151
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Pecini R, Thune JJ, Torp-Pedersen C, Hassager C, Køber L. The relationship between mitral regurgitation and ejection fraction as predictors for the prognosis of patients with heart failure. Eur J Heart Fail 2014; 13:1121-5. [DOI: 10.1093/eurjhf/hfr114] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Redi Pecini
- Department of Cardiology and Endocrinology; Frederiksberg Hospital, University of Copenhagen; Copenhagen Denmark
| | - Jens Jakob Thune
- Department of Cardiology; Bispebjerg Hospital, University of Copenhagen; Copenhagen Denmark
| | | | - Christian Hassager
- Department of Cardiology, Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet; University of Copenhagen; Copenhagen Denmark
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152
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Bhattacharya S, Pham T, He Z, Sun W. Tension to passively cinch the mitral annulus through coronary sinus access: an ex vivo study in ovine model. J Biomech 2014; 47:1382-8. [PMID: 24607007 DOI: 10.1016/j.jbiomech.2014.01.044] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Revised: 01/22/2014] [Accepted: 01/23/2014] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The transcatheter mitral valve repair (TMVR) technique utilizes a stent to cinch a segment of the mitral annulus (MA) and reduces mitral regurgitation. The cinching mechanism results in reduction of the septal-lateral distance. However, the mechanism has not been characterized completely. In this study, a method was developed to quantify the relation between cinching tension and MA area in an ex vivo ovine model. METHOD The cinching tension was measured from a suture inserted within the coronary sinus (CS) vessel with one end tied to the distal end of the vessel and the other end exited to the CS ostium where it was attached to a force transducer on a linear stage. The cinching tension, MA area, septal-lateral (S-L) and commissure-commissure (C-C) diameters and leakage was simultaneously measured in normal and dilated condition, under a hydrostatic left ventricular pressure of 90 mm Hg. RESULTS The MA area was increased up to 22.8% after MA dilation. A mean tension of 2.1 ± 0.5 N reduced the MA area by 21.3 ± 5.6% and S-L diameter by 24.2 ± 5.3%. Thus, leakage was improved by 51.7 ± 16.2% following restoration of normal MA geometry. CONCLUSION The cinching tension generated by the suture acts as a compensation force in MA reduction, implying the maximum tension needed to be generated by annuloplasty device to restore normal annular size. The relationship between cinching tension and the corresponding MA geometry will contribute to the development of future TMVR devices and understanding of myocardial contraction function.
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Affiliation(s)
- Shamik Bhattacharya
- Tissue Mechanics Laboratory Biomedical Engineering Program and Department of Mechanical Engineering University of Connecticut, Storrs, CT 06269, United States
| | - Thuy Pham
- Tissue Mechanics Laboratory Biomedical Engineering Program and Department of Mechanical Engineering University of Connecticut, Storrs, CT 06269, United States
| | - Zhaoming He
- Department of Mechanical Engineering Texas Tech University, Lubbock, TX 79409, United States
| | - Wei Sun
- Tissue Mechanics Laboratory Biomedical Engineering Program and Department of Mechanical Engineering University of Connecticut, Storrs, CT 06269, United States.
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153
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Ducas RA, White CW, Wassef AW, Farag A, Bhagirath KM, Freed DH, Tam JW. Functional Mitral Regurgitation: Current Understanding and Approach to Management. Can J Cardiol 2014; 30:173-80. [DOI: 10.1016/j.cjca.2013.11.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 11/21/2013] [Accepted: 11/21/2013] [Indexed: 11/25/2022] Open
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154
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Paparella D, Malvindi PG, Romito R, Fiore G, Tupputi Schinosa LDL. Ischemic mitral regurgitation: pathophysiology, diagnosis and surgical treatment. Expert Rev Cardiovasc Ther 2014; 4:827-38. [PMID: 17173499 DOI: 10.1586/14779072.4.6.827] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Ischemic mitral valve regurgitation often complicates acute myocardial infarction and also represents a negative prognostic factor for long-term survival in patients undergoing surgical myocardial revascularization. While severe mitral regurgitation should always be corrected during a coronary artery bypass operation, the decision making is more difficult in patients with a mild-to-moderate degree of regurgitation. Recent studies and experimental protocols have elucidated the pathophysiological mechanisms leading to mitral regurgitation with great interest in annular modifications and subvalvular alterations. These data suggest that new and integrated surgical approaches that address annuloplasty ring sizing, ring type selection and tethering phenomenon (i.e., chordal cutting, 'edge-to-edge' technique and left-ventricular plasty techniques) are required for a safer and durable valve repair. Transthoracic and transesophageal echocardiography are useful in determining the etiology and the degree of mitral regurgitation, to assess mitral deformation and to measure indexes of global and regional left-ventricular remodeling. Stress echocardiography may unmask higher degrees of mitral regurgitation. More data are needed in order to confirm the promising and interesting preliminary experimental findings of magnetic resonance imaging in diagnosis and clinical evaluation of ischemic mitral regurgitation.
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Affiliation(s)
- Domenico Paparella
- University of Bari, Division of Cardiac Surgery, Piazza Giulio Cesare 11, 70100 Bari, Italy.
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155
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Cubeddu RJ, Palacios IF. Percutaneous heart valve replacement and repair: advances and future potential. Expert Rev Cardiovasc Ther 2014; 7:811-21. [DOI: 10.1586/erc.09.67] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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156
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Connell JM, Worthington A, Chen FY, Shernan SK. Ischemic mitral regurgitation: mechanisms, intraoperative echocardiographic evaluation, and surgical considerations. Anesthesiol Clin 2014; 31:281-98. [PMID: 23711645 DOI: 10.1016/j.anclin.2013.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Ischemic mitral regurgitation (IMR) is a subcategory of functional rather than organic, mitral valve (MV) disease. Whether reversible or permanent, left ventricular remodeling creates IMR that is complex and multifactorial. A comprehensive TEE examination in patients with IMR may have important implications for perioperative clinical decision making. Several TEE measures predictive of MV repair failure have been identified. Current practice among most surgeons is to typically repair the MV in patients with IMR. MV replacement is usually reserved for situations in which the valve cannot be reasonably repaired, or repair is unlikely to be tolerated clinically.
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Affiliation(s)
- John M Connell
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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157
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Acker MA, Parides MK, Perrault LP, Moskowitz AJ, Gelijns AC, Voisine P, Smith PK, Hung JW, Blackstone EH, Puskas JD, Argenziano M, Gammie JS, Mack M, Ascheim DD, Bagiella E, Moquete EG, Ferguson TB, Horvath KA, Geller NL, Miller MA, Woo YJ, D'Alessandro DA, Ailawadi G, Dagenais F, Gardner TJ, O'Gara PT, Michler RE, Kron IL. Mitral-valve repair versus replacement for severe ischemic mitral regurgitation. N Engl J Med 2014; 370:23-32. [PMID: 24245543 PMCID: PMC4128011 DOI: 10.1056/nejmoa1312808] [Citation(s) in RCA: 655] [Impact Index Per Article: 65.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Ischemic mitral regurgitation is associated with a substantial risk of death. Practice guidelines recommend surgery for patients with a severe form of this condition but acknowledge that the supporting evidence for repair or replacement is limited. METHODS We randomly assigned 251 patients with severe ischemic mitral regurgitation to undergo either mitral-valve repair or chordal-sparing replacement in order to evaluate efficacy and safety. The primary end point was the left ventricular end-systolic volume index (LVESVI) at 12 months, as assessed with the use of a Wilcoxon rank-sum test in which deaths were categorized below the lowest LVESVI rank. RESULTS At 12 months, the mean LVESVI among surviving patients was 54.6±25.0 ml per square meter of body-surface area in the repair group and 60.7±31.5 ml per square meter in the replacement group (mean change from baseline, -6.6 and -6.8 ml per square meter, respectively). The rate of death was 14.3% in the repair group and 17.6% in the replacement group (hazard ratio with repair, 0.79; 95% confidence interval, 0.42 to 1.47; P=0.45 by the log-rank test). There was no significant between-group difference in LVESVI after adjustment for death (z score, 1.33; P=0.18). The rate of moderate or severe recurrence of mitral regurgitation at 12 months was higher in the repair group than in the replacement group (32.6% vs. 2.3%, P<0.001). There were no significant between-group differences in the rate of a composite of major adverse cardiac or cerebrovascular events, in functional status, or in quality of life at 12 months. CONCLUSIONS We observed no significant difference in left ventricular reverse remodeling or survival at 12 months between patients who underwent mitral-valve repair and those who underwent mitral-valve replacement. Replacement provided a more durable correction of mitral regurgitation, but there was no significant between-group difference in clinical outcomes. (Funded by the National Institutes of Health and the Canadian Institutes of Health; ClinicalTrials.gov number, NCT00807040.).
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Affiliation(s)
- Michael A Acker
- From the Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia (M.A.A., Y.J.W.); the International Center for Health Outcomes and Innovation Research (InCHOIR), Department of Health Evidence and Policy, Mount Sinai School of Medicine (M.K.P., A.J.M., A.C.G., D.D.A., E.B., E.G.M.), Division of Cardiothoracic Surgery, Department of Surgery, College of Physicians and Surgeons, Columbia University (M.A.), and the Department of Cardiothoracic Surgery, Montefiore Medical Center and Albert Einstein College of Medicine (D.A.D., R.E.M.) - all in New York; Montreal Heart Institute, University of Montreal, Montreal (L.P.P.); Institut Universitaire de Cardiologie de Québec, Hôpital Laval, Quebec, QC, Canada (P.V., F.D.); the Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham (P.K.S.), and the Department of Cardiovascular Sciences, East Carolina Heart Institute at East Carolina University, Greenville (T.B.F.) - both in North Carolina; Echocardiography Core Lab, Massachusetts General Hospital (J.W.H.), and Cardiovascular Division, Brigham and Women's Hospital (P.T.O.) - both in Boston; the Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland (E.H.B.); Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta (J.D.P.); Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore (J.S.G.); Baylor Research Institute, Dallas (M.M.); National Institutes of Health (NIH) Heart Center at Suburban Hospital (K.A.H.), and the Office of Biostatistics Research (N.L.G.) and the Division of Cardiovascular Sciences (M.A.M.), NIH - all in Bethesda, MD; the Division of Thoracic and Cardiovascular Surgery, University of Virginia School of Medicine, Charlottesville (G.A., I.L.K.); and the Center for Heart and Vascular Health, Christiana Care Health System, Newark, DE (T.J
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158
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Kuhl E. Growing matter: a review of growth in living systems. J Mech Behav Biomed Mater 2013; 29:529-43. [PMID: 24239171 DOI: 10.1016/j.jmbbm.2013.10.009] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Revised: 10/05/2013] [Accepted: 10/09/2013] [Indexed: 12/26/2022]
Abstract
Living systems can grow, develop, adapt, and evolve. These phenomena are non-intuitive to traditional engineers and often difficult to understand. Yet, classical engineering tools can provide valuable insight into the mechanisms of growth in health and disease. Within the past decade, the concept of incompatible configurations has evolved as a powerful tool to model growing systems within the framework of nonlinear continuum mechanics. However, there is still a substantial disconnect between the individual disciplines, which explore the phenomenon of growth from different angles. Here we show that the nonlinear field theories of mechanics provide a unified concept to model finite growth by means of a single tensorial internal variable, the second order growth tensor. We review the literature and categorize existing growth models by means of two criteria: the microstructural appearance of growth, either isotropic or anisotropic; and the microenvironmental cues that drive the growth process, either chemical or mechanical. We demonstrate that this generic concept is applicable to a broad range of phenomena such as growing arteries, growing tumors, growing skin, growing airway walls, growing heart valve leaflets, growing skeletal muscle, growing plant stems, growing heart valve annuli, and growing cardiac muscle. The proposed approach has important biological and clinical applications in atherosclerosis, in-stent restenosis, tumor invasion, tissue expansion, chronic bronchitis, mitral regurgitation, limb lengthening, tendon tear, plant physiology, dilated and hypertrophic cardiomyopathy, and heart failure. Understanding the mechanisms of growth in these chronic conditions may open new avenues in medical device design and personalized medicine to surgically or pharmacologically manipulate development and alter, control, or revert disease progression.
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Affiliation(s)
- Ellen Kuhl
- Departments of Mechanical Engineering, Bioengineering, and Cardiothoracic Surgery, Stanford University, Stanford, CA, USA.
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159
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Nouri M, Tokaldany ML, Shahrzad M, Mardanloo AS, Ahmadi SH, Roomi ZS, Sadeghian H. Echocardiographic determinants of ischemic mitral regurgitation. J Card Surg 2013; 28:359-65. [PMID: 23879338 DOI: 10.1111/jocs.12145] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES It is not clear whether the presence and degree of chronic ischemic mitral regurgitation (IMR) in patients with left ventricular (LV) dysfunction are related to LV dysfunction, local LV remodeling or mitral valve deformation. We sought to establish the strongest determinants of IMR severity in patients with LV dysfunction and IMR. METHODS We prospectively performed transthoracic echocardiography for 135 patients (mean age = 60.76 ± 9.69 years, 71.9% male) with LV dysfunction (ejection fraction ≤ 50%) and coronary artery disease (70% stenosis in ≥ 1 coronary artery and no myocardial infarction during the previous 16 days). Global and local LV remodeling and mitral deformity indices were measured. Using the vena contracta, MR severity was graded as no regurgitation; mild; moderate; and severe. RESULTS Mild regurgitation was found in 45 (33.3%) patients, moderate in 71 (52.6%), severe in 6 (4.4%), and no regurgitation in 13 (9.6%). By linear logistic multivariable analysis, the major echocardiographic determinants of MR severity were tenting area (TA), sphericity index (LV systolic length/width), and C-septal (distance between the leaflet coaptation and the septum). TA was best related to coaptation depth and annulus diameter. Mitral annular diameter was best correlated with left atrial surface area (r = 0.630, p < 0.001). CONCLUSION TA was significantly correlated with annulus diameter and, along with sphericity index and C-septal, were the independent echocardiographic determinants of MR severity. These findings warrant consideration when performing mitral valve repairs for patients with IMR.
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Affiliation(s)
- Masoumeh Nouri
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
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160
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Ring L, Dutka DP, Wells FC, Fynn SP, Shapiro LM, Rana BS. Mechanisms of atrial mitral regurgitation: insights using 3D transoesophageal echo. Eur Heart J Cardiovasc Imaging 2013; 15:500-8. [DOI: 10.1093/ehjci/jet191] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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161
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Chen X, Hsiung MC, Mu Y. The impact of segmental volumetric changes on functional mitral regurgitation: a study using three-dimensional regional time-volume analysis combined with low-dose dobutamine. Echocardiography 2013; 31:172-8. [PMID: 24102964 DOI: 10.1111/echo.12306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
PURPOSE Using transthoracic three-dimensional (3D) echo regional volume analysis combined with low-dose dobutamine to investigate the effects on regional volume, mitral configuration and functional mitral regurgitation (FMR). METHODS Fifty-six patients with ischemic cardiomyopathy (ICM) were included in this study. The effective regurgitant orifice area (EROA) of FMR secondary to ICM with depressed left ventricular ejection fraction was compared with mitral tenting area and coaptation height (CH) before and after low-dose dobutamine (10 μg/kg per min). Using 3-DQ software we measured and calculated regional stroke-volumes (rSV), the ratio of the rSV to the whole left ventricular stroke volume (rgSVratio) in all 17 segments and the average rgSVratio of 4 anterior-PM attached segments (rgSVratio-aver anter-PM), 4 posterior-PM attached segments (rgSVratio-aver post-PM), 8 PMs attached segments (rgSVratio-aver PMs) and all 17 segments before and after dobutamine. RESULTS Compared with the resting condition, the SVr and rgSVratio on the basal and mid segments of anterior, lateral, inferior, and posterior walls were increased after dobutamine infusion (P < 0.05). EROA at rest was associated with tenting area, CH and rgSVratio-aver of PMs and the reduction in EROA caused by dobutamine was associated with reductions in tenting area, CH and increases in rgSVratio-aver of PMs. Tenting area was associated with rgSVratio-aver of PMs and reduction caused by dobutamine was associated with increases in rgSVratio-aver of PMs. CONCLUSIONS The FMR decreasing during low-dose dobutamine is quantitatively associated with the regional LV volume change of attached PMs. Real time transthoracic three-dimensional echocardiography may provide a simple and noninvasive approach to assess regional LV time-volume characteristic during FMR.
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Affiliation(s)
- Xiaofeng Chen
- Department of Echocardiography, First Affiliated Hospital, Xinjiang Medical University, Urmuqi, China
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162
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Mancuso FJN, Moisés VA, Almeida DR, Oliveira WA, Poyares D, Brito FS, de Paola AAV, Carvalho ACC, Campos O. Criteria for mitral regurgitation classification were inadequate for dilated cardiomyopathy. Arq Bras Cardiol 2013; 101:457-65. [PMID: 24100692 PMCID: PMC4081170 DOI: 10.5935/abc.20130200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 06/07/2013] [Indexed: 01/20/2023] Open
Abstract
Background Mitral regurgitation (MR) is common in patients with dilated cardiomyopathy (DCM).
It is unknown whether the criteria for MR classification are inadequate for
patients with DCM. Objective We aimed to evaluate the agreement among the four most common echocardiographic
methods for MR classification. Methods Ninety patients with DCM were included. Functional MR was classified using four
echocardiographic methods: color flow jet area (JA), vena contracta (VC),
effective regurgitant orifice area (ERO) and regurgitant volume (RV). MR was
classified as mild, moderate or important according to the American Society of
Echocardiography criteria and by dividing the values into terciles. The Kappa test
was used to evaluate whether the methods agreed, and the Pearson correlation
coefficient was used to evaluate the correlation between the absolute values of
each method. Results MR classification according to each method was as follows: JA: 26 mild, 44
moderate, 20 important; VC: 12 mild, 72 moderate, 6 important; ERO: 70 mild, 15
moderate, 5 important; RV: 70 mild, 16 moderate, 4 important. The agreement was
poor among methods (kappa = 0.11; p < 0.001). It was observed a strong
correlation between the absolute values of each method, ranging from 0.70 to 0.95
(p < 0.01) and the agreement was higher when values were divided into terciles
(kappa = 0.44; p < 0.01) Conclusion The use of conventional echocardiographic criteria for MR classification seems
inadequate in patients with DCM. It is necessary to establish new cutoff values
for MR classification in these patients.
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Affiliation(s)
- Frederico José Neves Mancuso
- Disciplina de Cardiologia - EPM/UNIFESP - Escola Paulista de Medicina -
Universidade Federal de São Paulo, São Paulo, SP - Brazil
- Mailing Addres: Frederico José Neves Mancuso, Rua Domiciano Leite
Ribeiro, 51, Apto. 13 - bloco 2, Vila Guarani. Postal Code 04317-000, São Paulo, SP -
Brazil. ,
| | - Valdir Ambrosio Moisés
- Disciplina de Cardiologia - EPM/UNIFESP - Escola Paulista de Medicina -
Universidade Federal de São Paulo, São Paulo, SP - Brazil
| | - Dirceu Rodrigues Almeida
- Disciplina de Cardiologia - EPM/UNIFESP - Escola Paulista de Medicina -
Universidade Federal de São Paulo, São Paulo, SP - Brazil
| | - Wercules Antonio Oliveira
- Instituto do Sono - EPM/UNIFESP - Escola Paulista de Medicina -
Universidade Federal de São Paulo, São Paulo, SP - Brazil
| | - Dalva Poyares
- Instituto do Sono - EPM/UNIFESP - Escola Paulista de Medicina -
Universidade Federal de São Paulo, São Paulo, SP - Brazil
| | - Flavio Souza Brito
- Disciplina de Cardiologia - EPM/UNIFESP - Escola Paulista de Medicina -
Universidade Federal de São Paulo, São Paulo, SP - Brazil
| | - Angelo Amato Vincenzo de Paola
- Disciplina de Cardiologia - EPM/UNIFESP - Escola Paulista de Medicina -
Universidade Federal de São Paulo, São Paulo, SP - Brazil
| | - Antonio Carlos Camargo Carvalho
- Disciplina de Cardiologia - EPM/UNIFESP - Escola Paulista de Medicina -
Universidade Federal de São Paulo, São Paulo, SP - Brazil
| | - Orlando Campos
- Disciplina de Cardiologia - EPM/UNIFESP - Escola Paulista de Medicina -
Universidade Federal de São Paulo, São Paulo, SP - Brazil
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Magne J, Pibarot P. Left Ventricular Systolic Function in Ischemic Mitral Regurgitation: Time to Look beyond Ejection Fraction. J Am Soc Echocardiogr 2013; 26:1130-1134. [DOI: 10.1016/j.echo.2013.08.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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164
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Right Ventricular Mechanical Dyssynchrony and Asymmetric Contraction in Hypoplastic Heart Syndrome are Associated with Tricuspid Regurgitation. J Am Soc Echocardiogr 2013; 26:1214-1220. [DOI: 10.1016/j.echo.2013.06.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2012] [Indexed: 11/23/2022]
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165
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Rabbah JPM, Saikrishnan N, Siefert AW, Santhanakrishnan A, Yoganathan AP. Mechanics of healthy and functionally diseased mitral valves: a critical review. J Biomech Eng 2013; 135:021007. [PMID: 23445052 DOI: 10.1115/1.4023238] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The mitral valve is a complex apparatus with multiple constituents that work cohesively to ensure unidirectional flow between the left atrium and ventricle. Disruption to any or all of the components-the annulus, leaflets, chordae, and papillary muscles-can lead to backflow of blood, or regurgitation, into the left atrium, which deleteriously effects patient health. Through the years, a myriad of surgical repairs have been proposed; however, a careful appreciation for the underlying structural mechanics can help optimize long-term repair durability and inform medical device design. In this review, we aim to present the experimental methods and significant results that have shaped the current understanding of mitral valve mechanics. Data will be presented for all components of the mitral valve apparatus in control, pathological, and repaired conditions from human, animal, and in vitro studies. Finally, current strategies of patient specific and noninvasive surgical planning will be critically outlined.
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Affiliation(s)
- Jean-Pierre M Rabbah
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA 30332, USA
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166
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Mahmood F, Shakil O, Mahmood B, Chaudhry M, Matyal R, Khabbaz KR. Mitral annulus: an intraoperative echocardiographic perspective. J Cardiothorac Vasc Anesth 2013; 27:1355-63. [PMID: 23962462 DOI: 10.1053/j.jvca.2013.02.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Indexed: 11/11/2022]
Affiliation(s)
- Feroze Mahmood
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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167
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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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168
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Three-dimensional echocardiography: a new paradigm shift. J Echocardiogr 2013; 12:1-11. [DOI: 10.1007/s12574-013-0189-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Revised: 07/04/2013] [Accepted: 07/15/2013] [Indexed: 11/25/2022]
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Attari M, Legrand M, Philippe C, Rosak P. [Valvular surgery for an exercise-induced functional mitral regurgitation in heart failure and preserved ejection fraction: a case study]. Ann Cardiol Angeiol (Paris) 2013; 62:278-281. [PMID: 22436632 DOI: 10.1016/j.ancard.2011.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2011] [Accepted: 09/26/2011] [Indexed: 05/31/2023]
Abstract
We here report the case of a 67-year-old woman with moderate mitral regurgitation without significant structural abnormalities that get worse during severe recurrent heart failures and preserved ejection fraction with concomitant paroxysmal atrial fibrillation. Atrial fibrillation became permanent and despite a well-controlled cardiac frequency, new heart failure episodes occurred. Exercise doppler echocardiography showed that the mechanism of this mitral regurgitation was a two leaflet mitral tenting. We discuss here the different mechanisms that could induce these kinds of mitral regurgitation with excessive tenting. We emphasize the interest of early detection by exercise doppler echocardiography even when a triggering factor like atrial fibrillation seems to be involved. We also discuss the interest of mitral valve replacement for these patients.
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Affiliation(s)
- M Attari
- Pôle Neurocardiologie, centre hospitalier du Mans, 194, avenue Rubillard, 72037 Le Mans cedex 9, France
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170
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Guo YK, Yang ZG, Shao H, Deng W, Ning G, Dong ZH. Right ventricular dysfunction and dilatation in patients with mitral regurgitation: Analysis using ECG-gated multidetector row computed tomography. Int J Cardiol 2013; 167:1585-90. [DOI: 10.1016/j.ijcard.2012.04.104] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2011] [Revised: 03/29/2012] [Accepted: 04/15/2012] [Indexed: 11/29/2022]
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171
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Shakil O, Jainandunsing JS, Ilic R, Matyal R, Mahmood F. Ischemic Mitral Regurgitation: An Intraoperative Echocardiographic Perspective. J Cardiothorac Vasc Anesth 2013; 27:573-85. [DOI: 10.1053/j.jvca.2012.06.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2012] [Indexed: 11/11/2022]
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172
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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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Buziashvili YI, Koksheneva IV, Khuzurauli EM, Arutyunova YE, Makhmudov SG. LEFT VENTRICULAR REMODELLING AND MITRAL VALVE REMODELLING IN CORONARY HEART DISEASE PATIENTS WITH POST-SURGERY PROGRESSION OF MITRAL REGURGITATION. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2013. [DOI: 10.15829/1728-8800-2013-2-30-40] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
The progression of ischemic mitral regurgitation (MR) after coronary arty bypass graft (CABG) surgery remains one of the most complex and still unresolved problems in the treatment of coronary heart disease (CHD).Aim. To study myocardial function, left ventricular (LV) remodelling, and mitral valve (MV) remodelling in CHD patients with MR progression after isolated CABG or CABG combined with LV reconstructive surgery.Material and methods. In total, 101 CHD patients after CABG were included in the analysis.Results. The mechanisms of MR progression after isolated CABG differ from those after CABG and LV reconstructive surgery. After the former, LV remodelling progresses both locally and globally, while after the latter, the LV remodelling progression is predominantly global. The patients with post-surgery MR progression differ from their peers without MR in terms of all key parameters of MV geometry.Conclusion. The leading mechanism of MR progression is local and global LV remodelling, which leads to papillary muscle dislocation and MV leaflet tension and restricted motion. The categories of patients with a high risk of post-surgery MR progression are defined.
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Affiliation(s)
- Yu. I. Buziashvili
- A. N. Bakoulev Research Centre for Cardiovascular Surgery, Russian Academy of Medical Sciences. Moscow
| | - I. V. Koksheneva
- A. N. Bakoulev Research Centre for Cardiovascular Surgery, Russian Academy of Medical Sciences. Moscow
| | - E. M. Khuzurauli
- A. N. Bakoulev Research Centre for Cardiovascular Surgery, Russian Academy of Medical Sciences. Moscow
| | - Ya. E. Arutyunova
- A. N. Bakoulev Research Centre for Cardiovascular Surgery, Russian Academy of Medical Sciences. Moscow
| | - Sh. G. Makhmudov
- A. N. Bakoulev Research Centre for Cardiovascular Surgery, Russian Academy of Medical Sciences. Moscow
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Functional mitral regurgitation: a 30-year unresolved surgical journey from valve replacement to complex valve repairs. Heart Fail Rev 2013; 19:341-58. [DOI: 10.1007/s10741-013-9392-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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175
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Abstract
The mitral valve apparatus is a complex 3-dimensional (3D) functional unit that is critical to unidirectional heart pump function. This review details the normal anatomy, histology, and function of the main mitral valve apparatus components: mitral annulus, mitral valve leaflets, chordae tendineae, and papillary muscles. Two-dimensional and 3D echocardiography is ideally suited to examine the mitral valve apparatus and has provided important insights into the mechanism of mitral valve disease. An overview of standardized echocardiography image acquisition and interpretation is provided. Understanding normal mitral valve apparatus function is essential to comprehend alterations in mitral valve disease and the rationale for repair strategies.
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176
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Abe H, Caracciolo G, Kheradvar A, Pedrizzetti G, Khandheria BK, Narula J, Sengupta PP. Contrast echocardiography for assessing left ventricular vortex strength in heart failure: a prospective cohort study. ACTA ACUST UNITED AC 2013; 14:1049-60. [DOI: 10.1093/ehjci/jet049] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Hsuan CF, Yu HY, Tseng WK, Lin LC, Hsu KL, Wu CC. Quantitation of the mitral tetrahedron in patients with ischemic heart disease using real-time three-dimensional echocardiography to evaluate the geometric determinants of ischemic mitral regurgitation. Clin Cardiol 2013; 36:286-92. [PMID: 23494571 DOI: 10.1002/clc.22111] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Accepted: 02/09/2013] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Ischemic mitral regurgitation (IMR) is common in ischemic heart disease and results in poor prognosis. However, the exact mechanism of IMR has not been fully elucidated. HYPOTHESIS Quantitation of the mitral tetrahedron using three-dimentianl (3D) echocardiography is capable of evaluating the geometric determinants and mechanisms of IMR. METHODS Forty patients with a history of ST-elevation myocardial infarction at least 6 months earlier were studied. Parameters of mitral deformation and global left ventricular (LV) function and shape were evaluated by 2-dimensional echocardiography. The effective regurgitant orifice (ERO) of IMR was obtained by the quantitative continuous-wave Doppler technique. Three-dimensional (3D) echocardiography was applied to assess the mitral tetrahedron. RESULTS Mitral valvular tenting area (P < 0.001), mitral annular area (P = 0.032), dilation of the LV in diastole, impairment of the LV ejection fraction, and volume of the spherically shaped LV in systole were greater in patients with an ERO ≥20 mm(2) than in those with an ERO <20 mm(2). In the mitral tetrahedron, only the interpapillary muscle roots distance showed a significant difference (P = 0.004). Multivariate analysis with the logistic regression model showed the systolic mitral tenting area (odds ratio [OR]: 280.49, 95% confidence interval [CI]: 4.59-1.72 × 10(4), P = 0.007) and interpapillary muscle distance (OR: 1.50, 95% CI: 1.03-2.19, P = 0.036) to be independent factors in predicting significant IMR (ERO ≥20 mm(2)). CONCLUSIONS 3D echocardiography can be effectively applied in measuring the mitral tetrahedron and evaluating the mechanism of IMR. Mitral valvular tenting and interpapillary muscle distance are 2 independent factors of significant IMR.
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Affiliation(s)
- Chin-Feng Hsuan
- Division of Cardiology, Department of Internal Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
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178
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Nickenig G, Mohr F, Kelm M, Kuck KH, Boekstegers P, Hausleiter J, Schillinger W, Brachmann J, Lange R, Reichenspurner H. Konsensus der Deutschen Gesellschaft für Kardiologie – Herz- und Kreislaufforschung – und der Deutschen Gesellschaft für Thorax-, Herz- und Gefäßchirurgie zur Behandlung der Mitralklappeninsuffizienz. KARDIOLOGE 2013. [DOI: 10.1007/s12181-013-0488-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Beaudoin J, Handschumacher MD, Zeng X, Hung J, Morris EL, Levine RA, Schwammenthal E. Mitral valve enlargement in chronic aortic regurgitation as a compensatory mechanism to prevent functional mitral regurgitation in the dilated left ventricle. J Am Coll Cardiol 2013; 61:1809-16. [PMID: 23500248 DOI: 10.1016/j.jacc.2013.01.064] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 01/01/2013] [Accepted: 01/21/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The aim of this study was to test the hypothesis that mitral valve (MV) enlargement occurring in chronic aortic regurgitation (AR) prevents functional mitral regurgitation (FMR). BACKGROUND Chronic AR causes left ventricular (LV) dilation, creating the potential for FMR. However, FMR is typically absent during compensated AR despite substantial LV enlargement. Increased mitral leaflet area has been identified in AR, but it is unknown whether increased MV size can represent a compensatory mechanism capable of preventing FMR. METHODS Database review of 816 patients with at least moderate AR evaluated the prevalence of FMR. A total of 90 patients were enrolled prospectively for 3-dimensional echocardiography (30 AR, 30 FMR, and 30 controls) to assess MV geometry including total leaflet area. RESULTS FMR was present in 5.6% of AR patients by database review. Prospectively, only 1 AR patient had more than mild FMR despite increased LV end-diastolic volume (82 ± 22, 86 ± 23, and 51 ± 12 cm(3)/m(2), respectively, for AR, FMR vs. control patients; p < 0.01) and similar sphericity index, annular area, and tethering distances compared with FMR. Total MV area was largest in AR (31.3% greater than normal), increasing significantly more than in FMR. The ratio of valve size to closure area was maintained in AR, whereas decreases in this ratio and LV ejection fraction independently predicted FMR. CONCLUSIONS FMR prevalence is low in chronic AR. MV leaflet area is significantly increased compared with control and FMR patients, preserving a normal relationship to the area needed for closure in the dilated LV. Understanding the mechanisms underlying this adaptation could lead to new therapeutic interventions to prevent FMR.
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Affiliation(s)
- Jonathan Beaudoin
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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180
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Sá MPB, Soares EF, Santos CA, Figueiredo OJ, Lima RO, Escobar RR, Vasconcelos FP, Lima RC. Mitral valve replacement combined with coronary artery bypass graft surgery in patients with moderate-to-severe ischemic mitral regurgitation. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2013. [DOI: 10.1016/j.repce.2013.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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181
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Sá MPB, Soares EF, Santos CA, Figueiredo OJ, Lima RO, Escobar RR, Vasconcelos FP, Lima RC. Mitral valve replacement combined with coronary artery bypass graft surgery in patients with moderate-to-severe ischemic mitral regurgitation. Rev Port Cardiol 2013; 32:131-7. [DOI: 10.1016/j.repc.2012.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2012] [Accepted: 07/12/2012] [Indexed: 10/27/2022] Open
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Abstract
Heart failure (HF) is a global phenomenon, and the overall incidence and prevalence of the condition are steadily increasing. Medical therapies have proven efficacious, but only a small number of pharmacological options are in development. When patients cease to respond adequately to optimal medical therapy, cardiac resynchronization therapy has been shown to improve symptoms, reduce hospitalizations, promote reverse remodelling, and decrease mortality. However, challenges remain in identifying the ideal recipients for this therapy. The field of mechanical circulatory support has seen immense growth since the early 2000s, and left ventricular assist devices (LVADs) have transitioned over the past decade from large, pulsatile devices to smaller, more-compact, continuous-flow devices. Infections and haematological issues are still important areas that need to be addressed. Whereas LVADs were once approved only for 'bridge to transplantation', these devices are now used as destination therapy for critically ill patients with HF, allowing these individuals to return to the community. A host of novel strategies, including cardiac contractility modulation, implantable haemodynamic-monitoring devices, and phrenic and vagus nerve stimulation, are under investigation and might have an impact on the future care of patients with chronic HF.
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Tatsumi K, Tanaka H, Kataoka T, Norisada K, Onishi T, Kawai H, Hirata KI. Impact of Preserved Myocardial Contractile Function in the Segments Attached to the Papillary Muscles on Reduction in Functional Mitral Regurgitation. Echocardiography 2012; 30:147-54. [DOI: 10.1111/echo.12024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Kazuhiro Tatsumi
- Division of Cardiovascular Medicine, Department of Internal Medicine; Kobe University Graduate School of Medicine; Kobe; Japan
| | - Hidekazu Tanaka
- Division of Cardiovascular Medicine, Department of Internal Medicine; Kobe University Graduate School of Medicine; Kobe; Japan
| | - Toshiya Kataoka
- Division of Cardiovascular Medicine, Department of Internal Medicine; Kobe University Graduate School of Medicine; Kobe; Japan
| | - Kazuko Norisada
- Division of Cardiovascular Medicine, Department of Internal Medicine; Kobe University Graduate School of Medicine; Kobe; Japan
| | - Tetsuari Onishi
- Division of Cardiovascular Medicine, Department of Internal Medicine; Kobe University Graduate School of Medicine; Kobe; Japan
| | - Hiroya Kawai
- Division of Cardiovascular Medicine, Department of Internal Medicine; Kobe University Graduate School of Medicine; Kobe; Japan
| | - Ken-ichi Hirata
- Division of Cardiovascular Medicine, Department of Internal Medicine; Kobe University Graduate School of Medicine; Kobe; Japan
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van Garsse L, Gelsomino S, Cheriex E, Lucà F, Rao CM, Parise O, Gensini GF, Maessen J. Tethering Symmetry Reflects Advanced Left Ventricular Mechanical Dyssynchrony in Patients With Ischemic Mitral Regurgitation Undergoing Restrictive Mitral Valve Repair. Ann Thorac Surg 2012; 94:1418-28. [DOI: 10.1016/j.athoracsur.2012.05.099] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Revised: 05/22/2012] [Accepted: 05/25/2012] [Indexed: 11/30/2022]
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185
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Siefert AW, Jimenez JH, Koomalsingh KJ, Aguel F, West DS, Shuto T, Snow TK, Gorman RC, Gorman JH, Yoganathan AP. Contractile mitral annular forces are reduced with ischemic mitral regurgitation. J Thorac Cardiovasc Surg 2012; 146:422-8. [PMID: 23111017 DOI: 10.1016/j.jtcvs.2012.10.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Revised: 09/14/2012] [Accepted: 10/02/2012] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Forces acting on mitral annular devices in the setting of ischemic mitral regurgitation are currently unknown. The aim of this study was to quantify the cyclic forces that result from mitral annular contraction in a chronic ischemic mitral regurgitation ovine model and compare them with forces measured previously in healthy animals. METHODS A novel force transducer was implanted in the mitral annulus of 6 ovine subjects 8 weeks after an inferior left ventricle infarction that produced progressive, severe chronic ischemic mitral regurgitation. Septal-lateral and transverse forces were measured continuously for cardiac cycles reaching a peak left ventricular pressure of 90, 125, 150, 175, and 200 mm Hg. Cyclic forces and their rate of change during isovolumetric contraction were quantified and compared with those measured in healthy animals. RESULTS Animals with chronic ischemic mitral regurgitation exhibited a mean mitral regurgitation grade of 2.3 ± 0.5. Ischemic mitral regurgitation was observed to decrease significantly septal-lateral forces at each level of left ventricular pressure (P < .01). Transverse forces were consistently lower in the ischemic mitral regurgitation group despite not reaching statistical significance. The rate of change of these forces during isovolumetric contraction was found to increase significantly with peak left ventricular pressure (P < .005), but did not differ significantly between animal groups. CONCLUSIONS Mitral annular forces were measured for the first time in a chronic ischemic mitral regurgitation animal model. Our findings demonstrated an inferior left ventricular infarct to decrease significantly cyclic septal-lateral forces while modestly lowering those in the transverse. The measurement of these forces and their variation with left ventricular pressure contributes significantly to the development of mitral annular ischemic mitral regurgitation devices.
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Affiliation(s)
- Andrew W Siefert
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Ga, USA
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Rossi A, Bonapace S, Cicoira M, Conte L, Anselmi A, Vassanelli C. Aortic stiffness: an old concept for new insights into the pathophysiology of functional mitral regurgitation. Heart Vessels 2012; 28:606-12. [DOI: 10.1007/s00380-012-0295-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 09/21/2012] [Indexed: 11/24/2022]
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187
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Karimov JH, Kobayashi M, Fukamachi K. Functional mitral regurgitation: modern concepts for ventricular geometry reshaping. Expert Rev Med Devices 2012; 9:131-8. [PMID: 22404774 DOI: 10.1586/erd.11.69] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Functional mitral valve regurgitation (MR), a condition affecting millions of primarily elderly patients worldwide, is associated with poor clinical outcomes. Functional MR has traditionally been considered a disorder of regional or global left ventricular (LV) remodeling secondary to myocardial disease, in which anatomically normal leaflets fail to coapt adequately. The primary mechanisms of MR are mitral annular dilatation and leaflet restriction secondary to LV remodeling. Although annuloplasty is commonly used to correct valve incompetence, the effects of altered ventricular mechanics on MR need to be specifically addressed. This review focuses on current concepts of geometric reconfiguration of the LV and mitral-ventricular apparatus to reduce MR.
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Affiliation(s)
- Jamshid H Karimov
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA
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188
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Taramasso M, Denti P, Buzzatti N, De Bonis M, La Canna G, Colombo A, Alfieri O, Maisano F. Mitraclip therapy and surgical mitral repair in patients with moderate to severe left ventricular failure causing functional mitral regurgitation: a single-centre experience. Eur J Cardiothorac Surg 2012; 42:920-6. [PMID: 22961958 DOI: 10.1093/ejcts/ezs294] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Maurizio Taramasso
- Cardiac Surgery Department, San Raffaele University Hospital, Milan, Italy
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189
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Ultrasound and radiology surrogate endpoints in pharmacological studies. Atherosclerosis 2012; 224:12-24. [DOI: 10.1016/j.atherosclerosis.2012.03.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Revised: 03/26/2012] [Accepted: 03/29/2012] [Indexed: 11/17/2022]
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190
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Shudo Y, Nakatani S, Sakaguchi T, Miyagawa S, Yoshikawa Y, Takeda K, Saito S, Takeda Y, Sakata Y, Yamamoto K, Sawa Y. Left ventricular mechanics following restrictive mitral annuloplasty for functional mitral regurgitation: two-dimensional speckle tracking echocardiographic study. Echocardiography 2012; 29:445-50. [PMID: 22486374 DOI: 10.1111/j.1540-8175.2011.01607.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Restrictive mitral annuloplasty (RMA) is widely employed for patients with functional mitral regurgitation (MR). Its improvement of left ventricular (LV) function has been demonstrated by only a gradual increase in LV ejection fraction (EF) in the chronic phase. However, the detailed evaluation of changes in LV function has not been fully elucidated in functional MR patients before and after RMA. Therefore, we performed two-dimensional speckle tracking echocardiography (2D-STE), which enables accurate evaluation of myocardial deformation and rotation that are undetectable by conventional echocardiography. METHODS We studied 13 patients (mean age 61 ± 10 years) with functional MR associated with cardiomyopathy undergoing RMA. In addition to conventional echocardiographic measurements, 2D-STE was performed to measure peak systolic radial (RS), circumferential (CS), and longitudinal (LS) strains and twist before and 4 ± 2 weeks after surgery. LV twist was defined as the difference between the apical and basal rotations. RESULTS After RMA, EF and LS remained unchanged, but RS and CS were significantly improved at the mid-LV (RS, 20.6 ± 10.8 vs 24.5 ± 11.6%; CS, -9.6 ± 5.2 vs -12.8 ± 5.6%) and at the apex (RS, 15.0 ± 12.2 vs 18.7 ± 8.6%; CS, -4.4 ± 3.0 vs -7.8 ± 4.8%). RS and CS were unchanged at the base. The apical and basal rotations changed significantly, from 3.5°± 0.7° to 9.2°± 2.1°, and -2.1°± 0.7° to -3.8°± 1.0°, respectively. Consequently, the LV twist increased significantly, from 5.6°± 1.0° to 13.0°± 1.9°. CONCLUSIONS Radial and circumferential strains and LV twist increased significantly in the early postoperative period in functional MR patients after RMA and concomitant procedures.
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Affiliation(s)
- Yasuhiro Shudo
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
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191
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Rausch MK, Tibayan FA, Miller DC, Kuhl E. Evidence of adaptive mitral leaflet growth. J Mech Behav Biomed Mater 2012; 15:208-17. [PMID: 23159489 DOI: 10.1016/j.jmbbm.2012.07.001] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2012] [Revised: 06/30/2012] [Accepted: 07/02/2012] [Indexed: 01/09/2023]
Abstract
Ischemic mitral regurgitation is mitral insufficiency caused by myocardial infarction. Recent studies suggest that mitral leaflets have the potential to grow and reduce the degree of regurgitation. Leaflet growth has been associated with papillary muscle displacement, but role of annular dilation in leaflet growth is unclear. We tested the hypothesis that chronic leaflet stretch, induced by papillary muscle tethering and annular dilation, triggers chronic leaflet growth. To decipher the mechanisms that drive the growth process, we further quantified regional and directional variations of growth. Five adult sheep underwent coronary snare and marker placement on the left ventricle, papillary muscles, mitral annulus, and mitral leaflet. After eight days, we tightened the snares to create inferior myocardial infarction. We recorded marker coordinates at baseline, acutely (immediately post-infarction), and chronically (five weeks post-infarction). From these coordinates, we calculated acute and chronic changes in ventricular, papillary muscle, and annular geometry along with acute and chronic leaflet strains. Chronic left ventricular dilation of 17.15% (p<0.001) induced chronic posterior papillary muscle displacement of 13.49 mm (p=0.07). Chronic mitral annular area, commissural and septal-lateral distances increased by 32.50% (p=0.010), 14.11% (p=0.007), and 10.84% (p=0.010). Chronic area, circumferential, and radial growth were 15.57%, 5.91%, and 3.58%, with non-significant regional variations (p=0.868). Our study demonstrates that mechanical stretch, induced by annular dilation and papillary muscle tethering, triggers mitral leaflet growth. Understanding the mechanisms of leaflet adaptation may open new avenues to pharmacologically or surgically manipulate mechanotransduction pathways to augment mitral leaflet area and reduce the degree of regurgitation.
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Unger P, Magne J, Dedobbeleer C, Lancellotti P. Ischemic mitral regurgitation: not only a bystander. Curr Cardiol Rep 2012; 14:180-9. [PMID: 22203438 DOI: 10.1007/s11886-011-0241-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Ischemic mitral regurgitation (MR) is a common complication of left ventricular (LV) dysfunction related to chronic coronary artery disease. This complex multifactorial disease involves global and regional LV remodeling, as well as dysfunction and distortion of the components of the mitral valve including the chordae, the annulus, and the leaflets. Its occurrence is associated with a poor prognosis. The suboptimal results obtained with the most commonly used surgical strategy, involving mitral valve annuloplasty with coronary bypass grafting, emphasize the need to develop alternative surgical techniques targeting the causal mechanisms of the disease. A comprehensive preoperative assessment of mitral valve configuration and LV geometry and function and an accurate quantification of MR severity at rest and during exercise may contribute to improve risk stratification and to tailor the surgical strategy according to the individual characteristics of the patient.
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Affiliation(s)
- Philippe Unger
- Cardiology Department, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.
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193
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Bharucha T, Honjo O, Seller N, Atlin C, Redington A, Caldarone CA, van Arsdell G, Mertens L. Mechanisms of tricuspid valve regurgitation in hypoplastic left heart syndrome: a case-matched echocardiographic–surgical comparison study. ACTA ACUST UNITED AC 2012; 14:135-41. [DOI: 10.1093/ehjci/jes123] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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194
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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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195
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Timek TA, Miller DC. Another multidisciplinary look at ischemic mitral regurgitation. Semin Thorac Cardiovasc Surg 2012; 23:220-31. [PMID: 22172360 DOI: 10.1053/j.semtcvs.2011.07.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2011] [Indexed: 12/31/2022]
Abstract
Ischemic mitral regurgitation (IMR) continues to challenge surgeons and scientists alike. This vexing clinical entity frequently complicates myocardial infarction and carries a poor prognosis both in the setting of coronary disease and idiopathic dilated cardiomyopathy. Ischemic mitral regurgitation encompasses a difficult patient population that is characterized by high operative mortality, poor long term outcomes, and frequent recurrent insufficiency after standard surgical repair. Yet optimal surgical repair and improved clinical outcomes can only be achieved with better knowledge of the pathophysiology of IMR which is still incompletely understood. The causative mechanism of IMR appears to lie in the annular and subvalvular frame of the valve rather than leaflet or chordal structure leading to such labels as "ischemic," "functional," "non-organic," and "cardiomyopathy associated" being applied in the clinical literature. Although ischemic mitral regurgitation is a prevailing clinical entity, it has not been consistently defined in the literature, contributing to considerable confusion and contradictory results of clinical studies. As the mechanisms of pathophysiology have been better elucidated, novel surgical and interventional strategies have been developed recently to provide better treatment for this difficult patient population. In this review, we undertake a multidisciplinary update of the pathophysiology, classification, and surgical and interventional treatment of ischemic mitral regurgitation in today's clinical practice.
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Affiliation(s)
- Tomasz A Timek
- West Michigan Cardiothoracic Surgeons and Spectrum Health System, Grand Rapids, Michigan, USA
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196
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Pressman GS, Figueredo VM, Romero-Corral A, Murali G, Kotler MN. Effect of obstructive sleep apnea on mitral valve tenting. Am J Cardiol 2012; 109:1055-9. [PMID: 22264596 DOI: 10.1016/j.amjcard.2011.11.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Revised: 11/16/2011] [Accepted: 11/16/2011] [Indexed: 11/18/2022]
Abstract
Obstructive apneas produce high negative intrathoracic pressure that imposes an afterload burden on the left ventricle. Such episodes might produce structural changes in the left ventricle over time. Doppler echocardiograms were obtained within 2 months of attended polysomnography. Patients were grouped according to apnea-hypopnea index (AHI): mild/no obstructive sleep apnea (OSA; AHI <15) and moderate/severe OSA (AHI ≥15). Mitral valve tenting height and area, left ventricular (LV) long and short axes, and LV end-diastolic volume were measured in addition to tissue Doppler parameters. Comparisons of measurements at baseline and follow-up between and within groups were obtained; correlations between absolute changes (Δ) in echocardiographic parameters were also performed. After a mean follow-up of 240 days mitral valve tenting height increased significantly (1.17 ± 0.12 to 1.28 ± 0.17 cm, p = 0.001) in moderate/severe OSA as did tenting area (2.30 ± 0.41 to 2.66 ± 0.60 cm(2), p = 0.0002); Δtenting height correlated with ΔLV end-diastolic volume (rho 0.43, p = 0.01) and Δtenting area (rho 0.35, p = 0.04). In patients with mild/no OSA there was no significant change in tenting height; there was a borderline significant increase in tenting area (2.20 ± 0.44 to 2.31 ± 0.43 cm(2), p = 0.05). Septal tissue Doppler early diastolic wave decreased (8.04 ± 2.49 to 7.10 ± 1.83 cm/s, p = 0.005) in subjects with moderate/severe OSA but not in in those with mild/no OSA. In conclusion, in patients with moderate/severe OSA, mitral valve tenting height and tenting area increase significantly over time. This appears to be related, at least in part, to changes in LV geometry.
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Affiliation(s)
- Gregg S Pressman
- Department of Medicine, Division of Cardiology, Albert Einstein Medical Center, Philadelphia, Pennsylvania, USA.
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197
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De Bonis M, Taramasso M, Verzini A, Ferrara D, Lapenna E, Calabrese MC, Grimaldi A, Alfieri O. Long-term results of mitral repair for functional mitral regurgitation in idiopathic dilated cardiomyopathy. Eur J Cardiothorac Surg 2012; 42:640-6. [DOI: 10.1093/ejcts/ezs078] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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198
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Javid F, Angeles J, Pasini D, Cecere R. Shape Optimization of a Self-deployable Anchor Designed for Percutaneous Mitral Valve Repair. J Med Device 2012. [DOI: 10.1115/1.4005780] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
A new percutaneous annuloplasty technique for mitral regurgitation is proposed here. In this technique, inter-related anchors are first inserted around the annulus via a trans-septal catheter. The tethered wire passed through the anchors is then pulled to shrink the annulus and stop regurgitation. The anchors should withstand large deformation, applied during the delivery process, and should recover their original shape after being released inside the tissue. The shape of the anchors is, thus, optimized in an iterative process, to avoid stress concentration by minimizing the weighted rms value of the curvature along the anchor. The weight coefficients in each iteration are defined based on the stress distribution of the anchor obtained in the previous iteration. The procedure finally results in a structurally optimum anchor with a minimum in the maximum von Mises stress. This anchor is fabricated from Nitinol and tested in a cadaveric swine heart.
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Affiliation(s)
- Farhad Javid
- Centre for Intelligent Machines (CIM) andDepartment of Mechanical Engineering, McGill University, Montreal, Quebec, H3A 0C3
| | - Jorge Angeles
- ASME Fellow
- Centre for Intelligent Machines (CIM) andDepartment of Mechanical Engineering, McGill University, Montreal, Quebec, H3A 0C3
| | - Damiano Pasini
- Department of Mechanical Engineering, McGill University, Montreal, Quebec, H3A 0C3
| | - Renzo Cecere
- Biosurgery and Design Unit,Department of Surgery, McGill University Health Centre, Montreal, Quebec, H3A 1A1
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199
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Oh JK, Pellikka PA, Panza JA, Biernat J, Attisano T, Manahan BG, Wiste HJ, Lin G, Lee K, Miller FA, Stevens S, Sopko G, She L, Velazquez EJ. Core lab analysis of baseline echocardiographic studies in the STICH trial and recommendation for use of echocardiography in future clinical trials. J Am Soc Echocardiogr 2012; 25:327-36. [PMID: 22227341 PMCID: PMC3310914 DOI: 10.1016/j.echo.2011.12.002] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2011] [Indexed: 12/20/2022]
Abstract
BACKGROUND The Surgical Treatment for Ischemic Heart Failure (STICH) randomized trial was designed to identify an optimal management strategy for patients with ischemic cardiomyopathy. Baseline echocardiographic examinations were required for all patients. The primary aim of this report is to describe the baseline STICH Echocardiography Core Laboratory data. The secondary aim is to provide recommendations regarding how echocardiography should be used in clinical practice and research on the basis of the experience gained from echocardiography in STICH. METHODS Between September 2002 and January 2006, 2,136 patients with ejection fractions (EFs) ≤ 35% and coronary artery disease amenable to coronary artery bypass grafting were enrolled. Echocardiography was acquired by 122 clinical enrolling sites, and measurements were performed by the Echocardiography Core Laboratory after a certification process for all clinical sites. RESULTS Echocardiography was available for analysis in 2,006 patients (93.9%); 1,734 (86.4%) were men, and the mean age was 60.9 ± 9.5 years. The mean left ventricular end-systolic volume index, measureable in 72.8%, was 84.0 ± 30.9 mL/m(2), and the mean EF was 28.9 ± 8.3%, with 18.5% of patients having EFs > 35%. Single-plane measurements of left ventricular and left atrial volumes were similar to their volumes by biplane measurement (r = 0.97 and r = 0.92, respectively). Mitral regurgitation severity by visual assessment was associated with a wide range of effective regurgitant orifice area, while effective regurgitant orifice area ≥ 0.2 cm(2) indicated at least moderate mitral regurgitation by visual assessment. Deceleration time of mitral inflow velocity had a weak correlation with EF (r = 0.25) but was inversely related to estimated pulmonary artery systolic pressure (r = -0.49). CONCLUSIONS In STICH patients with ischemic cardiomyopathy, Echocardiography Core Laboratory analysis of baseline echocardiographic findings demonstrated a wide spectrum of left ventricular shape, function, and hemodynamics, as well as the feasibility and limitations of obtaining essential echocardiographic measurements. It is critical that the use of echocardiographic parameters in clinical practice and research balance the strengths and weaknesses of the technique.
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Affiliation(s)
- Jae K Oh
- Echocardiography Core Laboratory, Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.
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Mechanisms and predictors of mitral regurgitation after high-risk myocardial infarction. J Am Soc Echocardiogr 2012; 25:535-42. [PMID: 22305962 DOI: 10.1016/j.echo.2012.01.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Indexed: 11/21/2022]
Abstract
BACKGROUND Mitral regurgitation (MR) has been associated with adverse outcomes after myocardial infarction (MI). Without structural valve disease, functional MR has been related to left ventricular (LV) remodeling and geometric deformation of the mitral apparatus. The aims of this study were to elucidate the mechanistic components of MR after high-risk MI and to identify predictors of MR progression during follow-up. METHODS The Valsartan in Acute Myocardial Infarction Echo substudy prospectively enrolled 610 patients with LV dysfunction, heart failure, or both after MI. MR at baseline, 1 month, and 20 months was quantified by mapping jet expansion in the left atrium in 341 patients with good-quality echocardiograms. Indices of LV remodeling, left atrial size, and diastolic function and parameters of mitral valve deformation, including tenting area, coaptation depth, anterior leaflet concavity, annular diameters, and contractility, were assessed and related to baseline MR. The progression of MR was further analyzed, and predictors of worsening among the baseline characteristics were identified. RESULTS Tenting area, coaptation depth, annular dilatation, and left atrial size were all associated with the degree of baseline MR. Tenting area was the only significant and independent predictor of worsening MR; a tenting area of 4 cm(2) was a useful cutoff to identify worsening of MR after MI and moderate to severe MR after 20 months. CONCLUSIONS Increased mitral tenting and larger mitral annular area are determinants of MR degree at baseline, and tenting area is an independent predictor of progression of MR after MI. Although LV remodeling itself contributes to ischemic MR, this influence is directly dependent on alterations in mitral geometry.
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