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Koukos M, Dimitroglou Y, Tsartsalis D, Beneki E, Tolis E, Patsourakos D, Kalompatsou A, Aggeli C, Tsioufis K. Left Atrium: A New Prognostic Marker and Therapeutic Target in Secondary Mitral Regurgitation? Eur Cardiol 2024; 19:e04. [PMID: 38807855 PMCID: PMC11131153 DOI: 10.15420/ecr.2023.47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 03/13/2024] [Indexed: 05/30/2024] Open
Abstract
Mitral regurgitation (MR) is one of the most common valvular abnormalities worldwide and can be subdivided into primary and secondary causes. Atrial MR consists of a novel type of secondary MR (SMR), most often observed in patients with AF and heart failure with preserved ejection fraction. The main pathophysiological mechanism of atrial MR is mitral valve annular dilatation. Recently published studies have highlighted the clinical significance of left atrium (LA) evaluation in the early diagnosis and prognosis of patients with primary MR. However, there are little data regarding the role of the LA in SMR. The present literature review aims to elucidate the use of the echocardiographic parameters regarding LA evaluation in the prognosis prediction and therapeutic strategy of patients with SMR.
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Affiliation(s)
- Markos Koukos
- 1st Department of Cardiology, Hippokration Hospital of Athens, University of Athens Athens, Greece
| | - Yannis Dimitroglou
- 1st Department of Cardiology, Hippokration Hospital of Athens, University of Athens Athens, Greece
| | - Dimitrios Tsartsalis
- 1st Department of Cardiology, Hippokration Hospital of Athens, University of Athens Athens, Greece
| | - Eirini Beneki
- 1st Department of Cardiology, Hippokration Hospital of Athens, University of Athens Athens, Greece
| | - Elias Tolis
- 1st Department of Cardiology, Hippokration Hospital of Athens, University of Athens Athens, Greece
| | - Dimitrios Patsourakos
- 1st Department of Cardiology, Hippokration Hospital of Athens, University of Athens Athens, Greece
| | - Argyro Kalompatsou
- 1st Department of Cardiology, Hippokration Hospital of Athens, University of Athens Athens, Greece
| | - Constantina Aggeli
- 1st Department of Cardiology, Hippokration Hospital of Athens, University of Athens Athens, Greece
| | - Konstantinos Tsioufis
- 1st Department of Cardiology, Hippokration Hospital of Athens, University of Athens Athens, Greece
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Daios S, Anastasiou V, Bazmpani MA, Angelopoulou SM, Karamitsos T, Zegkos T, Didagelos M, Savopoulos C, Ziakas A, Kamperidis V. Moving from left ventricular ejection fraction to deformation imaging in mitral valve regurgitation. Curr Probl Cardiol 2024; 49:102432. [PMID: 38309543 DOI: 10.1016/j.cpcardiol.2024.102432] [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: 01/27/2024] [Accepted: 01/29/2024] [Indexed: 02/05/2024]
Abstract
The increasing prevalence of valvular heart diseases, specifically mitral regurgitation (MR), underscores the need for a careful and timely approach to intervention. Severe MR, whether primary or secondary, when left untreated leads to adverse outcomes, emphasizing the critical role of a timely surgical or transcatheter intervention. While left ventricular ejection fraction (LVEF) remains the guideline-recommended measure for assessing left ventricle damage, emerging evidence raises concerns regarding its reliability in MR due to its volume-dependent nature. This review summarizes the existing literature on the role of LVEF and deformation imaging techniques, emphasizing the latter's potential in providing a more accurate evaluation of intrinsic myocardial function. Moreover, it advocates the need for an integrated approach that combines traditional with emerging measures, aiming to optimize the management of patients with MR. It attempts to highlight the need for future research to validate the clinical application of deformation imaging techniques through large-scale studies.
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Affiliation(s)
- Stylianos Daios
- First Department of Cardiology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, AHEPA Hospital, St. Kiriakidi 1, Thessaloniki 54636, Greece
| | - Vasileios Anastasiou
- First Department of Cardiology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, AHEPA Hospital, St. Kiriakidi 1, Thessaloniki 54636, Greece
| | - Maria-Anna Bazmpani
- First Department of Cardiology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, AHEPA Hospital, St. Kiriakidi 1, Thessaloniki 54636, Greece
| | - Stella-Maria Angelopoulou
- First Department of Cardiology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, AHEPA Hospital, St. Kiriakidi 1, Thessaloniki 54636, Greece
| | - Theodoros Karamitsos
- First Department of Cardiology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, AHEPA Hospital, St. Kiriakidi 1, Thessaloniki 54636, Greece
| | - Thomas Zegkos
- First Department of Cardiology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, AHEPA Hospital, St. Kiriakidi 1, Thessaloniki 54636, Greece
| | - Matthaios Didagelos
- First Department of Cardiology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, AHEPA Hospital, St. Kiriakidi 1, Thessaloniki 54636, Greece
| | - Christos Savopoulos
- First Propaedeutic Department of Internal Medicine, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, Thessaloniki 54636, Greece
| | - Antonios Ziakas
- First Department of Cardiology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, AHEPA Hospital, St. Kiriakidi 1, Thessaloniki 54636, Greece
| | - Vasileios Kamperidis
- First Department of Cardiology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, AHEPA Hospital, St. Kiriakidi 1, Thessaloniki 54636, Greece.
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Anthony CM, Wang TKM, Salam D, Obuchowski N, Turkmani M, Al-Deiri D, Popovic Z, Griffin B, Flamm S, Chen D, Nguyen C, Tang WW, Kwon D. Impact of Cardiac Magnetic Resonance Left Atrial Ejection Fraction in Advanced Ischemic Cardiomyopathy. JACC. ADVANCES 2024; 3:100796. [PMID: 38549681 PMCID: PMC10977265 DOI: 10.1016/j.jacadv.2023.100796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/22/2023] [Accepted: 08/16/2023] [Indexed: 06/29/2024]
Abstract
BACKGROUND The prognostic significance of cardiac magnetic resonance (CMR)-based left atrial ejection fraction (LAEF) is not well defined in the ischemic cardiomyopathy (ICM) cohort. OBJECTIVES The authors sought to assess the prognostic impact of LAEF, when adjusted for left ventricular remodeling, myocardial infarct size (MIS), left atrial volume index, and functional mitral regurgitation (FMR), on outcomes in patients with advanced ICM. METHODS ICM patients who underwent CMR were retrospectively evaluated (April 2001-December 2019). LAEF, left atrial volume index, MIS, left ventricular remodeling, and FMR were derived from CMR. The primary clinical endpoint was a composite of all-cause mortality and cardiac transplant. A baseline multivariable Cox proportional hazards regression model was constructed to assess prognostic power of LAEF. RESULTS There were 718 patients (416 primary events) evaluated, with a median duration of follow-up of 1,763 days (4.8 years) and a mean LAEF of 36% ± 15%. On multivariable analysis, higher LAEF was independently associated with reduced risk (HR: 0.24, 95% CI: 0.12-0.48, P < 0.001), even after adjusting for FMR and MIS. The highest adjusted risk was observed in patients with an LAEF <20% and an MIS of >30% (HR: 3.20, 95% CI: 1.73-5.93). The lowest risk was in patients within the comparator group with an LAEF of >50% and a MIS of <15% (HR: 1.07, 95% CI: 0.81-1.42). CONCLUSIONS Reduced LAEF is independently associated with increased mortality in ICM. Risk associated with declining LAEF is continuous and incremental to other risk factors for adverse outcomes in patients with ICM even after adjusting for MIS and FMR severity.
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Affiliation(s)
- Chris M. Anthony
- Department of Cardiology, The Alfred Hospital, Melbourne, Australia
- Monash Alfred Baker Centre for Cardiovascular Research, Melbourne, Australia
| | - Tom Kai Ming Wang
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Imaging Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Donna Salam
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nancy Obuchowski
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mustafa Turkmani
- Internal Medicine, McLaren Oakland Program, Pontiac, Michigan, USA
| | - Danah Al-Deiri
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Zoran Popovic
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Imaging Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Brian Griffin
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Scott Flamm
- Imaging Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - David Chen
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Christopher Nguyen
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Wilson W.H. Tang
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Deborah Kwon
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Imaging Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Molnár AÁ, Sánta A, Pásztor DT, Merkely B. Atrial Cardiomyopathy in Valvular Heart Disease: From Molecular Biology to Clinical Perspectives. Cells 2023; 12:1796. [PMID: 37443830 PMCID: PMC10340254 DOI: 10.3390/cells12131796] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/01/2023] [Accepted: 07/04/2023] [Indexed: 07/15/2023] Open
Abstract
This review discusses the evolving topic of atrial cardiomyopathy concerning valvular heart disease. The pathogenesis of atrial cardiomyopathy involves multiple factors, such as valvular disease leading to atrial structural and functional remodeling due to pressure and volume overload. Atrial enlargement and dysfunction can trigger atrial tachyarrhythmia. The complex interaction between valvular disease and atrial cardiomyopathy creates a vicious cycle of aggravating atrial enlargement, dysfunction, and valvular disease severity. Furthermore, atrial remodeling and arrhythmia can predispose to atrial thrombus formation and stroke. The underlying pathomechanism of atrial myopathy involves molecular, cellular, and subcellular alterations resulting in chronic inflammation, atrial fibrosis, and electrophysiological changes. Atrial dysfunction has emerged as an essential determinant of outcomes in valvular disease and heart failure. Despite its predictive value, the detection of atrial fibrosis and dysfunction is challenging and is not included in the clinical routine. Transthoracic echocardiography and cardiac magnetic resonance imaging are the main diagnostic tools for atrial cardiomyopathy. Recently published data have revealed that both left atrial volumes and functional parameters are independent predictors of cardiovascular events in valvular disease. The integration of atrial function assessment in clinical practice might help in early cardiovascular risk estimation, promoting early therapeutic intervention in valvular disease.
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Kotrc M, Bartunek J, Benes J, Beles M, Vanderheyden M, Casselman F, Ondrus T, Mo Y, Praet FV, Penicka M. Global longitudinal strain and outcome after endoscopic mitral valve repair. ESC Heart Fail 2022; 9:2686-2694. [PMID: 35670015 PMCID: PMC9288807 DOI: 10.1002/ehf2.14001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 04/01/2022] [Accepted: 05/22/2022] [Indexed: 11/12/2022] Open
Abstract
Aims Identification of heart failure (HF) patients with secondary mitral regurgitation (SMR) that benefit from mitral valve (MV) repair remains challenging. We have focused on the role of left ventricular global longitudinal strain (LV‐GLS) and reservoir left atrial longitudinal strain (LASr) for the prediction of long‐term survival and reverse remodelling in patients with SMR undergoing endoscopic MV repair. Methods and results The study population consisted of 110 patients (age 67 ± 11 years, 66% men) with symptomatic SMR undergoing isolated MV repair using a minimally invasive surgical approach. Speckle tracking‐derived LV‐GLS and LASr were assessed in apical views using vendor‐independent software. Over a median of 7.7 years (IQRs 2.9–11.2), 64 patients (58%) died. Significant reverse LV (↓ LVESVI >10 mL/m2), LA (↓ LAVI >10 mL/m2) remodelling or both were observed in 43 (39%), 37 (34%) and 19 (17%) patients, respectively. LV‐GLS (HR 0.68, 95% CI 0.58–0.79, P < 0.001) and LASr (HR 0.93, 95% CI 0.88–0.97, P < 0.01) but not LV ejection fraction (LVEF) and LA volume index (LAVi) emerged as independent predictors of all‐cause mortality in Cox regression analysis. LV‐GLS was the only independent predictor of LV reverse remodelling (OR 1.24, 95% CI 1.05–1.43, P < 0.001) whereas LAVi and LASr were both independent predictors of LA reverse remodelling (both P < 0.05). In patients with atrial fibrillation at baseline, only LASr was an independent predictor (P < 0.05) of LA reverse remodelling. Conclusions In patients with SMR undergoing endoscopic MV repair, LV‐GLS and LASr are independently associated with long‐term survival and reverse remodelling and may be helpful in selecting SMR patients who may benefit from this procedure.
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Affiliation(s)
- Martin Kotrc
- Cardiovascular Center Aalst Belgium
- Department of Cardiology Institute for Clinical and Experimental Medicine (IKEM) Prague Czech Republic
| | | | - Jan Benes
- Department of Cardiology Institute for Clinical and Experimental Medicine (IKEM) Prague Czech Republic
| | | | | | - Filip Casselman
- Department of Cardiovascular and Thoracic Surgery OLV Clinic Aalst Belgium
| | | | | | - Frank Van Praet
- Department of Cardiovascular and Thoracic Surgery OLV Clinic Aalst Belgium
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Molnár AÁ, Merkely B. The Added Value of Atrial Strain Assessment in Clinical Practice. Diagnostics (Basel) 2022; 12:diagnostics12040982. [PMID: 35454030 PMCID: PMC9025202 DOI: 10.3390/diagnostics12040982] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 04/05/2022] [Accepted: 04/12/2022] [Indexed: 12/28/2022] Open
Abstract
Speckle tracking echocardiography has emerged as a sensitive tool to analyze myocardial function with improved diagnostic accuracy and prognostic value. Left atrial strain assessment has become a novel imaging method in cardiology with superior prognostic value compared to conventional left atrial volume indices. Left atrial function is divided into three phases, reservoir function being the most important. This review summarizes the added value of speckle tracking echocardiography derived left atrial strain assessment in clinical practice. Recently published data suggest the prognostic value of left atrial reservoir function in heart failure, atrial fibrillation, stroke and valvular heart disease. Furthermore, left atrial reservoir strain proved to be a predictor of cardiovascular morbidity and mortality in the general population. Thus, routine assessment of left atrial function can be an optimal strategy to improve cardiovascular risk prediction and supplement the current risk prediction models.
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Zahr F, Cigaarroa JE. Left atrial function, the cherrie on top in understanding clinical outcomes in functional mitral regurgitation. Catheter Cardiovasc Interv 2020; 96:685-686. [PMID: 32935941 DOI: 10.1002/ccd.29214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 08/05/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Firas Zahr
- Division of Cardiology, Knight Cardiovascular Institute, OHSU, Portland, Oregon, USA
| | - Joaquin E Cigaarroa
- Division of Cardiology, Knight Cardiovascular Institute, OHSU, Portland, Oregon, USA
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