101
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2020 Focused Update of the 2017 ACC Expert Consensus Decision Pathway on the Management of Mitral Regurgitation. J Am Coll Cardiol 2020; 75:2236-2270. [DOI: 10.1016/j.jacc.2020.02.005] [Citation(s) in RCA: 99] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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102
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Nappi F, Nenna A, Sing SSA, Timofeeva I, Mihos C, Gentile F, Chello M. Mitral regurgitation: lessons learned from COAPT and MITRA-Fr. J Thorac Dis 2020; 12:2936-2944. [PMID: 32642206 PMCID: PMC7330366 DOI: 10.21037/jtd.2020.01.67] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Recent studies about percutaneous treatment of secondary mitral regurgitation (MR) underlined the importance of left ventricular geometry and features of mitral valve as determinants of procedural and long-term success. Guideline-directed medical therapy (GDMT), transcatheter mitral valve treatment (TMVT) and surgical procedures (mitral valve replacement, mitral valve repair at level of the annulus or subvalvular apparatus) have been extensively evaluated but not adequately compared in current clinical studies. A detailed analysis of the results of the study about transcatheter mitral valve repair would allow to evaluate the safety and effectiveness of such procedure and would provide potential indications for improving the quality of percutaneous and surgical repair in patients with moderate-to-severe secondary MR. Patients with proportionate MR (i.e., MR severity is proportional to the amount of left ventricular dilatation) are prone to respond to the optimization of medical therapy, while patients with disproportionate MR (i.e., MR severity is disproportionately higher than predicted by left ventricular dilatation, with high EROA and small left ventricle) are likely to benefit from additional repair. The identification of specific subpopulation of "high responders", based on the anatomic characteristics of the mitral valve and the relative dimensions of the annulus, the regurgitation and the left ventricle, can also apply to medical therapy. However, some pivotal component of MR (such as the symmetry of tethering and the differences in biomechanical features of leaflets) are not adequately investigated in current studies and warrant further evaluation.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France
| | - Antonio Nenna
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Sanjeet Singh Avvtar Sing
- Department of Cardiac Surgery, Golden Jubilee National Hospital. Glasgow, UK.,Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Irina Timofeeva
- Department of Imaging, Centre Cardiologique du Nord de Saint-Denis, Paris, France
| | - Christos Mihos
- Echocardiography Lab, Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami, USA
| | | | - Massimo Chello
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
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103
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Cardiovascular Imaging Through the Prism of Modern Metrics. JACC Cardiovasc Imaging 2020; 13:1256-1269. [DOI: 10.1016/j.jcmg.2020.03.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 02/28/2020] [Accepted: 03/02/2020] [Indexed: 12/21/2022]
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104
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Abstract
Structural heart disease (SHD) emergencies include acute deterioration of a stable lesion or development of a new critical lesion. Structural heart disease emergencies can produce heart failure and cardiogenic shock despite preserved systolic function that may not respond to standard medical therapy and typically necessitate surgical or percutaneous intervention. Comprehensive Doppler echocardiography is the initial diagnostic modality of choice to determine the cause and severity of the underlying SHD lesion. Patients with chronic SHD lesions which deteriorate due to intercurrent illness (eg, infection or arrhythmia) may not require urgent intervention, whereas patients with an acute SHD lesion often require definitive therapy. Medical stabilization prior to definitive intervention differs substantially between stenotic lesions (aortic stenosis, mitral stenosis, left ventricular outflow tract obstruction) and regurgitant lesions (aortic regurgitation, mitral regurgitation, ventricular septal defect). Patients with regurgitant lesions typically require aggressive afterload reduction and inotropic support, whereas patients with stenotic lesions may paradoxically require β-blockade and vasoconstrictors. Emergent cardiac surgery for patients with decompensated heart failure or cardiogenic shock carries a substantial mortality risk but may be necessary for patients who are not eligible for catheter-based percutaneous SHD intervention. This review explores initial medical stabilization and subsequent definitive therapy for patients with SHD emergencies.
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Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, 4352Mayo Clinic Rochester, MN, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, 4352Mayo Clinic Rochester, MN, USA
| | - Bradley Ternus
- Division of Cardiovascular Medicine, 5228University of Wisconsin, Madison, WI, USA
| | - Mackram Eleid
- Department of Cardiovascular Medicine, 4352Mayo Clinic Rochester, MN, USA
| | - Charanjit Rihal
- Department of Cardiovascular Medicine, 4352Mayo Clinic Rochester, MN, USA
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105
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Noack T, Kiefer P, Vivell N, Sieg F, Marin-Cuartas M, Leontyev S, Holzhey DM, Garbade J, Pfannmueller B, Davierwala P, Misfeld M, Seeburger J, Borger MA. Annuloplasty ring dehiscence after mitral valve repair: incidence, localization and reoperation. Eur J Cardiothorac Surg 2020; 57:300-307. [PMID: 31369069 DOI: 10.1093/ejcts/ezz219] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 06/24/2019] [Accepted: 07/02/2019] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Mitral valve (MV) annuloplasty ring dehiscence with subsequent recurrent mitral regurgitation represents an unusual but challenging clinical problem. Incidence, localization and outcomes for this complication have not been well defined. METHODS From 1996 to 2016, a total of 3478 patients underwent isolated MV repair with ring annuloplasty at the Leipzig Heart Centre. Of these patients, 57 (1.6%) underwent reoperation due to annuloplasty ring dehiscence. Echocardiographic data, operative and early postoperative characteristics as well as short- and long-term survival rates after MV reoperation were analysed. RESULTS Occurrences of ring dehiscence were acute (<30 days), early (≤1 year) and late (>1 year) in 44%, 33% and 23% of patients, respectively. Localization of annuloplasty ring dehiscence was found most frequently in the P3 segment (68%), followed by the P2 (51%) and the P1 segments (47%). The 30-day mortality rate and 1- and 5-year survival rates after MV reoperation were 2%, 89% and 74%, respectively. During reoperation, MV replacement was performed in 38 (67%) and MV re-repair in 19 (33%) patients. CONCLUSIONS Annuloplasty ring dehiscence is clinically less common, localized more frequently on the posterior annulus and occurs mostly acutely or early after MV repair. MV reoperation can be performed safely in such patients.
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Affiliation(s)
- Thilo Noack
- University Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany
| | - Philipp Kiefer
- University Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany
| | - Nina Vivell
- University Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany
| | - Franz Sieg
- University Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany
| | - Mateo Marin-Cuartas
- University Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany
| | - Sergey Leontyev
- University Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany
| | | | - Jens Garbade
- University Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany
| | - Bettina Pfannmueller
- University Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany
| | - Piroze Davierwala
- University Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany
| | - Martin Misfeld
- University Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany
| | - Joerg Seeburger
- University Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany
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106
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Rajapreyar I, Rame JE, Fiorilli P, Pamboukian SV, Hoopes CW, Silvestry SC, Pagani FD, Rajagopal K. Pathological insights into persistent mitral regurgitation following continuous flow left ventricular assist device implantation. J Heart Lung Transplant 2020; 39:184-186. [DOI: 10.1016/j.healun.2019.11.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 11/15/2019] [Accepted: 11/20/2019] [Indexed: 10/25/2022] Open
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107
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Sims JR, Reeder GS, Guerrero M, Alkhouli M, Nkomo VT, Nishimura RA, Rihal CS, Eleid MF. Characteristics and outcomes of patients with normal left atrial pressure undergoing transcatheter mitral valve repair. Heart 2020; 106:898-903. [DOI: 10.1136/heartjnl-2019-316133] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 01/03/2020] [Accepted: 01/06/2020] [Indexed: 12/17/2022] Open
Abstract
ObjectiveA subset of patients at the time of transcatheter mitral valve repair (TMVR) will have normal left atrial pressure (LAP) (<13 mm Hg) despite having severe mitral regurgitation (MR). The goal of this study was to determine clinical characteristics and outcomes in patients with normal LAP undergoing TMVR.MethodsA single-centre retrospective cohort of consecutive patients who underwent transcatheter edge-to-edge mitral valve clip and continuous LAP monitoring between 5/1/2014 and 5/1/2018 was analysed. One-year mortality was compared by Kaplan–Meier survival curves. Multivariable analysis was performed to identify predictors of normal LAP and 1 year mortality.ResultsOf the 204 patients undergoing TMVR, 65% were men and the mean age was 81. Of these patients, 31 (15%) had normal LAP (mean LAP 10.5 mm Hg, mean V wave 16.5 mm Hg) and 173 had elevated LAP (mean LAP 19 mm Hg, mean V wave 32.5 mm Hg). The prevalence of severe MR was not different between groups, although the normal LAP group had significantly lower effective regurgitant orifice area and regurgitant volume. Other notable baseline characteristics including prior cardiac surgery, atrial fibrillation, hypertension, diabetes, congestive heart failure, body mass index, mechanism of MR and ejection fraction were similar between groups. However, there was an increased prevalence of chronic lung disease (CLD) (45.2% vs 17.3%, p<0.001) in the normal LAP group. On multivariate analysis, the only significant predictor of normal LAP was the presence of CLD (OR 4.79 (1.83–12.36), p=0.001) and 1-year mortality was significantly higher in the normal LAP group (32.3% vs 12.7%, p=0.006). After adjustment for comorbidities, normal LAP was no longer a predictor of 1-year mortality (RR 1.62 (0.64–4.06), p=0.32); however, CLD (RR 3.44 (1.37–8.67), p=0.01) remained a statistically significant predictor.ConclusionNormal LAP at the time of TMVR is associated with a higher incidence of CLD which independently predicts increased 1-year mortality. In patients with CLD and apparently severe MR, measurement of LAP may help identify those with lower likelihood of benefit from TMVR.
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108
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MRI Evaluation of an Atrial-Anchored Transcatheter Mitral Valve Replacement Implant. AJR Am J Roentgenol 2020; 214:524-528. [PMID: 31939695 DOI: 10.2214/ajr.19.22206] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE. A medical implant that is made from metal must undergo proper MRI testing to ensure patient safety. The purpose of this investigation was to assess issues with MRI with a newly developed atrial-anchored transcatheter mitral valve replacement (TMVR) implant. MATERIALS AND METHODS. The atrial-anchored TMVR implant underwent an in vitro evaluation for MRI safety issues using standardized techniques and well-accepted methods. Magnetic field interactions including translational attraction and torque and artifacts were tested at 3 T. MRI-related heating was assessed at 1.5 T/64 MHz and 3 T/128 MHz using numeric simulations with analytical modeling and experimental testing. RESULTS. The atrial-anchored TMVR implant exhibited minor magnetic field interactions (9° deflection angle and no torque) at 3 T. The findings from the numeric simulations with analytical modeling were used to guide the placement of the implant in the phantom for the heating test and to identify the position on the implant that would result in the highest temperature rise. The highest temperature elevations recorded for the TMVR implant obtained on MRI at 1.5 T/64 MHz and 3 T/128 MHz were 2.7°C and 2.4°C, respectively. The maximum artifact size seen on a gradient echo pulse sequence extended approximately 5 mm relative to the size of the implant. CONCLUSION. The results of the tests performed on the atrial-anchored TMVR implant revealed no substantial concerns with respect to the conditions used in this investigation. Therefore, a patient with this new implant can safely undergo MRI by following the specific conditions defined by this study. The implant was deemed MR Conditional.
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109
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Mauricio R, Kumbhani DJ. MitraClip: How Do We Reconcile the Inconsistent Findings of MITRA-FR and COAPT? Curr Cardiol Rep 2019; 21:150. [DOI: 10.1007/s11886-019-1239-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Hayashi H, Abe Y, Morita Y, Yamaji Y, Nakane E, Haruna Y, Haruna T, Inoko M. Prognostic significance of moderate primary mitral regurgitation and concomitant paroxysmal atrial fibrillation. J Cardiol 2019; 75:309-314. [PMID: 31522793 DOI: 10.1016/j.jjcc.2019.08.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 08/02/2019] [Accepted: 08/05/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND Severe primary mitral regurgitation [degenerative MR (DMR)] is associated with poor outcomes, including cardiac death and hospitalization due to worsening heart failure. However, little information is available regarding the characteristics of moderate DMR and their impacts on prognostic outcome. The aim of the present study was to investigate the prognosis and its determinants in patients with moderate DMR. METHODS We retroactively reviewed 13,700 consecutive patients who underwent transthoracic echocardiography and selected those with moderate DMR but without other underlying cardiac diseases. We assessed the characteristics and event-free rate of patients with moderate DMR compared with those of age- and gender-matched patients with mild or no MR. RESULTS The cohort included 182 (1%) patients with moderate DMR, and these were compared with 182 age- and gender-matched patients with mild or no MR. During the follow-up period of 1376 ± 652 days, 30 patients (8%) met the composite endpoint defined as cardiac death or hospitalization due to worsening heart failure. Kaplan-Meier analysis showed that patients with moderate DMR were significantly associated with a poor outcome compared to patients with mild or no MR (log-rank test p < 0.0001). Cox proportional hazard ratio revealed that moderate DMR and paroxysmal atrial fibrillation (PAF) were the independent predictors of the composite endpoint. CONCLUSIONS Patients with moderate DMR and concomitant PAF had a significantly worse outcome compared to those with mild or no MR. Active surveillance and some intervention for patients with PAF and moderate DMR may be required.
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Affiliation(s)
| | - Yukio Abe
- Department of Cardiology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka 534-0021, Japan.
| | - Yusuke Morita
- Cardiovascular Center, Kitano Hospital, Osaka, Japan
| | - Yuhei Yamaji
- Cardiovascular Center, Kitano Hospital, Osaka, Japan
| | - Eisaku Nakane
- Cardiovascular Center, Kitano Hospital, Osaka, Japan
| | | | | | - Moriaki Inoko
- Cardiovascular Center, Kitano Hospital, Osaka, Japan
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111
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Mantovani F, Bursi F, Di Giannuario G, Barbieri A. Echocardiographic prediction of surgical reparability in degenerative mitral regurgitation due to leaflet prolapse: a review. Expert Rev Cardiovasc Ther 2019; 17:653-662. [PMID: 31483165 DOI: 10.1080/14779072.2019.1664289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: Despite current guidelines provide recommendations for the optimal management of degenerative mitral regurgitation (MR), this condition remains often undertreated with delay in surgical referral and dismal effect on outcomes. Areas covered: This review focuses on the role of echocardiography in guiding mitral valve (MV) surgical repair in degenerative MR due to leaflet prolapse. Expert opinion: A stepwise protocol-driven echocardiography shared by referring physician and surgeon may help to guide referral to surgical repair in degenerative MR. This protocol particularly is useful to identify the ideal patho-anatomy for a successful and durable repair especially when early surgery is proposed and to refer the patient to centers of excellence in case of complex anatomy. Nearly 100% repair rate can be achieved when the surgical technique is adapted to the lesions seen in each valve. Three-dimensional echocardiography predicts repair complexity may be useful and should therefore be implemented. However, the current literature is far from comprehensive deriving from small, single-center studies. Therefore, reproducibility and external validation, especially with newly developed quantitative automated software, are still needed.
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Affiliation(s)
- Francesca Mantovani
- Department of Cardiology, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia , Reggio Emilia , Italy
| | - Francesca Bursi
- Department of Cardiology, Azienda Socio Sanitaria Territoriale (A.S.S.T.) SANTI PAOLO E CARLO - Presidio Ospedale San Paolo , Milano , Italy
| | | | - Andrea Barbieri
- Department of Cardiology, Azienda Ospedaliera-Universitaria di Modena , Modena , Italy
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112
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Nappi F, Avtaar Singh SS, Padala M, Attias D, Nejjari M, Mihos CG, Benedetto U, Michler R. The Choice of Treatment in Ischemic Mitral Regurgitation With Reduced Left Ventricular Function. Ann Thorac Surg 2019; 108:1901-1912. [PMID: 31445916 DOI: 10.1016/j.athoracsur.2019.06.039] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 05/15/2019] [Accepted: 06/10/2019] [Indexed: 01/26/2023]
Abstract
BACKGROUND Ischemic mitral regurgitation is a condition characterized by mitral insufficiency secondary to an ischemic left ventricle. Primarily, the pathology is the result of perturbation of normal regional left ventricular geometry combined with adverse remodeling. We present a comprehensive review of contemporary surgical, medical, and percutaneous treatment options for ischemic mitral regurgitation, rigorously examined by current guidelines and literature. METHODS We conducted a literature search of the PubMed database, Embase, and the Cochrane Library (through November 2018) for studies reporting perioperative or late mortality and echocardiographic outcomes after surgical and nonsurgical intervention for ischemic mitral regurgitation. RESULTS Treatment of this condition is challenging and often requires a multimodality approach. These patients usually have multiple comorbidities that may preclude surgery as a viable option. A multidisciplinary team discussion is crucial in optimizing outcomes. There are several options for treatment and management of ischemic mitral regurgitation with differing benefits and risks. Guideline-directed medical therapy for heart failure is the treatment choice for moderate and severe ischemic mitral regurgitation, with consideration of coronary revascularization, mitral valve surgery, cardiac resynchronization therapy, or a combination of these, in appropriate candidates. The use of transcatheter mitral valve therapy is considered appropriate in high-risk patients with severe ischemic mitral regurgitation, heart failure, and reduced left ventricular ejection fraction, especially in those with hemodynamic instability. CONCLUSIONS The role of mitral valve surgery and transcatheter mitral valve therapy continues to evolve.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France.
| | | | - Muralidhar Padala
- Structural Heart Research & Innovation, Laboratory, Carlyle Fraser Heart Center, Division of Cardiothoracic Surgery, Emory University, Atlanta, Georgia
| | - David Attias
- Department of Cardiology, Centre Cardiologique du Nord, Saint-Denis, France
| | - Mohammed Nejjari
- Department of Cardiology, Interventional Cardiology Centre Cardiologique du Nord, Saint-Denis, France
| | - Christos G Mihos
- Echocardiography Laboratory, Division of Cardiology, Columbia University, Mount Sinai Heart Institute, Miami Beach, Florida
| | - Umberto Benedetto
- Department of Cardiothoracic Surgery, Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Robert Michler
- Department of Surgery and Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York
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113
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Reddy YNV, Borlaug BA, O’Connor CM, Gersh BJ. Novel approaches to the management of chronic systolic heart failure: future directions and unanswered questions. Eur Heart J 2019; 41:1764-1774. [DOI: 10.1093/eurheartj/ehz364] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 03/25/2019] [Accepted: 05/10/2019] [Indexed: 02/06/2023] Open
Abstract
Abstract
Despite improvements in outcomes in the last few decades for heart failure (HF) with reduced ejection fraction (HFrEF), there still remains a need for novel therapies as many patients incompletely recover with existing therapies and progress to advanced HF. In this review, we will discuss recent advances in the management of HFrEF with a focus on upcoming therapies that hold the greatest promise for clinical use. We will discuss novel pharmacological therapies and areas of uncertainty with existing therapies. We will also discuss the potential utility and controversy surrounding novel interventions for HF such as percutaneous mitral valve repair, atrial fibrillation ablation, and other emerging interventions with positive signals for benefit in HFrEF. Finally, we will summarize the current state of stem cell and gene therapy for HFrEF and future directions.
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Affiliation(s)
- Yogesh N V Reddy
- The Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 First Street SW, MN 55906, USA
| | - Barry A Borlaug
- The Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 First Street SW, MN 55906, USA
| | | | - Bernard J Gersh
- The Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 First Street SW, MN 55906, USA
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114
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Kam D, Patel PA, Steinberg T, Feinman JW, MacKay EJ, Patel S, Mickus GJ, Fabbro M, Augoustides JGT. Percutaneous Edge-to-Edge Mitral Valve Repair: Navigating the Challenges of Multiple Mechanisms for Mitral Regurgitation. J Cardiothorac Vasc Anesth 2019; 33:2327-2333. [PMID: 31079894 DOI: 10.1053/j.jvca.2019.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Accepted: 04/07/2019] [Indexed: 12/14/2022]
Affiliation(s)
- David Kam
- Department of Anesthesiology, Perioperative Medicine and Pain Management, Miller School of Medicine, University of Miami, Miami, FL
| | - Prakash A Patel
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Toby Steinberg
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jared W Feinman
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Emily J MacKay
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Saumil Patel
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Gregory J Mickus
- Department of Anesthesiology, Perioperative Medicine and Pain Management, Miller School of Medicine, University of Miami, Miami, FL
| | - Michael Fabbro
- Department of Anesthesiology, Perioperative Medicine and Pain Management, Miller School of Medicine, University of Miami, Miami, FL
| | - John G T Augoustides
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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115
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Noack T, Janietz M, Lurz P, Kiefer P, Sieg F, Marin-Cuartas M, Spampinato R, Besler C, Rommel KP, Holzhey D, Mohr FW, Ender J, Borger MA, Seeburger J. Dynamic mitral valve geometry in patients with primary and secondary mitral regurgitation: implications for mitral valve repair†. Eur J Cardiothorac Surg 2019; 56:983-992. [DOI: 10.1093/ejcts/ezz096] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 03/04/2019] [Accepted: 03/04/2019] [Indexed: 01/02/2023] Open
Abstract
Abstract
OBJECTIVES
The goal of this study was to quantify the mitral valve (MV) annulus, the MV shape and the anatomical MV orifice area throughout the cardiac cycle using 4-dimensional MV analysis software in patients with primary mitral regurgitation (PMR) and secondary mitral regurgitation (SMR) in comparison to a healthy control group.
METHODS
Three-dimensional transoesophageal echocardiograms of the MV were acquired for 29 patients with PMR, for 28 patients with SMR and for 18 healthy control subjects. The MV was quantified with regards to anterior-posterior and lateromedial diameter, annular area and circumference, intertrigonal (IT) distance, annular sphericity index, annular height to commissural width ration, and anatomical MV orifice area throughout the cardiac cycle using 3-dimensional transoesophageal echocardiography-based 4-dimensional MV advanced analysis software.
RESULTS
Normal annulus dynamics display a systolic enlargement followed by an early-diastolic plateau phase and a late-diastolic contraction. The IT distance showed a linear association with the anterior-posterior diameter (= 1.11 × IT distance) and lateromedial diameter (= 1.44 × IT distance) in the control subjects. Mitral regurgitation is associated with a less dynamic, planar and dilated annulus with small variations between PMR and SMR. The IT distance was less affected by mitral regurgitation compared to the control subjects.
CONCLUSIONS
The novel 4-dimensional MV analysis allows new insights into the dynamic MV geometry in patients with PMR and SMR compared to the control subjects. The IT distance may be used to predict annuloplasty ring sizing.
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Affiliation(s)
- Thilo Noack
- University Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
| | - Marie Janietz
- University Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
| | - Philipp Lurz
- University Department of Internal Medicine/Cardiology, Heart Center Leipzig, Leipzig, Germany
| | - Philipp Kiefer
- University Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
| | - Franz Sieg
- University Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
| | - Mateo Marin-Cuartas
- University Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
| | - Ricardo Spampinato
- University Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
| | - Christian Besler
- University Department of Internal Medicine/Cardiology, Heart Center Leipzig, Leipzig, Germany
| | - Karl-Philipp Rommel
- University Department of Internal Medicine/Cardiology, Heart Center Leipzig, Leipzig, Germany
| | - David Holzhey
- University Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
| | | | - Joerg Ender
- Department of Anaesthesiology, Heart Center Leipzig, Leipzig, Germany
| | | | - Joerg Seeburger
- University Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
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116
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Moliterno DJ, Windecker S. Mitral Regurgitation and Evolving Transcatheter Treatments: Insights From the JACC Family of Journals. J Am Coll Cardiol 2019; 73:1353-1357. [PMID: 30898211 DOI: 10.1016/j.jacc.2019.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- David J Moliterno
- Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky.
| | - Stephan Windecker
- Department of Cardiology, Swiss Cardiovascular Center, University of Bern, Bern, Switzerland
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Pal N, Weitzel N, Kertai MD. Repair, Replace, or Watchful Waiting: A Contemporary Management of Mitral Valve Disease and Its Related Conditions. Semin Cardiothorac Vasc Anesth 2019; 23:5-10. [PMID: 30791858 DOI: 10.1177/1089253218817856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Nirvik Pal
- 1 Virginia Commonwealth University-Medical College of Virginia, Richmond, VA, USA
| | - Nathaen Weitzel
- 2 University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
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118
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Larouche-Lebel É, Loughran KA, Oyama MA. Echocardiographic indices and severity of mitral regurgitation in dogs with preclinical degenerative mitral valve disease. J Vet Intern Med 2019; 33:489-498. [PMID: 30793808 PMCID: PMC6430891 DOI: 10.1111/jvim.15461] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 02/06/2019] [Indexed: 12/03/2022] Open
Abstract
Background Describing severity of mitral regurgitation (MR) in dogs with degenerative mitral valve disease (DMVD) is challenging. Hypothesis/Objectives Mitral regurgitant fraction (RF), effective regurgitant orifice area (EROA), and the ratio of mitral regurgitant to aortic flow (QMR:QAo) can be calculated from routine echocardiographic measurements and provide additional information regarding MR severity. Animals Fifty‐seven dogs with preclinical DMVD including 36 without and 21 with cardiomegaly. Methods Prospective observational study. The expected relationships among RF, EROA, and QMR:QAo and 1‐dimensional measurements including left atrium to aortic root diameter ratio (LA:Ao) and normalized left ventricular internal dimension at end‐diastole (LVIDdN) were mathematically derived and calculated using echocardiographic data from the study population. Nonlinear goodness of fit was determined by calculation of the root mean standard error. The correlations between 1‐dimensional and multidimensional indices were analyzed using receiver operating characteristic curves. Results The relationships among RF, EROA, QMR:QAo, and both LA:Ao and LVIDdN were curvilinear, and the multidimensional indices differentiated MR of variable severity. By contrast, 1‐dimensional measurements were insensitive to MR severity until RF equaled or exceeded 50%. Regurgitant fraction ≥50%, EROA to body surface area ≥0.347 and QMR:QAo ≥0.79 were strongly associated with LA:Ao ≥1.6 and LVIDdN ≥1.7. Conclusions and Clinical Importance Regurgitant fraction, EROA, and QMR:QAo quantify MR severity in dogs with preclinical DMVD in a manner that 1‐dimensional measurements do not.
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Affiliation(s)
- Éva Larouche-Lebel
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kerry A Loughran
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark A Oyama
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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119
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Maksuti E, Westerhof BE, Ugander M, Donker DW, Carlsson M, Broomé M. Cardiac remodeling in aortic and mitral valve disease: a simulation study with clinical validation. J Appl Physiol (1985) 2019; 126:1377-1389. [PMID: 30730809 DOI: 10.1152/japplphysiol.00791.2018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Remodeling is an important long-term determinant of cardiac function throughout the progression of heart disease. Numerous biomolecular pathways for mechanosensing and transduction are involved. However, we hypothesize that biomechanical factors alone can explain changes in myocardial volume and chamber size in valve disease. A validated model of the human vasculature and the four cardiac chambers was used to simulate aortic stenosis, mitral regurgitation, and aortic regurgitation. Remodeling was simulated with adaptive feedback preserving myocardial fiber stress and wall shear stress in all four cardiac chambers. Briefly, the model used myocardial fiber stress to determine wall thickness and cardiac chamber wall shear stress to determine chamber volume. Aortic stenosis resulted in the development of concentric left ventricular hypertrophy. Aortic and mitral regurgitation resulted in eccentric remodeling and eccentric hypertrophy, with more pronounced hypertrophy for aortic regurgitation. Comparisons with published clinical data showed the same direction and similar magnitudes of changes in end-diastolic volume index and left ventricular diameters. Changes in myocardial wall volume and wall thickness were within a realistic range in both stenotic and regurgitant valvular disease. Simulations of remodeling in left-sided valvular disease support, in both a qualitative and quantitative manner, that left ventricular chamber size and hypertrophy are primarily determined by preservation of wall shear stress and myocardial fiber stress. NEW & NOTEWORTHY Cardiovascular simulations with adaptive feedback that normalizes wall shear stress and fiber stress in the cardiac chambers could predict, in a quantitative and qualitative manner, remodeling patterns seen in patients with left-sided valvular disease. This highlights how mechanical stress remains a fundamental aspect of cardiac remodeling. This in silico study validated with clinical data paves the way for future patient-specific predictions of remodeling in valvular disease.
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Affiliation(s)
- Elira Maksuti
- Extracorporeal Membrane Oxygenation Department, Karolinska University Hospital, Stockholm, Sweden
| | - Berend E Westerhof
- Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Universitair Medische Centra, Vrije Universiteit Amsterdam , Amsterdam , The Netherlands
| | - Martin Ugander
- Department of Clinical Physiology, Karolinska Institutet and Karolinska University Hospital , Stockholm , Sweden
| | - Dirk W Donker
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University , Utrecht , The Netherlands
| | - Marcus Carlsson
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Skane University Hospital , Lund , Sweden
| | - Michael Broomé
- Extracorporeal Membrane Oxygenation Department, Karolinska University Hospital, Stockholm, Sweden.,Anesthesia and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet , Stockholm , Sweden
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McConkey H, Zhao Z, Redwood S, Chen M, Prendergast BD. Timing and mode of intervention for patients with left sided valvular heart disease: an individualized approach. PRECISION CLINICAL MEDICINE 2018; 1:118-128. [PMID: 35692702 PMCID: PMC8985789 DOI: 10.1093/pcmedi/pby017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 11/20/2018] [Accepted: 11/20/2018] [Indexed: 02/05/2023] Open
Abstract
Left sided valvular heart disease poses major impact on life and lifestyle. Medical therapy merely palliates chronic severe valve disease and once symptoms or haemodynamic sequelae appear, life expectancy is markedly truncated. In this article, we review the mechanisms of valve pathology, latest evidence in the quest for pharmacological options, means by which to predict deterioration, and standard and novel treatment options.
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Affiliation(s)
- Hannah McConkey
- King’s College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas’ Hospital Campus, London, United Kingdom, and the Department of Cardiology, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Zhengang Zhao
- Department of Cardiology, West China Hospital, Sichuan University
| | - S Redwood
- King’s College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas’ Hospital Campus, London, United Kingdom, and the Department of Cardiology, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom
| | - M Chen
- Department of Cardiology, West China Hospital, Sichuan University
| | - B D Prendergast
- King’s College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas’ Hospital Campus, London, United Kingdom, and the Department of Cardiology, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom
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