt also improved after CRT. There was no change in dyssynchrony or MAA contraction. CONCLUSIONS Reduction in MR after CRT is associated with favorable changes in MV geometry and closing forces on the MV. It does so by favorably affecting the force balance acting on the MV in 2 ways: reducing tethering through reversal of LV remodeling and increasing the systolic duration of peak transmitral closing pressures.
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Affiliation(s)
- Jorge Solis
- Division of Cardiology, Massachusetts General Hospital, Boston, MA 02114, USA
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75
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Foster GP, Dunn AK, Abraham S, Ahmadi N, Sarraf G. Accurate Measurement of Mitral Annular Dimensions by Echocardiography: Importance of Correctly Aligned Imaging Planes and Anatomic Landmarks. J Am Soc Echocardiogr 2009; 22:458-63. [DOI: 10.1016/j.echo.2009.02.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2008] [Indexed: 10/20/2022]
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76
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Alharthi MS, Mookadam F, Tajik AJ. Echocardiographic quantitation of mitral regurgitation. Expert Rev Cardiovasc Ther 2008; 6:1151-60. [PMID: 18793117 DOI: 10.1586/14779072.6.8.1151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Mitral valve regurgitation is a common valvular problem, particularly in developing nations. It causes significant morbidity and mortality, especially if the severity of valve regurgitation is underestimated. Echocardiography plays a significant role in the diagnoses, serial follow-up and management of patients with valvular heart disease. However, precise quantitation of the severity of mitral regurgitation is a crucial element in the therapeutic decisions for managing mitral regurgitation. An accurate assessment of the severity of mitral regurgitation allows for optimal timing of surgical intervention, culminating in improved patient outcomes. This review provides a systematic approach to the quantitation of mitral regurgitation using the echocardiography and Doppler methodologies that are available in the modern noninvasive imaging and hemodynamic laboratory. Additional, novel and evolving noninvasive imaging modalities are reviewed briefly.
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Affiliation(s)
- Mohsen S Alharthi
- Cardiovascular Division, Mayo Clinic Arizona, Scottsdale, AZ 85259, USA.
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77
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Buchner S, Debl K, Poschenrieder F, Feuerbach S, Riegger GA, Luchner A, Djavidani B. Cardiovascular Magnetic Resonance for Direct Assessment of Anatomic Regurgitant Orifice in Mitral Regurgitation. Circ Cardiovasc Imaging 2008; 1:148-55. [DOI: 10.1161/circimaging.107.753103] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
In patients with mitral regurgitation (MR), assessment of the severity of valvular dysfunction is crucial. Recently, regurgitant orifice area has been proposed as the most useful indicator of the severity of MR. The purpose of our study was to determine whether planimetry of the anatomic regurgitant orifice (ARO) in patients with MR is feasible by cardiovascular magnetic resonance (CMR) and correlates with invasive catheterization and echocardiography effective regurgitant orifice [ECHO-ERO] by proximal isovelocity surface area.
Methods and Results—
Planimetry of ARO was performed with a 1.5-T CMR scanner using a breath-hold balanced gradient echo sequence true fast imaging with steady state precession (TrueFISP). CMR planimetry of ARO was possible in 35 of 38 patients and was closely correlated with angiographic grading (
r
=0.84,
P
<0.0001). In patients with MR grade ≥III on catheterization, CMR-ARO (0.60�0.29 cm
2
versus 0.30�0.19 cm
2
,
P
<0.0001) as well as ECHO-ERO (0.49�0.17 cm
2
versus 0.27�0.10 cm
2
) were significantly elevated in comparison with MR grade <III. Further, CMR-ARO was closely correlated to CMR regurgitant fraction and volume (
r
=0.90 and
r
=0.91,
P
<0.0001, respectively) and catheterization regurgitant fraction and volume (
r
=0.86 and 0.83,
P
<0.0001, respectively). The correlation between CMR-ARO and ECHO-ERO was 0.81 (
P
<0.0001) and CMR slightly overestimated ECHO-ERO by 0.06 cm
2
(
P
<0.05). As assessed by receiver operating characteristic analysis, CMR-ARO at a threshold of 0.40 cm
2
detected MR grade ≥III as defined by catheterization, with a sensitivity and specificity of 94% and 94%, respectively.
Conclusion—
CMR planimetry of the anatomic mitral regurgitant lesion in patients with MR is feasible and permits quantification of MR with good agreement with the accepted invasive and noninvasive methods. Direct measurement by CMR is a promising new method for the precise assessment of ARO area and the severity of MR.
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Affiliation(s)
- Stefan Buchner
- From the Klinik und Poliklinik für Innere Medizin II (S.B., K.D., G.R., A.L.) and Institut für Röntgendiagnostik (F.P., S.F., B.D.), Klinikum der Universität Regensburg, Regensburg, Germany
| | - Kurt Debl
- From the Klinik und Poliklinik für Innere Medizin II (S.B., K.D., G.R., A.L.) and Institut für Röntgendiagnostik (F.P., S.F., B.D.), Klinikum der Universität Regensburg, Regensburg, Germany
| | - Florian Poschenrieder
- From the Klinik und Poliklinik für Innere Medizin II (S.B., K.D., G.R., A.L.) and Institut für Röntgendiagnostik (F.P., S.F., B.D.), Klinikum der Universität Regensburg, Regensburg, Germany
| | - Stefan Feuerbach
- From the Klinik und Poliklinik für Innere Medizin II (S.B., K.D., G.R., A.L.) and Institut für Röntgendiagnostik (F.P., S.F., B.D.), Klinikum der Universität Regensburg, Regensburg, Germany
| | - Günter A.J. Riegger
- From the Klinik und Poliklinik für Innere Medizin II (S.B., K.D., G.R., A.L.) and Institut für Röntgendiagnostik (F.P., S.F., B.D.), Klinikum der Universität Regensburg, Regensburg, Germany
| | - Andreas Luchner
- From the Klinik und Poliklinik für Innere Medizin II (S.B., K.D., G.R., A.L.) and Institut für Röntgendiagnostik (F.P., S.F., B.D.), Klinikum der Universität Regensburg, Regensburg, Germany
| | - Behrus Djavidani
- From the Klinik und Poliklinik für Innere Medizin II (S.B., K.D., G.R., A.L.) and Institut für Röntgendiagnostik (F.P., S.F., B.D.), Klinikum der Universität Regensburg, Regensburg, Germany
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78
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Effect of Dynamic Flow Rate and Orifice Area on Mitral Regurgitant Stroke Volume Quantification Using the Proximal Isovelocity Surface Area Method. J Am Coll Cardiol 2008; 52:767-78. [DOI: 10.1016/j.jacc.2008.05.028] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2008] [Revised: 05/06/2008] [Accepted: 05/21/2008] [Indexed: 11/22/2022]
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79
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80
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Otsuji Y, Levine RA, Takeuchi M, Sakata R, Tei C. Mechanism of Ischemic Mitral Regurgitation. J Cardiovasc Ultrasound 2008. [DOI: 10.4250/jcu.2008.16.1.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Yutaka Otsuji
- Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Robert A. Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Boston, USA
| | - Masaaki Takeuchi
- Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Ryuzo Sakata
- Department of Cardiovascular Surgery, Kagoshima University, Kagoshima, Japan
| | - Chuwa Tei
- Department of Cardiovascular Medicine, Kagoshima University, Kagoshima, Japan
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81
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Savage RM, Konstadt S. CON: Proximal isovelocity surface area should not be measured routinely in all patients with mitral regurgitation. Anesth Analg 2007; 105:944-6. [PMID: 17898370 DOI: 10.1213/01.ane.0000278524.33706.95] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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82
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Fazel SS, Ihlberg L, David TE. Mitral valve reconstruction in the failing heart. Scand J Surg 2007; 96:111-20. [PMID: 17679352 DOI: 10.1177/145749690709600205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- S S Fazel
- Peter Munk Cardiac Centre, Division of Cardiac Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
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83
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Song JM, Fukuda S, Kihara T, Shin MS, Garcia MJ, Thomas JD, Shiota T. Value of mitral valve tenting volume determined by real-time three-dimensional echocardiography in patients with functional mitral regurgitation. Am J Cardiol 2006; 98:1088-93. [PMID: 17027577 DOI: 10.1016/j.amjcard.2006.05.036] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2006] [Revised: 05/01/2006] [Accepted: 05/01/2006] [Indexed: 11/24/2022]
Abstract
This study sought to evaluate mitral valve tenting volume (TnV) as a clinical parameter using real-time 3-dimensional echocardiography in patients with functional mitral regurgitation (MR). In 27 patients with functional MR and 4 controls without mitral disease, real-time 3-dimensional echocardiographic images were obtained to measure TnV frame by frame from presystole to end-systole. The maximal and minimal TnVs during systole were identified in each patient, and mitral annular areas and tenting heights were also measured. Using 2-dimensional echocardiography, tenting area (TnA) was measured from the apical long-axis, apical 4-chamber, and apical 2-chamber views. The regurgitant orifice area was measured by the proximal isovelocity surface area method. Maximal and minimal TnVs occurred at the time of 2 +/- 6% and 78 +/- 6% of whole systolic duration, respectively, and the systolic percentage change of TnV was related to that of tenting height but not to that of mitral annular area. TnA on the long-axis images was significantly larger than that on the 4- and 2-chamber images (2.5 +/- 1.4 vs 1.7 +/- 1.3 and 1.9 +/- 1.4 cm(2), respectively, p <0.001). Regurgitant orifice area was significantly correlated with maximal TnV (r = 0.90), minimal TnV (r = 0.86), and TnA on the long-axis (r = 0.79), 4-chamber (r = 0.75), and 2-chamber (r = 0.73) images. Among minimal TnV and 3 TnAs, minimal TnV was the only independent determinant of regurgitant orifice area (p <0.001). Minimal TnV >or=3.90 ml identified significant functional MR with a sensitivity of 86% and a specificity of 100%. In conclusion, TnV derived from real-time 3-dimensional echocardiography is a preferable novel single index for assessing mitral valve tethering in functional MR to TnA that is dependent on the location of 2-dimensional planes.
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Affiliation(s)
- Jong-Min Song
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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84
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Song JM, Qin JX, Kongsaerepong V, Shiota M, Agler DA, Smedira NG, McCarthy PM, Marc Gillinov A, Thomas JD, Shiota T. Determinants of Ischemic Mitral Regurgitation in Patients with Chronic Anterior Wall Myocardial Infarction: A Real Time Three-Dimensional Echocardiography Study. Echocardiography 2006; 23:650-7. [PMID: 16970716 DOI: 10.1111/j.1540-8175.2006.00284.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE We sought to elucidate the geometric determinants of ischemic mitral regurgitation (IMR) in patients with chronic anterior myocardial infarction (MI). MATERIALS AND METHODS In 16 patients with anterior MI only (Group A) and 18 patients with both anterior and inferoposterior MI (Group B), three parallel equidistant anteroposterior (AP) planes (medial, central, lateral) perpendicular to the mitral valvular commissure-commissure plane were generated. The systolic tenting area of the mitral valve (MVTa) and the angles between the annular plane and leaflets (anterior, Aalpha; posterior, Palpha) on the AP planes were measured. The left ventricular end-systolic and end-diastolic volumes, and end-diastolic and end-systolic mitral annular area (MAAs) were obtained. RESULT The regurgitant orifice area (ROA) was significantly smaller in Group A than Group B (0.08 +/- 0.09 vs 0.20 +/- 0.18 cm(2), P < 0.05). In the total of 34 patients, the medial MVTa (P < 0.001), MAAs (P < 0.05) and the spherical index (P < 0.05) were three independent determinants of ROA while the left ventricular volumes were not. MAAs was the only independent determinant of ROA in Group A, while the medial MVTa was in Group B. Palpha (P < 0.05) and MVTa (P = 0.06) tended to be larger in the medial than the lateral side in Group B, while no differences were found in Group A. CONCLUSION The geometry of the mitral valve apparatus was more important than the left ventricular volumes in determining the severity of IMR in patients with anterior MI. The posteromedial side tenting could play a critical role in causing significant IMR when the inferoposterior MI coexists with anterior MI.
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Affiliation(s)
- Jong-Min Song
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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85
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Nof E, Glikson M, Bar-Lev D, Gurevitz O, Luria D, Eldar M, Schwammenthal E. Mechanism of diastolic mitral regurgitation in candidates for cardiac resynchronization therapy. Am J Cardiol 2006; 97:1611-4. [PMID: 16728224 DOI: 10.1016/j.amjcard.2005.12.064] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2005] [Revised: 12/08/2005] [Accepted: 12/08/2005] [Indexed: 10/24/2022]
Abstract
It was hypothesized that restricted diastolic leaflet motion is implicated not only in the mechanism of systolic mitral regurgitation (MR) but also in the mechanism of diastolic MR observed in patients with severe heart failure. Cardiac resynchronization therapy (CRT) can oppose increased mitral leaflet tethering by increasing transmitral pressure, thereby providing an opportunity to explore this hypothesis. A total of 26 consecutive candidates for CRT with diastolic MR were compared with 26 candidates without diastolic MR. Maximal diastolic mitral leaflet opening and inflow direction and measures of mitral valve apparatus (i.e., mitral annular diameters, calculated mitral annular area, and tethering distance) were assessed from the apical 4-chamber view before and during CRT. There were no significant differences in New York Heart Association functional class, ejection fraction, QRS duration, PR interval, systolic MR grade, or 2-dimensional geometry of the mitral valve apparatus between the groups. Patients with diastolic MR had more restricted maximal diastolic leaflet openings (54 degrees +/- 17 degrees vs 71 degrees +/- 11 degrees , p = 0.003) and substantially smaller inflow angles (66 degrees +/- 7 degrees vs 79 degrees +/- 9 degrees , p = 0.0003) compared with patients without diastolic MR. After the institution of CRT, diastolic MR was eliminated in all patients, although there were no significant changes in any of the parameters of mitral valve apparatus. In conclusion, abnormal mitral valve tethering is a constitutive element of the mechanism of diastolic MR in patients with left ventricular dysfunction. Its acute resolution after CRT does not seem to be caused by changes in mitral valve geometry but rather by an increase in transmitral closing forces.
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Affiliation(s)
- Eyal Nof
- Heart Institute, Chaim Sheba Medical Center, Tel Hashomer, Israel
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Nagasaki M, Nishimura S, Ohtaki E, Kasegawa H, Matsumura T, Nagayama M, Koyanagi T, Tohbaru T, Misu K, Asano R, Sumiyoshi T, Hosoda S. The echocardiographic determinants of functional mitral regurgitation differ in ischemic and non-ischemic cardiomyopathy. Int J Cardiol 2006; 108:171-6. [PMID: 15916824 DOI: 10.1016/j.ijcard.2005.04.028] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2004] [Revised: 03/08/2005] [Accepted: 04/20/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Functional mitral regurgitation (MR) is one of the common and severe complications in patients with dilated cardiomyopathy. The detailed mechanisms that cause functional MR remain to be elucidated. Using two-dimensional transthoracic echocardiography, we investigated the differences in major determinants of MR severity between ischemic cardiomyopathy (ICM) and non-ICM patients. METHODS We enrolled 103 patients (91 males; age 64+/-12 years) with significant left ventricular (LV) dilatation. They were divided into ICM group (n=69) with significant coronary disease, and non-ICM (n=34) group without coronary disease. We devised a novel and simple parameter; the short-axis sphericity index (SI), to evaluate global LV remodeling, and used coaptation depth (CD) and tenting area (TA) to evaluate mitral deformity. RESULTS In all cases, CD, TA and left atrium diameter (LAD) correlated positively with maximum regurgitation area (MRA) (r=0.54, 0.57, 0.57; P<0.0001). A negative correlation was observed between MRA and SI (r=-0.33, P=0.0008). There was no significant relationship between MRA and LV ejection fraction (EF). In non-ICM cases, SI tended to be lower with reduced EF. Multivariate stepwise linear regression analysis showed the following equations; ICM: MRA=-9.4+0.81CD+0.21LAD (r2=0.47, P<0.0001), non-ICM: MRA=-7.2+0.17LVDs (LV end systolic diameter) -8.7SI+0.27LAD (r2=0.63, P<0.0001). CONCLUSIONS The strongest determinants of functional MR severity differ in ICM and non-ICM. While LV diameter and SI (global LV remodeling index) mainly determine the severity in non-ICM, CD that reflects mitral deformity is the major determinant in ICM.
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Affiliation(s)
- Mika Nagasaki
- Sakakibara Heart Institute, Cardiology, 3-16-1 Asahi-Cho, Fuchu City Tokyo 183-0003, Japan
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Pascual Figal DA, de la Morena Valenzuela G, González Carrillo J, Ansaldo Ruiz P, Ruipérez Abizanda JA, Valdés Chavarri M. Evolución de la insuficiencia mitral severa tras optimización del tratamiento médico en la miocardiopatía dilatada no isquémica. Rev Esp Cardiol 2006. [DOI: 10.1157/13084647] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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A. Levine R, Otsuji Y, Schwammenthal E, Sakata R, Tei C. Ischemic Mitral Regurgitation: From New Understanding to New Solutions Role of Echocardiography. J Echocardiogr 2006. [DOI: 10.2303/jecho.4.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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89
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Fukuda S, Grimm R, Song JM, Kihara T, Daimon M, Agler DA, Wilkoff BL, Natale A, Thomas JD, Shiota T. Electrical Conduction Disturbance Effects on Dynamic Changes of Functional Mitral Regurgitation. J Am Coll Cardiol 2005; 46:2270-6. [PMID: 16360057 DOI: 10.1016/j.jacc.2005.08.037] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2005] [Revised: 07/11/2005] [Accepted: 08/15/2005] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of this study was to investigate the relationship between dynamics of functional mitral regurgitation (MR) and the degree of electrical conduction disturbance, and to evaluate the impact of cardiac resynchronization therapy (CRT) on MR severity and its phasic pattern. BACKGROUND Mechanisms of phasic changes of functional MR, which may be determined by annulus dilation and tethering of the leaflet, remain unclear. METHODS Transthoracic two-dimensional echocardiography was performed in 60 patients with functional MR. A biventricular pacemaker was implanted in 19 patients. The mitral annulus area (MAA) and the tenting area (TA) were measured from apical views. The MR volume and fraction were assessed by the quantitative pulsed Doppler method. Instantaneous regurgitation flow rate was measured by proximal flow convergence method. A dynamic change in MR flow rate was evaluated by frame-by-frame analysis throughout systole. RESULTS A phasic pattern with two peaks at early- and late-systole and decrease in mid-systole was noticed in 57 patients. The early-systolic peak of MR was larger than the late-systolic peak (128.4 +/- 64.3 ml/s vs. 73.9 +/- 55.1 ml/s, p < 0.001). The ratio of flow rate at these two peaks correlated with QRS duration (r = 0.55, p < 0.001). Early-systolic flow rate reduced after CRT (143.9 +/- 60.8 ml/s to 90.7 +/- 54.1 ml/s, p < 0.05), but late-systolic flow rate did not (61.5 +/- 55.0 ml/s to 51.2 +/- 40.9 ml/s, p = NS). A similar pattern was observed for TA, whereas MAA did not change after CRT. CONCLUSIONS Biphasic pattern was found in functional MR, and the ratio of flow rate at two peaks correlated with QRS duration. The CRT decreased regurgitation flow volume by reducing early-systolic MR but not late-systolic MR, resulting in the change in phasic pattern of functional MR.
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Affiliation(s)
- Shota Fukuda
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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90
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Affiliation(s)
- Robert A Levine
- Massachusetts General Hospital, Department of Medicine, Harvard Medical School, Boston, MA, USA.
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91
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Schwammenthal E, Levine RA. The non-ischaemic dynamics of ischaemic mitral regurgitation: solving the paradoxThe opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology. Eur Heart J 2005; 26:1454-5. [PMID: 15917274 DOI: 10.1093/eurheartj/ehi323] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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92
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Piérard LA, Lancellotti P. The role of ischemic mitral regurgitation in the pathogenesis of acute pulmonary edema. N Engl J Med 2004; 351:1627-34. [PMID: 15483281 DOI: 10.1056/nejmoa040532] [Citation(s) in RCA: 187] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Acute mitral regurgitation may cause pulmonary edema, but the pathogenetic role of chronic ischemic mitral regurgitation, a dynamic condition, has not yet been characterized. METHODS We prospectively studied 28 patients (mean [+/-SD] age, 65+/-11 years) with acute pulmonary edema and left ventricular systolic dysfunction and 46 patients without a history of acute pulmonary edema. The two groups were matched for all baseline characteristics. Patients underwent quantitative Doppler echocardiography during exercise. Exercise-induced changes in the left ventricular volume, the ejection fraction, the mitral regurgitant volume, the effective regurgitant orifice area, and the transtricuspid pressure gradient were compared in patients with and without acute pulmonary edema. RESULTS The two groups had similar clinical and baseline echocardiographic characteristics. They also had similar exercise-induced changes in heart rate, systolic blood pressure, and left ventricular volumes. In the univariate analysis, patients with recent pulmonary edema had a much higher increase than did the patients without pulmonary edema in mitral regurgitant volume (26+/-14 ml vs. 5+/-14 ml, P<0.001), the effective regurgitant orifice area (16+/-10 mm2 vs. 2+/-9 mm2, P<0.001), and the transtricuspid pressure gradient (29+/-10 mm Hg vs. 13+/-11 mm Hg, P<0.001). In the multivariate analysis, exercise-induced changes in the effective regurgitant orifice area (P<0.001), in the transtricuspid pressure gradient (P=0.001), and in the left ventricular ejection fraction (P=0.02) were independently associated with a history of recent pulmonary edema. CONCLUSIONS In patients with left ventricular systolic dysfunction, acute pulmonary edema is associated with the dynamic changes in ischemic mitral regurgitation and the resulting increase in pulmonary vascular pressure.
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Affiliation(s)
- Luc A Piérard
- Division of Cardiology, University Hospital of Liege, Liege, Belgium.
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93
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Grossmann G, Hoffmeister A, Imhof A, Giesler M, Hombach V, Spiess J. Reproducibility of the proximal flow convergence method in mitral and tricuspid regurgitation. Am Heart J 2004; 147:721-8. [PMID: 15077090 DOI: 10.1016/j.ahj.2003.11.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND The follow-up of patients with mitral and tricuspid regurgitation is important for their clinical treatment. We aimed to evaluate the reproducibility of the flow convergence method in mitral and tricuspid regurgitation. METHODS The proximal flow convergence region was imaged with color Doppler ultrasound scanning echocardiography in 83 patients with mitral regurgitation, tricuspid regurgitation, or both. Proximal isovelocity surface area radii for aliasing velocities of 27 to 29 cm/s and 41 to 43 cm/s were repeatedly measured by the same experienced investigator on different days and by experienced and less experienced investigators at 1 day. RESULTS In mitral regurgitation, the intraobserver variability rate was 0.2% +/- 13.5% (2.8% +/- 13.3%) and the interobserver variability was 0.1% +/- 13.8% (1.7% +/- 18.0%) for an aliasing velocity of 27 to 29 cm/s (41-43 cm/s). For the aliasing velocity of 27 to 29 cm/s (41-43 cm/s), the 95% ranges for change of the proximal isovelocity surface area radii were +/- 2.7 mm (+/- 1.8 mm) for measurements repeated by the same investigator and +/- 2.7 mm ( +/- 2.4 mm) for different investigators. Interobserver variability was independent of the investigators' experience. Similar data were achieved in tricuspid regurgitation. CONCLUSIONS The proximal flow convergence method is acceptably reproducible in mitral and tricuspid regurgitation independent of the investigators experience. For the aliasing velocity of 27 to 29 cm/s (41-43 cm/s), the proximal isovelocity surface area radius has to change for >2.7 (2.4) mm before an altered severity of mitral or tricuspid regurgitation in a single patient can be assumed.
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Affiliation(s)
- Georg Grossmann
- Department of Internal Medicine, Division of Cardiology, University of Ulm, Ulm, Germany.
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Nesta F, Otsuji Y, Handschumacher MD, Messas E, Leavitt M, Carpentier A, Levine RA, Hung J. Leaflet concavity: a rapid visual clue to the presence and mechanism of functional mitral regurgitation. J Am Soc Echocardiogr 2003; 16:1301-8. [PMID: 14652610 DOI: 10.1067/j.echo.2003.09.003] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Repairing mitral regurgitation (MR) requires an understanding of its mechanism. Evaluating restricted leaflet closure in functional MR is challenging. Tenting area between leaflets and annulus in long-axis (LAX) views correlates with MR, but is positive even in control subjects; in the 4-chamber view, the incomplete mitral leaflet closure (IMLC) tenting pattern may be subtle and variable. We tested the hypothesis that leaflet concavity toward the left atrium in the LAX view, a rapid visual clue indicating abnormal tethering predominantly by intermediate chords, is a strong indicator of functional MR. We reviewed 90 patients: 40 with inferior myocardial infarction and ejection fraction > or = 50%; 40 with global left ventricular dysfunction and ejection fraction < 50%; and 10 control subjects. We assessed leaflet shape (concave or convex toward the left atrium) and maximum systolic proximal MR jet width in the LAX views. To quantify shape, we measured the leaflet concavity area between the anterior leaflet and a line connecting its ends. Conventional IMLC area was also assessed. Patients with leaflet concavity had significantly greater MR than those without this finding (jet width of 4.6 +/- 0.7 vs 0.5 +/- 0.1 mm, P <.0001), indicating mild-moderate versus trace MR, with differences comparable in those with inferior myocardial infarction and left ventricular dysfunction. Leaflet concavity area most strongly predicted MR by multivariate regression (R(2) = 0.7). Conventional IMLC area did not uniquely distinguish patients with or without MR and correlated more weakly with MR (R(2) = 0.30 vs 0.73). Mitral leaflet concavity in the LAX view provides rapid and reliable recognition of functional MR, with greater reliability than IMLC area. This shape, consistent with tethering by intermediate chords, may have implications for potential intervention.
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Affiliation(s)
- Francesca Nesta
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, 02114, USA
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96
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Breithardt OA, Sinha AM, Schwammenthal E, Bidaoui N, Markus KU, Franke A, Stellbrink C. Acute effects of cardiac resynchronization therapy on functional mitral regurgitation in advanced systolic heart failure. J Am Coll Cardiol 2003; 41:765-70. [PMID: 12628720 DOI: 10.1016/s0735-1097(02)02937-6] [Citation(s) in RCA: 372] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES We studied the acute effects of cardiac resynchronization therapy (CRT) on functional mitral regurgitation in heart failure (HF) patients with left bundle branch block (LBBB). BACKGROUND Both an decrease [corrected] in left ventricular (LV) closing force and mitral valve tethering have been implicated as mechanisms for functional mitral regurgitation (FMR) in dilated hearts. We hypothesized that an increase in LV closing force achieved by CRT could act to reduce FMR. METHODS Twenty-four HF patients with LBBB and FMR were studied after implantation of a biventricular CRT system. Acute changes in FMR severity between intrinsic conduction (OFF) and CRT were quantified according to the proximal isovelocity surface area method by measuring the effective regurgitant orifice area (EROA). Results were compared with the changes in estimated maximal rate of left ventricular systolic pressure rise (LV+dP/dt(max)) and transmitral pressure gradients (TMP), both measured by Doppler echocardiography. RESULTS Cardiac resynchronization therapy was associated with a significant reduction in FMR severity. Effective regurgitant orifice area decreased from 25 +/- 19 mm(2) (OFF) to 13 +/- 8 mm(2) (CRT). The change in EROA was directly related to the increase in LV+dP/dt(max) (r = -0.83, p < 0.0001). Compared with OFF, TMP increased more rapidly during CRT, and a higher maximal TMP was observed (OFF 73 +/- 24 mm Hg vs. CRT 85 +/- 26 mm Hg, p < 0.01). CONCLUSIONS Functional mitral regurgitation is reduced by CRT in patients with HF and LBBB. This effect is directly related to the increased closing force (LV+dP/dt(max)). The results support the hypothesis that an increase in TMP, mediated by a rise in LV+dP/dt(max) due to more coordinated LV contraction, may facilitate effective mitral valve closure.
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97
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Kwan J, Shiota T, Agler DA, Popović ZB, Qin JX, Gillinov MA, Stewart WJ, Cosgrove DM, McCarthy PM, Thomas JD. Geometric differences of the mitral apparatus between ischemic and dilated cardiomyopathy with significant mitral regurgitation: real-time three-dimensional echocardiography study. Circulation 2003; 107:1135-40. [PMID: 12615791 DOI: 10.1161/01.cir.0000053558.55471.2d] [Citation(s) in RCA: 282] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND This study was conducted to elucidate the geometric differences of the mitral apparatus in patients with significant mitral regurgitation caused by ischemic cardiomyopathy (ICM-MR) and by idiopathic dilated cardiomyopathy (DCM-MR) by use of real-time 3D echocardiography (RT3DE). METHODS AND RESULTS Twenty-six patients with ICM-MR caused by posterior infarction, 18 patients with DCM-MR, and 8 control subjects were studied. With the 3D software, commissure-commissure plane and 3 perpendicular anteroposterior (AP) planes were generated for imaging the medial, central, and lateral sides of the mitral valve (MV) during mid systole. In 3 AP planes, the angles between the annular plane and each leaflet (anterior, Aalpha; posterior, Palpha) were measured. In ICM-MR, Aalpha measured in the medial and central planes was significantly larger than that in the lateral plane (39+/-5 degrees, 34+/-6 degrees, and 27+/-5 degrees, respectively; P<0.01), whereas Palpha showed no significant difference in any of the 3 AP planes (61+/-7 degrees, 57+/-7 degrees, and 56+/-7 degrees, P>0.05). In DCM-MR, both Aalpha (38+/-8 degrees, 37+/-9 degrees, and 36+/-7 degrees, P>0.05) and Palpha (59+/-6 degrees, 58+/-5 degrees, and 57+/-6 degrees, P>0.05) revealed no significant differences in the 3 planes. CONCLUSIONS The pattern of MV deformation from the medial to the lateral side was asymmetrical in ICM-MR, whereas it was symmetrical in DCM-MR. RT3DE is a helpful tool for differentiating the geometry of the mitral apparatus between these 2 different types of functional mitral regurgitation.
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Affiliation(s)
- Jun Kwan
- Cardiovascular Imaging Center, Department of Cardiovascular Medicine, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Takagaki M, McCarthy PM, Goormastic M, Ochiai Y, Doi K, Kopcak MW, Tabata T, Cardon LA, Thomas JD, Fukamachi K. Determinants of the development of mitral regurgitation in pacing-induced heart failure. Circ J 2003; 67:78-82. [PMID: 12520157 DOI: 10.1253/circj.67.78] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The pacing-induced heart failure model provides an opportunity to assess the structural and functional determinants of mitral regurgitation (MR) in dilated cardiomyopathy. This study aimed to evaluate MR to better understand the multitude of factors contributing to its development. Heart failure was induced by rapid ventricular pacing (230 beats/min) in 40 mongrel dogs. Left ventricular (LV) size and MR were evaluated echocardiographically. LV contractility was analyzed using a conductance catheter. MR increased to mild in 12 animals (regurgitant orifice area, 0.06+/-0.05 cm(2)), moderate in 15 (0.14+/-0.07 cm(2)), and severe in 13 (0.34+/-0.16 cm(2)). The grade of MR had an inverse relationships with E(max) (the slope of the end-systolic pressure-volume relationship, p<0.01) and dE/dt (the slope of the maximum rate of change of pressure-end-diastolic volume [V(ED)] relationship, p<0.01) and positive relationships with V(ED) and end-diastolic cross-sectional areas and lengths (p<0.05) by univariate analysis. The dE/dt had an independently significant (p<0.01) relationship by multivariable logistic regression. Many factors influence the development of MR and because of its similarity to the clinical situation, this model can be used to investigate MR and heart failure, as well as new surgical therapies.
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Affiliation(s)
- Masami Takagaki
- Department of Biomedical Engineering, Lerner Research Institute, The Cleveland Clinic Foundation, OH 44195, USA
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99
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Kumanohoso T, Otsuji Y, Yoshifuku S, Matsukida K, Koriyama C, Kisanuki A, Minagoe S, Levine RA, Tei C. Mechanism of higher incidence of ischemic mitral regurgitation in patients with inferior myocardial infarction: quantitative analysis of left ventricular and mitral valve geometry in 103 patients with prior myocardial infarction. J Thorac Cardiovasc Surg 2003; 125:135-43. [PMID: 12538997 DOI: 10.1067/mtc.2003.78] [Citation(s) in RCA: 229] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The mechanism of higher incidence of ischemic mitral regurgitation in patients with inferior compared with anterior myocardial infarction despite less global left ventricular remodeling and dysfunction is controversial. We hypothesized that inferior myocardial infarction causes left ventricular remodeling, which displaces posterior papillary muscle away from its normal position, leading to ischemic mitral regurgitation. METHODS In 103 patients with prior myocardial infarction (61 anterior and 42 inferior) and 20 normal control subjects, we evaluated the grade of ischemic mitral regurgitation on the basis of the percentage of Doppler jet area, left ventricular end-diastolic and end-systolic volumes, midsystolic mitral annular area, and midsystolic leaflet-tethering distance between papillary muscle tips and the contralateral anterior mitral annulus, which were determined by means of quantitative echocardiography. RESULTS Global left ventricular dilatation and dysfunction were significantly less pronounced in patients with inferior myocardial infarction (left ventricular end-systolic volume: 52 +/- 18 vs 60 +/- 24 mL, inferior vs anterior infarction, P<.05; left ventricular ejection fraction: 51% +/- 9% vs 42% +/- 7%, P <.0001). However, the percentage of mitral regurgitation jet area and the incidence of significant regurgitation (percentage of jet area of 10% or greater) was greater in inferior infarction (percentage of jet area: 10.1% +/- 7.5% vs 4.4% +/- 7.0%, P =.0002; incidence: 16/42 (38%) vs 6/61 (10%), P <.0001). The mitral annulus (area = 8.2 +/- 1.2 cm2 in control subjects) was similarly dilated in both inferior and anterior myocardial infarction (9.7 +/- 1.7 vs. 9.5 +/- 2.3 cm2, no significant difference), and the anterior papillary muscle-tethering distance (33.8 +/- 2.6 mm in control subjects) was also similarly and mildly increased in both groups (35.2 +/- 2.4 vs 35.2 +/- 2.8 mm, no significant difference). However, the posterior papillary muscle-tethering distance (33.3 +/- 2.3 mm in control subjects) was significantly greater in inferior compared with anterior myocardial infarction (38.3 +/- 4.1 vs 34.7 +/- 2.9 mm, P =.0001). Multiple stepwise regression analysis identified the increase in posterior papillary muscle-tethering distance divided by body surface area as an independent contributing factor to the percentage of mitral regurgitation jet area (r2 = 0.70, P <.0001). CONCLUSIONS It is suggested that the higher incidence and greater severity of ischemic mitral regurgitation in patients with inferior compared with anterior myocardial infarction can be related to more severe geometric changes in the mitral valve apparatus with greater displacement of posterior papillary muscle caused by localized inferior basal left ventricular remodeling, which results in therapeutic implications for potential benefit of procedures, such as infarct plication and leaflet or chordal elongation, to reduce leaflet tethering.
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Affiliation(s)
- Toshiro Kumanohoso
- First Department of Internal Medicine, Department of Public Health, Kagoshima University School of Medicine, Kagoshima, Japan
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Hung J, Guerrero JL, Handschumacher MD, Supple G, Sullivan S, Levine RA. Reverse ventricular remodeling reduces ischemic mitral regurgitation: echo-guided device application in the beating heart. Circulation 2002; 106:2594-600. [PMID: 12427657 DOI: 10.1161/01.cir.0000038363.83133.6d] [Citation(s) in RCA: 129] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND In ischemic mitral regurgitation (MR), mitral leaflet closure is restricted by ventricular remodeling with displacement of the papillary muscles (PMs). Therapy is uncertain because ring annuloplasty does not alleviate PM displacement. We tested the hypothesis that echo-guided PM repositioning using an external device can reduce MR without compromising left ventricular (LV) function. METHODS AND RESULTS We studied 10 sheep with ischemic MR produced by circumflex ligation with inferior infarction, 6 acutely and 4 eight weeks after myocardial infarction (MI). A Dacron patch containing an inflatable balloon was placed over the PMs and adjusted under echo guidance to reverse LV remodeling and reposition the infarcted PM. 3D echo assessed mitral valve geometric changes. In 7 sheep, sonomicrometry and Millar catheters assessed changes in end-systolic and end-diastolic pressure-volume relationships, and microspheres were injected to assess coronary flow. Moderate MR after MI resolved with patch application alone (n=3) or echo-guided balloon inflation, which repositioned the infarcted PM, decreasing the PM tethering distance from 31.1+/-2.5 mm after MI to 26.8+/-1.8 with patch (P<0.01; baseline=25.5+/-1.5). LV contractility was unchanged (end-systolic slope=3.4+/-1.6 mm Hg/mL with patch versus 2.8+/-1.6 after MI). Although there was a nonsignificant trend for a mild increase in stiffness constant (0.07+/-0.05 mL(-1) versus 0.05+/-0.03 after MI, P=0.06), LV end-diastolic pressure was unchanged as MR resolved. Coronary flow to noninfarcted regions was not reduced. CONCLUSIONS An external device that repositions the PMs can reduce ischemic MR without compromising LV function. This relatively simple technique can be applied under echo guidance in the beating heart.
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Affiliation(s)
- Judy Hung
- Cardiac Ultrasound Laboratory and Surgical Cardiovascular Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Mass 02114, USA
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