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Song K, Lee JH, Woo HT, Kim YS, Jang WS, Chung S, Cho YH, Kim WS, Sung K. Surgical outcome of mitral valve surgery in atrial functional mitral regurgitation compared with degenerative etiology. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00515-4. [PMID: 38879118 DOI: 10.1016/j.jtcvs.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 05/06/2024] [Accepted: 06/02/2024] [Indexed: 07/07/2024]
Abstract
OBJECTIVE To analyze and compare the outcomes of mitral valve surgery for atrial functional mitral regurgitation (AFMR) and for degenerative mitral regurgitation (DMR). METHODS Patients with AFMR or DMR who underwent mitral valve repair/replacement at 2 institutions between January 2012 and December 2022 were included. Patients <18 years of age and patients undergoing concomitant cardiac surgery (except for the maze procedure or tricuspid annuloplasty) were excluded. Propensity score analysis was used to adjust for baseline differences. RESULTS A total of 642 patients were enrolled. After propensity score analysis, 164 patients were classified into the DMR group, and 82 patients were classified into the AFMR group. All matched patients in both groups had atrial fibrillation. In DMR and AFMR, the 5-year freedom from readmission for heart failure and cardiac death was 96.3% in the DMR group versus 88.6% in the AFMR group (P = .045) and freedom from readmission for cardiac death in the 2 groups was 100% and 90.0%, respectively (P = .002). The recurrence rate of significant mitral regurgitation (MR) after mitral valve repair was not significantly different between the 2 groups (P = .699, log-rank test), and the 5-year freedom from MR recurrence (moderate or greater) was 89.8% and 93.0%, respectively. After the maze procedure, significantly more patients in the AFMR group than the DMR group were in junctional rhythm (49.1% vs 3.3%; P < .001) and required permanent pacemaker insertion during the follow-up period (11.4% vs 1.5% after 5 years; P = .041, log-rank test). CONCLUSIONS AFMR was associated with acceptable outcomes of mitral valve surgery, and mitral valve repair is a good treatment option. However, significantly more patients were in junctional rhythm after the maze procedure, needing more permanent pacemaker insertion.
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Affiliation(s)
- Kyungsub Song
- Department of Thoracic and Cardiovascular Surgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Jun Ho Lee
- Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Hyeong Taek Woo
- Department of Preventive Medicine, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Yun Seok Kim
- Department of Thoracic and Cardiovascular Surgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Woo Sung Jang
- Department of Thoracic and Cardiovascular Surgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Suryeun Chung
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yang Hyun Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Wook Sung Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kiick Sung
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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Stolz L, Doldi PM, Sannino A, Hausleiter J, Grayburn PA. The Evolving Concept of Secondary Mitral Regurgitation Phenotypes: Lessons From the M-TEER Trials. JACC Cardiovasc Imaging 2024; 17:659-668. [PMID: 38551534 DOI: 10.1016/j.jcmg.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 01/17/2024] [Accepted: 01/18/2024] [Indexed: 06/07/2024]
Abstract
Conflicting results from 2 randomized clinical trials of transcatheter mitral valve edge-to-edge repair in secondary mitral regurgitation (SMR) have led to the recognition that SMR is a heterogeneous disease entity presenting with different functional and morphological phenotypes. This review summarizes the current knowledge on SMR caused primarily by atrial secondary mitral regurgitation (aSMR) and ventricular SMR pathology. Although aSMR is generally characterized by severe left atrial enlargement in the setting of preserved left ventricular anatomy and function, different patterns of mitral annular distortion cause different phenotypes of aSMR. In ventricular SMR, the relation of SMR severity to left ventricular dilation as well as the degree of pulmonary hypertension and right ventricular dysfunction are important phenotypic characteristics, which are key for a better understanding of prognosis and treatment response.
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Affiliation(s)
- Lukas Stolz
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany.
| | - Philipp M Doldi
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany. https://twitter.com/DoldiP
| | - Anna Sannino
- Division of Cardiology, Department of Internal Medicine, Baylor Scott and White The Heart Hospital, Plano, Texas, USA; Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University, Naples, Italy. https://twitter.com/AnnaSannino1985
| | - Jörg Hausleiter
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany. https://twitter.com/j_hausleiter
| | - Paul A Grayburn
- Division of Cardiology, Department of Internal Medicine, Baylor Scott and White The Heart Hospital, Plano, Texas, USA.
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 PMCID: PMC11095842 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 231] [Impact Index Per Article: 231.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
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4
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:109-279. [PMID: 38043043 PMCID: PMC11104284 DOI: 10.1016/j.jacc.2023.08.017] [Citation(s) in RCA: 66] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Deferm S, Bertrand PB, Dhont S, von Bardeleben RS, Vandervoort PM. Arrythmia-Mediated Valvular Heart Disease. Heart Fail Clin 2023; 19:357-377. [PMID: 37230650 DOI: 10.1016/j.hfc.2023.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The aging population is rising at record pace worldwide. Along with it, a steep increase in the prevalence of atrial fibrillation and heart failure with preserved ejection fraction is to be expected. Similarly, both atrial functional mitral and tricuspid regurgitation (AFMR and AFTR) are increasingly observed in daily clinical practice. This article summarizes all current evidence regarding the epidemiology, prognosis, pathophysiology, and therapeutic options. Specific attention is addressed to discern AFMR and AFTR from their ventricular counterparts, given their different pathophysiology and therapeutic needs.
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Affiliation(s)
- Sébastien Deferm
- Hasselt University, Agoralaan Building D, 3590 Diepenbeek, Belgium; Department of Cardiology, Mainz University Hospital, Langenbeckstraße 1, Mainz, Germany. https://twitter.com/S_Deferm
| | - Philippe B Bertrand
- Hasselt University, Agoralaan Building D, 3590 Diepenbeek, Belgium; Department of Cardiology, Hospital Oost-Limburg Genk, Schiepse Bos 6, 3600 Genk, Belgium. https://twitter.com/Ph_Bertrand
| | - Sebastiaan Dhont
- Hasselt University, Agoralaan Building D, 3590 Diepenbeek, Belgium; Department of Cardiology, Hospital Oost-Limburg Genk, Schiepse Bos 6, 3600 Genk, Belgium. https://twitter.com/S_Dhont
| | - Ralph S von Bardeleben
- Department of Cardiology, Mainz University Hospital, Langenbeckstraße 1, Mainz, Germany. https://twitter.com/vonbardelebenRS
| | - Pieter M Vandervoort
- Hasselt University, Agoralaan Building D, 3590 Diepenbeek, Belgium; Department of Cardiology, Hospital Oost-Limburg Genk, Schiepse Bos 6, 3600 Genk, Belgium.
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Yoon SH, Makar M, Kar S, Chakravarty T, Oakley L, Sekhon N, Koseki K, Nakamura M, Hamilton M, Patel JK, Singh S, Skaf S, Siegel RJ, Bax JJ, Makkar RR. Outcomes After Transcatheter Edge-to-Edge Mitral Valve Repair According to Mitral Regurgitation Etiology and Cardiac Remodeling. JACC Cardiovasc Interv 2022; 15:1711-1722. [PMID: 36075642 DOI: 10.1016/j.jcin.2022.07.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 06/29/2022] [Accepted: 07/05/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Transcatheter edge-to-edge repair (TEER) has been increasingly used for selected patients with mitral regurgitation (MR), but limited data are available regarding clinical outcomes in patients with varied etiology and mechanism of MR. OBJECTIVES The aim of this study was to evaluate the outcomes of TEER according to etiology and left ventricular (LV) and left atrial remodeling. METHODS Consecutive patients who underwent TEER between 2007 and 2020 were included in the analysis. Among patients with functional MR (FMR), those with predominant LV remodeling were classified as having ventricular FMR (v-FMR), whereas those without LV remodeling but predominant left atrial remodeling were classified as having atrial FMR (a-FMR). The primary outcome was a composite of all-cause mortality and heart failure hospitalization at 2 years and was compared among patients with degenerative MR (DMR), a-FMR, and v-FMR. RESULTS A total of 1,044 patients (11% with a-FMR, 48% with v-FMR, and 41% with DMR) with a mean Society of Thoracic Surgeons score of 8.6 ± 7.8 underwent TEER. Patients with a-FMR had higher rates of atrial fibrillation and severe tricuspid regurgitation with larger left and right atria, whereas patients with v-FMR had lower LV ejection fractions with larger LV dimensions. Residual MR more than moderate at discharge was not significantly different among the 3 groups (5.2% vs 3.2% vs 2.6%; P = 0.37). Compared with patients with DMR, 2-year event rates of the primary outcome were significantly higher in patients with a-FMR and v-FMR (21.6% vs 31.5% vs 42.3%; log-rank P < 0.001). CONCLUSIONS Despite excellent procedural outcomes, patients with a-FMR and v-FMR had worse clinical outcomes compared with those with DMR.
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Affiliation(s)
- Sung-Han Yoon
- Cedars-Sinai Medical Center, Smidt Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Moody Makar
- Cedars-Sinai Medical Center, Smidt Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Saibal Kar
- Cedars-Sinai Medical Center, Smidt Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Tarun Chakravarty
- Cedars-Sinai Medical Center, Smidt Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Luke Oakley
- Cedars-Sinai Medical Center, Smidt Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Navjot Sekhon
- Cedars-Sinai Medical Center, Smidt Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Keita Koseki
- Cedars-Sinai Medical Center, Smidt Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Mamoo Nakamura
- Cedars-Sinai Medical Center, Smidt Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Michele Hamilton
- Cedars-Sinai Medical Center, Smidt Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Jignesh K Patel
- Cedars-Sinai Medical Center, Smidt Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Siddharth Singh
- Cedars-Sinai Medical Center, Smidt Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Sabah Skaf
- Cedars-Sinai Medical Center, Smidt Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Robert J Siegel
- Cedars-Sinai Medical Center, Smidt Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Jeroen J Bax
- Leiden University Medical Center, Leiden, the Netherlands
| | - Raj R Makkar
- Cedars-Sinai Medical Center, Smidt Cedars-Sinai Heart Institute, Los Angeles, California, USA.
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Amabile A, Fereydooni S, Mori M, Hameed I, Jung J, Krane M, Geirsson A. Variable definitions and treatment approaches for atrial functional mitral regurgitation: A scoping review of the literature. J Card Surg 2022; 37:1182-1191. [PMID: 35179258 DOI: 10.1111/jocs.16312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 01/14/2022] [Accepted: 01/17/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Atrial functional mitral regurgitation (AFMR) is a subtype of functional mitral regurgitation due to longstanding atrial fibrillation (AF) or heart failure with preserved ejection fraction. The variation in AFMR' definition and the common mode of treatment described in the literature remain unknown. METHODS We performed a scoping review of studies that surgically treated AFMR to characterize the existing variability in the definition of AFMR, the type of operations performed for AFMR valvulopathy, and the treatment for the chronic AF. We searched Medline, EMBASE, Cochrane Library, Scopus, and Web of Science since their inceptions for studies of patients affected by AFMR and surgically treated for their valvulopathy. RESULTS Twelve studies (n = 494 patients) met eligibility criteria. All studies excluded patients with signs of left ventricular (LV) dysfunction, but the way additional parameters were used to define AFMR at a more granular level varied across studies: nine studies (75%) used the presence of AF to define their AFMR cohorts, with five (41.2%) requiring a history of AF of >1 year; additionally, the threshold values for the LV ejection fraction differed (45%-55%). Isolated mitral annuloplasty was performed in 96.2% of patients. Broad variability was detected in the proportion of patients undergoing the Cox-Maze procedure (range, 17.8%-79.5%), pulmonary vein isolation (0.0%-66.7%), and left atrial appendage ligation (0.0%-100.0%). CONCLUSIONS AFMR remains variably defined in surgical studies, making comparisons across studies difficult. Mitral annuloplasty was most commonly performed. The proportion of AFMR patients undergoing concomitant procedures for AF varied substantially.
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Affiliation(s)
- Andrea Amabile
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Soraya Fereydooni
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Makoto Mori
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Irbaz Hameed
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jeenah Jung
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Markus Krane
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Arnar Geirsson
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
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Transcatheter edge-to-edge mitral valve repair in atrial functional mitral regurgitation: insights from the multi-center MITRA-TUNE registry. Int J Cardiol 2021; 349:39-45. [PMID: 34826500 DOI: 10.1016/j.ijcard.2021.11.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 11/12/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND A-FMR is considered a specific sub-type of secondary MR in patients with atrial fibrillation (AF) and preserved left ventricle ejection fraction (LVEF). Aim of the study was to investigate the acute and mid-term outcomes of transcatheter edge-to-edge mitral valve repair (TMVr) with the MitraClip in atrial functional mitral regurgitation (A-FMR). METHODS The study included patients with A-FMR and concomitant AF who underwent to the MitraClip at 7 Italian Centers. Aim of the study was to assess the safety, efficacy and mid-term cardiovascular outcomes. RESULTS After reviewing 1153 patients with FMR treated with TMVr from 2009 to 2021, 87 patients (median age 81 years, 61% female) with A-FMR were identified. Technical success was achieved in 97%, 30-day device success in 83% and 30-day procedural success in 80%. All-cause death at 30-day was 5%. Estimated two-year freedom from all-cause death and cardiac death was 60% and 77%, respectively, whereas freedom from all-cause death/heart failure hospitalization was 55%. Residual MR ≤ 2+ was encountered in 89% (n = 47/53) and improvement in NYHA class I/II in 79% (n = 48/61). Post-procedural MR ≥ 2+ (HR 5.400, CI 1.371-21.268) and inter-commissural annular diameter ≥ 35 mm (HR 4.159, CI 1.057-16.363) were independent predictors of all-cause death/heart failure hospitalization during the follow-up. Positive reverse remodeling of left atrium and mitral annular dimensions occurred after TMVr during the follow-up. CONCLUSIONS MitraClip resulted to be a safe and effective option to treat A-FMR in elderly patients.
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Gajjar K, Kashyap K, Badlani J, Williams RB, Biederman RWW. A review of the pivotal role of cardiac MRI in mitral valve regurgitation. Echocardiography 2020; 38:128-141. [PMID: 33270944 DOI: 10.1111/echo.14941] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 11/09/2020] [Accepted: 11/11/2020] [Indexed: 01/21/2023] Open
Abstract
Cardiac imaging is the cornerstone of defining the etiology, quantification, and management of mitral regurgitation (MR). This continues to be even more so the case with emerging transcatheter techniques to manage MR. Transthoracic echocardiography remains the first-line imaging modality to assess MR but has limitations. Cardiac MRI(CMR) provides the advantages of quantitative nonvisual estimation, 3D volumetric data, late gadolinium, T1, and extracellular volume measurements to comprehensively assess mitral valvular pathology, cardiac remodeling, and the prognostic impact of therapies. This review describes the superiority, technical aspects and growing evidence behind CMR, and lays the roadmap for the future of CMR in MR.
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Affiliation(s)
- Kushani Gajjar
- Department of Cardiology, Allegheny General Hospital- Allegheny Health Network, Pittsburgh, PA, USA
| | - Kartikeya Kashyap
- Department of Cardiology, Allegheny General Hospital- Allegheny Health Network, Pittsburgh, PA, USA
| | - Jayshiv Badlani
- Department of Cardiovascular Magnetic Resonance Imaging, Allegheny General Hospital- Allegheny Health Network, Pittsburgh, PA, USA
| | - Ronald B Williams
- Department of Cardiovascular Magnetic Resonance Imaging, Allegheny General Hospital- Allegheny Health Network, Pittsburgh, PA, USA
| | - Robert W W Biederman
- Department of Cardiology, Allegheny General Hospital- Allegheny Health Network, Pittsburgh, PA, USA.,Department of Cardiovascular Magnetic Resonance Imaging, Allegheny General Hospital- Allegheny Health Network, Pittsburgh, PA, USA.,Drexel University, Philadelphia, PA, USA.,Bioengineering Department, Carnegie Mellon University, Pittsburgh, PA, USA
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11
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Abstract
PURPOSE OF REVIEW To review the prevalence and prognosis of atrial functional mitral regurgitation (AFMR), the distinctive echocardiographic and mechanistic findings, and the therapeutic implications of this newly described disorder. RECENT FINDINGS Initial studies identified an association between atrial fibrillation, mitral annular dilation, and significant mitral regurgitation despite a normal mitral valve and left ventricle. Accumulating data suggest that AFMR is not rare and may have a prognosis as poor as functional MR associated with LV remodeling. Echocardiography has played an important role in understanding the unique pathophysiology of AFMR, and proposed mechanisms include not only atrial remodeling, but structural and functional abnormalities of the LV (HFpEF shares a common pathophysiology) and insufficient leaflet growth. Timely rhythm control of atrial fibrillation and strategies that reduce diastolic pressure, left atrial and mitral annular enlargement, and that favorably affect mitral leaflet adaptation, are promising preventive and treatment options that warrant clinical study. SUMMARY Functional mitral regurgitation may be atrial in origin and should be considered in patients with (particularly long-standing) atrial fibrillation and in those with HFpEF.
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12
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Functional Regurgitation of Atrioventricular Valves and Atrial Fibrillation: An Elusive Pathophysiological Link Deserving Further Attention. J Am Soc Echocardiogr 2020; 33:42-53. [DOI: 10.1016/j.echo.2019.08.016] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 08/23/2019] [Accepted: 08/27/2019] [Indexed: 12/15/2022]
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13
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Pype L, Embrechts L, Cornez B, Van Paesschen C, Sarkozy A, Miljoen H, Heuten H, Saenen J, Van Herck P, de Heyning CMV, Heidbuchel H, Claeys MJ. Long-term effect of atrial fibrillation on the evolution of mitral and tricuspid valve regurgitation. Acta Cardiol 2019; 75:639-647. [PMID: 31403908 DOI: 10.1080/00015385.2019.1649339] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Objective: The present study aims to identify the long-term effects of atrial fibrillation (AF) on atrial remodelling and on the progression of mitral/tricuspid valve regurgitation (MR/TR). Methods: The severity of MR/TR was assessed by the colour jet area and by multi-integrative approach at baseline and after a period of 65 ± 10 months in 37 patients with permanent AF, in 80 patients with non-permanent AF (of whom 43 were treated with ablation) and in 53 control patients with sinus rhythm. Results: At baseline, AF patients had larger MR jet areas than control patients. At follow up, progression of MR, expressed as delta MR jet area, was 0.05 ± 1.3 cm2 in the control group, 0.73 ± 2.1 cm2 in the non-permanent AF group and 1.95 ± 3.6 cm2 in the permanent AF group (p = .001). Severe MR at follow up was observed in 0%, 2.5%, 8%, respectively. There was a significant positive correlation between progression of MR and increase of left atrium volume (r = 0.31, p < .001). After adjustment for baseline clinical and echocardiographic parameters, permanent AF remained independently associated with the progression of MR. Although rhythm control was better with AF ablation than with medical treatment only, the MR evolution was similar. Comparable findings, albeit less pronounced, were observed for the association between of AF and TR progression. Conclusions: The presence of longstanding AF is associated with a significant progression of MR/TR mainly due to atrial remodelling. Our data showed a beneficial effect of sustained rhythm control, either medically or by ablation, on MR/TR progression.
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Affiliation(s)
- L. Pype
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
| | - L. Embrechts
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
| | - B. Cornez
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
| | - C. Van Paesschen
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
| | - A. Sarkozy
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
| | - H. Miljoen
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
| | - H. Heuten
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
| | - J. Saenen
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
| | - P. Van Herck
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
| | | | - H. Heidbuchel
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
| | - M. J. Claeys
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
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Deferm S, Bertrand PB, Verbrugge FH, Verhaert D, Rega F, Thomas JD, Vandervoort PM. Atrial Functional Mitral Regurgitation. J Am Coll Cardiol 2019; 73:2465-2476. [DOI: 10.1016/j.jacc.2019.02.061] [Citation(s) in RCA: 142] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 02/15/2019] [Accepted: 02/18/2019] [Indexed: 12/12/2022]
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Khidr S, Doyle M, Rayarao G, Abdel Ghany M, Hasan-Ali H, Fouad DA, Belden W, Biederman RW. Pulmonary vein remodeling following pulmonary vein isolation in patients with atrial fibrillation-do pulmonary veins represent only an epiphenomenon? A cardiac MRI study. Cardiovasc Diagn Ther 2019; 9:8-17. [PMID: 30881872 DOI: 10.21037/cdt.2018.09.07] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background After successful pulmonary vein isolation (PVI) for atrial fibrillation (AF), the left atrium (LA) undergoes reverse remodeling. However, few studies have directly studied pulmonary vein (PV) remodeling and focused on whether pre PVI-PV conditions could predict outcome of the procedure. We hypothesize that: (I) post PVI, in addition to LA remodeling the PVs undergo a parallel degree of remodeling; and (II) that PV characteristics pre PVI can be used to identify patients more likely to sustain normal sinus rhythm (NSR). Methods Patients (n=100) scheduled for PVI had a cardiovascular magnetic resonance (CMR) imaging before and 6±2 months following PVI. PV cross sectional areas (CSA) within 0.5 cm of the ostium and LA volumes were measured. Patients were categorized as responders (R) or non-responders (NR), based on two separate 14-day Holter monitoring. Results PVs CSA were significantly reduced post procedure in both groups, R (233±53 to 192±52 mm2, P<0.001) and NR (241±54 to 207±44 mm2, P<0.001), however, the difference between R and NR post PVI was not significant (192±52 to 207±44 mm2, P=0.19). Reduction in PVs CSAs post procedure moderately correlated with the 3D LA volume reduction (r=0.48, P<0.001). Conclusions PVs mirror the LA in that they significantly change in size following PVI yet they were not found to directly predict maintenance of NSR.
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Affiliation(s)
- Shimaa Khidr
- Cardiovascular Medicine Department, Assiut University Hospital, Assiut, Egypt
| | - Mark Doyle
- Cardiac MRI Unit, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Geetha Rayarao
- Cardiac MRI Unit, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Mohamed Abdel Ghany
- Cardiovascular Medicine Department, Assiut University Hospital, Assiut, Egypt
| | - Hosam Hasan-Ali
- Cardiovascular Medicine Department, Assiut University Hospital, Assiut, Egypt
| | - Doaa A Fouad
- Cardiovascular Medicine Department, Assiut University Hospital, Assiut, Egypt
| | - William Belden
- Cardiac MRI Unit, Allegheny General Hospital, Pittsburgh, PA, USA
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16
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Silbiger JJ. Mechanistic insights into atrial functional mitral regurgitation: Far more complicated than just left atrial remodeling. Echocardiography 2019; 36:164-169. [DOI: 10.1111/echo.14249] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 12/01/2018] [Accepted: 12/04/2018] [Indexed: 01/03/2023] Open
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17
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Liang JJ, Silvestry FE. Mechanistic insights into mitral regurgitation due to atrial fibrillation: “Atrial functional mitral regurgitation”. Trends Cardiovasc Med 2016; 26:681-689. [DOI: 10.1016/j.tcm.2016.04.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 04/26/2016] [Accepted: 04/27/2016] [Indexed: 10/21/2022]
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18
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Panovsky R, Pleva M, Feitova V, Kruzliak P, Meluzin J, Kincl V, Novotny P, Vanicek J. Left atrium assessment. J Cardiovasc Med (Hagerstown) 2015; 16:671-80. [DOI: 10.2459/jcm.0000000000000155] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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19
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McManus DD, Tanriverdi K, Lin H, Esa N, Kinno M, Mandapati D, Tam S, Okike ON, Ellinor PT, Keaney JF, Donahue JK, Benjamin EJ, Freedman JE. Plasma microRNAs are associated with atrial fibrillation and change after catheter ablation (the miRhythm study). Heart Rhythm 2015; 12:3-10. [PMID: 25257092 PMCID: PMC4277933 DOI: 10.1016/j.hrthm.2014.09.050] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Indexed: 01/14/2023]
Abstract
BACKGROUND MicroRNAs (miRNAs) are associated with cardiovascular disease and control gene expression and are detectable in the circulation. OBJECTIVE The purpose of this study was to test the hypothesis that circulating miRNAs may be associated with atrial fibrillation (AF). METHODS Using a prospective study design powered to detect subtle differences in miRNAs, we quantified plasma expression of 86 miRNAs by high-throughput quantitative reverse transcriptase-polymerase chain reaction in 112 participants with AF and 99 without AF. To examine parallels between cardiac and plasma miRNA profiles, we quantified atrial tissue and plasma miRNA expression using quantitative reverse transcriptase-polymerase chain reaction in 31 participants undergoing surgery. We also explored the hypothesis that lower AF burden after ablation would be reflected in the circulating blood pool by examining change in plasma miRNAs after AF ablation (n = 47). RESULTS Mean age of the cohort was 59 years; 58% of participants were men. Plasma miRs-21 and 150 were 2-fold lower in participants with AF than in those without AF after adjustment (P ≤.0006). Plasma levels of miRs-21 and 150 also were lower in participants with paroxysmal AF than in those with persistent AF (P <.05). Expression of miR-21, but not of miR-150, was lower in atrial tissue from patients with AF than in those without AF (P <.05). Plasma levels of miRs-21 and 150 increased 3-fold after AF ablation (P ≤.0006). CONCLUSION Cardiac miRs-21 and 150 are known to regulate genes implicated in atrial remodeling. Our findings show associations between plasma miRs-21 and 150 and AF, suggesting that circulating miRNAs can provide insights into cardiac gene regulation.
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Affiliation(s)
- David D McManus
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts; National Heart Lung and Blood Institute's and Boston University's Framingham Heart Study, Framingham, Massachusetts; Epidemiology Division, Department of Quantitative Health Sciences, University of Massachusetts Medical School Worcester, Massachusetts.
| | - Kahraman Tanriverdi
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Honghuang Lin
- National Heart Lung and Blood Institute's and Boston University's Framingham Heart Study, Framingham, Massachusetts; Computational Biomedicine Section, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Nada Esa
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Menhel Kinno
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Divakar Mandapati
- Cardiothoracic Surgery Division, Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Stanley Tam
- Cardiothoracic Surgery Division, Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Okike N Okike
- Cardiothoracic Surgery Division, Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Patrick T Ellinor
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts; Cardiovascular Research Center, Massachusetts General Hospital, Charlestown, Massachusetts
| | - John F Keaney
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - J Kevin Donahue
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Emelia J Benjamin
- National Heart Lung and Blood Institute's and Boston University's Framingham Heart Study, Framingham, Massachusetts; Epidemiology Department, Boston University School of Public Health, Boston, Massachusetts
| | - Jane E Freedman
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts; National Heart Lung and Blood Institute's and Boston University's Framingham Heart Study, Framingham, Massachusetts
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