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Pambianchi G, Giannetti M, Marchitelli L, Cundari G, Maestrini V, Mancone M, Francone M, Catalano C, Galea N. Papillary Muscle Involvement during Acute Myocardial Infarction: Detection by Cardiovascular Magnetic Resonance Using T1 Mapping Technique and Papillary Longitudinal Strain. J Clin Med 2023; 12:jcm12041497. [PMID: 36836032 PMCID: PMC9963367 DOI: 10.3390/jcm12041497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 02/10/2023] [Accepted: 02/11/2023] [Indexed: 02/16/2023] Open
Abstract
Papillary muscle (PPM) involvement in myocardial infarction (MI) increases the risk of secondary mitral valve regurgitation or PPM rupture and may be diagnosed using late gadolinium enhancement (LGE) imaging. The native T1-mapping (nT1) technique and PPM longitudinal strain (PPM-ls) have been used to identify PPM infarction (iPPM) without the use of the contrast agent. This study aimed to assess the diagnostic performance of nT1 and PPM-ls in the identification of iPPM. Forty-six patients, who performed CMR within 14-30 days after MI, were retrospectively enrolled: sixteen showed signs of iPPM on LGE images. nT1 values were measured within the infarcted area (IA), remote myocardium (RM), blood pool (BP), and anterolateral and posteromedial PPMs and compared using ANOVA. PPM-ls values have been assessed on cineMR images as the percentage of shortening between end-diastolic and end-systolic phases. Higher nT1 values and lower PPM-ls were found in infarcted compared to non-infarcted PPMs (nT1: 1219.3 ± 102.5 ms vs. 1052.2 ± 80.5 ms and 17.6 ± 6.3% vs. 21.6 ± 4.3%; p-value < 0.001 for both), with no significant differences between the nT1 of infarcted PPMs and IA and between the non-infarcted PPMs and RM. ROC analysis demonstrated an excellent discriminatory power for nT1 in detecting the iPPM (AUC = 0.874; 95% CI: 0.784-0.963; p < 0.001). nT1 and PPM-ls are valid tools in assessing iPPM with the advantage of avoiding contrast media administration.
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Affiliation(s)
- Giacomo Pambianchi
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Martina Giannetti
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Livia Marchitelli
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Giulia Cundari
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Viviana Maestrini
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, “Policlinico Umberto I” Hospital, 00161 Rome, Italy
| | - Massimo Mancone
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, “Policlinico Umberto I” Hospital, 00161 Rome, Italy
| | - Marco Francone
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Carlo Catalano
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Nicola Galea
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, 00161 Rome, Italy
- Correspondence:
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Axelsson E, Ljungvall I, Bhoumik P, Conn LB, Muren E, Ohlsson Å, Olsen LH, Engdahl K, Hagman R, Hanson J, Kryvokhyzha D, Pettersson M, Grenet O, Moggs J, Del Rio-Espinola A, Epe C, Taillon B, Tawari N, Mane S, Hawkins T, Hedhammar Å, Gruet P, Häggström J, Lindblad-Toh K. The genetic consequences of dog breed formation-Accumulation of deleterious genetic variation and fixation of mutations associated with myxomatous mitral valve disease in cavalier King Charles spaniels. PLoS Genet 2021; 17:e1009726. [PMID: 34473707 PMCID: PMC8412370 DOI: 10.1371/journal.pgen.1009726] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 07/20/2021] [Indexed: 02/07/2023] Open
Abstract
Selective breeding for desirable traits in strictly controlled populations has generated an extraordinary diversity in canine morphology and behaviour, but has also led to loss of genetic variation and random entrapment of disease alleles. As a consequence, specific diseases are now prevalent in certain breeds, but whether the recent breeding practice led to an overall increase in genetic load remains unclear. Here we generate whole genome sequencing (WGS) data from 20 dogs per breed from eight breeds and document a ~10% rise in the number of derived alleles per genome at evolutionarily conserved sites in the heavily bottlenecked cavalier King Charles spaniel breed (cKCs) relative to in most breeds studied here. Our finding represents the first clear indication of a relative increase in levels of deleterious genetic variation in a specific breed, arguing that recent breeding practices probably were associated with an accumulation of genetic load in dogs. We then use the WGS data to identify candidate risk alleles for the most common cause for veterinary care in cKCs–the heart disease myxomatous mitral valve disease (MMVD). We verify a potential link to MMVD for candidate variants near the heart specific NEBL gene in a dachshund population and show that two of the NEBL candidate variants have regulatory potential in heart-derived cell lines and are associated with reduced NEBL isoform nebulette expression in papillary muscle (but not in mitral valve, nor in left ventricular wall). Alleles linked to reduced nebulette expression may hence predispose cKCs and other breeds to MMVD via loss of papillary muscle integrity. As a consequence of selective breeding, specific disease-causing mutations have become more frequent in certain dog breeds. Whether the breeding practice also resulted in a general increase in the overall number of disease-causing mutations per dog genome is however not clear. To address this question, we compare the amount of harmful, potentially disease-causing, mutations in dogs from eight common breeds that have experienced varying degrees of intense selective breeding. We find that individuals belonging to the breed affected by the most intense breeding—cavalier King Charles spaniel (cKCs)—carry more harmful variants than other breeds, indicating that past breeding practices may have increased the overall levels of harmful genetic variation in dogs. The most common disease in cKCs is myxomatous mitral valve disease (MMVD). To identify variants linked to this disease we next characterize mutations that are common in cKCs, but rare in other breeds, and then investigate if these mutations can predict MMVD in dachshunds. We find that variants that regulate the expression of the gene NEBL in papillary muscles may increase the risk of the disease, indicating that loss of papillary muscle integrity could contribute to the development of MMVD.
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Affiliation(s)
- Erik Axelsson
- Science for Life Laboratory, Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
- * E-mail:
| | - Ingrid Ljungvall
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | - Priyasma Bhoumik
- Translational Medicine, Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Laura Bas Conn
- Science for Life Laboratory, Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
| | - Eva Muren
- Science for Life Laboratory, Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
| | - Åsa Ohlsson
- Department of Animal Breeding and Genetics, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | - Lisbeth Høier Olsen
- Department of Veterinary and Animal Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Karolina Engdahl
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | - Ragnvi Hagman
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | - Jeanette Hanson
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | - Dmytro Kryvokhyzha
- Science for Life Laboratory, Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
| | - Mats Pettersson
- Science for Life Laboratory, Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
| | - Olivier Grenet
- Translational Medicine, Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Jonathan Moggs
- Translational Medicine, Novartis Institutes for BioMedical Research, Basel, Switzerland
| | | | - Christian Epe
- Elanco Animal Health, Greenfield, Indiana, United States of America
| | - Bruce Taillon
- Elanco Animal Health, Greenfield, Indiana, United States of America
| | - Nilesh Tawari
- Elanco Animal Health, Greenfield, Indiana, United States of America
| | - Shrinivas Mane
- Elanco Animal Health, Greenfield, Indiana, United States of America
| | - Troy Hawkins
- Elanco Animal Health, Greenfield, Indiana, United States of America
| | - Åke Hedhammar
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | | | - Jens Häggström
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | - Kerstin Lindblad-Toh
- Science for Life Laboratory, Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, United States of America
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Kılıcgedik A, Kahveci G, Gurbuz AS, Karabay CY, Guler A, Efe SC, Aung SM, Arslantas U, Demir S, Izgi IA, Kirma C. Papillary Muscle Free Strain in Patients with Severe Degenerative and Functional Mitral Regurgitation. Arq Bras Cardiol 2017; 108:339-346. [PMID: 28538762 PMCID: PMC5421473 DOI: 10.5935/abc.20170035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 10/10/2016] [Accepted: 12/09/2016] [Indexed: 12/16/2022] Open
Abstract
FUNDAMENTO: The role of papillary muscle function in severe mitral regurgitation with preserved and reduced left ventricular ejection fraction and the method of choice to evaluate PM have still been the subjects of controversy. OBJECTIVES: To evaluate and compare papillary muscle function in and between patients with severe degenerative and functional mitral regurgitation by using the free strain method. METHODS: 64 patients with severe mitral regurgitation - 39 patients with degenerative mitral regurgitation (DMR group) and 25 patients with severe functional mitral regurgitation (FMR group) - and 30 control subjects (control group) were included in the study. Papillary muscle function was evaluated through the free strain method from apical four chamber images of the anterolateral papillary muscle (APM) and from apical three chamber images of the posteromedial papillary muscle (PPM). Global left ventricular longitudinal and circumferential strains were evaluated by applying 2D speckle tracking imaging. RESULTS: Global left ventricular longitudinal strain (DMR group, -17 [-14.2/-20]; FMR group, -9 [-7/-10.7]; control group, -20 [-18/-21] p < 0.001), global left ventricular circumferential strain (DMR group, -20 [-14.5/-22.7]; FMR group, -10 [-7/-12]; control group, -23 [-21/-27.5] p < 0.001) and papillary musle strains (PPMS; DMR group, -30.5 [-24/-46.7]; FMR group, -18 [-12/-30]; control group; -43 [-34.5/-39.5] p < 0.001; APMS; DMR group, (-35 [-23.5/-43]; FMR group, -20 [-13.5/-26]; control group, -40 [-32.5/-48] p < 0.001) were significantly different among all groups. APMS and PPMS were highly correlated with LVEF (p < 0.001, p < 0.001; respectively), GLS (p < 0.001, p < 0.001; respectively) and GCS (p < 0.001, p < 0.00; respectively) of LV among all groups. No correlation was found between papillary muscle strains and effective orifice area (EOA) in both groups of severe mitral regurgitation. CONCLUSIONS: Measuring papillary muscle longitudinal strain by the free strain method is practical and applicable. Papillary muscle dysfunction plays a small role in severe MR due to degenerative or functional causes and papillary muscle functions in general seems to follow left ventricular function. PPM is the most affected PM in severe mitral regurgitation in both groups of DMR and FMR. FUNDAMENTO: O papel da função do músculo papilar na regurgitação mitral grave com fração de ejeção do ventrículo esquerdo preservada e reduzida e o método de escolha para avaliar PM ainda são objetos de controvérsia. OBJETIVOS: Avaliar e comparar a função dos músculos papilares entre pacientes com insuficiência mitral funcional e degenerativa pelo método free strain. MÉTODOS: 64 pacientes com insuficiência mitral grave - 39 pacientes com insuficiência mitral degenerativa grave (grupo IMD) e 25 com insuficiência mitral funcional grave (grupo IMF) - e 30 indivíduos controle (grupo controle) foram incluídos no estudo. A função dos músculos papilares foi avaliada pelo método free strain a partir de imagens apicais quatro-câmaras do músculo papilar anterolateral (MPA) e imagens apicais três-câmaras do músculo papilar posteromedial (MPP). Strains circunferenciais e longitudinais globais do ventrículo esquerdo foram avaliados por meio de imagens bidimensionais a partir do rastreamento de conjunto de pontos de cinza (speckle tracking). RESULTADOS: O strain longitudinal global do ventrículo esquerdo (grupo IMD, -17 [-14,2/-20]; grupo IMF, -9 [-7/-10,7]; grupo controle, -20 [-18/-21] p < 0,001); strain circunferencial global do ventrículo esquerdo (grupo IMD, -20 [-14,5/-22,7]; grupo IMF, -10 [-7/-12]; grupo controle, -23 [-21/-27,5] p < 0,001) e strains de músculos papilares (MPP; grupo IMD, -30,5 [-24/-46,7]; grupo IMF, -18 [-12/-30]; grupo controle; -43 [-34,5/-39,5] p < 0,001; MPA; grupo IMD, (-35 [-23,5/-43]; grupo IMF, -20 [-13,5/-26]; grupo controle, -40 [-32,5/-48] p < 0,001) mostraram-se significativamente diferentes nos grupos. MPA e MPP mostraram-se altamente correlacionados com a FEVE (p < 0,001, p < 0,00; respectivamente), SLG (p < 0,001, p < 0,001; respectivamente) e SCG (p < 0,001, p < 0,001; respectivamente) do VE entre todos os grupos. Não foi encontrada correlação entre os strains de músculos papilares e área eficaz do orifício (AEO) nos grupos de insuficiência mitral grave. CONCLUSÕES: A medição do strain longitudinal de músculos papilares pelo método free strain é prática e aplicável. A disfunção dos músculos papilares tem um papel pequeno em IM grave devido a causas degenerativas e funcionais, e a função dos músculos papilares, em general, parece seguir a função ventricular esquerda. O MPP é o MP mais afetado na insuficiência mitral em ambos os grupos, IMD e IMF.
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Affiliation(s)
- Alev Kılıcgedik
- Kartal Koşuyolu Heart & Research Hospital, Department of
Cardiology, Turkey
| | - Gokhan Kahveci
- Kartal Koşuyolu Heart & Research Hospital, Department of
Cardiology, Turkey
| | | | - Can Yucel Karabay
- Kartal Koşuyolu Heart & Research Hospital, Department of
Cardiology, Turkey
| | - Ahmet Guler
- Kartal Koşuyolu Heart & Research Hospital, Department of
Cardiology, Turkey
| | - Suleyman Cagan Efe
- Kartal Koşuyolu Heart & Research Hospital, Department of
Cardiology, Turkey
| | - Soe Moe Aung
- Kartal Koşuyolu Heart & Research Hospital, Department of
Cardiology, Turkey
| | - Ugur Arslantas
- Kartal Koşuyolu Heart & Research Hospital, Department of
Cardiology, Turkey
| | - Serdar Demir
- Kartal Koşuyolu Heart & Research Hospital, Department of
Cardiology, Turkey
| | - Ibrahim Akin Izgi
- Kartal Koşuyolu Heart & Research Hospital, Department of
Cardiology, Turkey
| | - Cevat Kirma
- Kartal Koşuyolu Heart & Research Hospital, Department of
Cardiology, Turkey
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Kato S, Nakamori S, Roujol S, Delling FN, Akhtari S, Jang J, Basha T, Berg S, Kissinger KV, Goddu B, Manning WJ, Nezafat R. Relationship between native papillary muscle T 1 time and severity of functional mitral regurgitation in patients with non-ischemic dilated cardiomyopathy. J Cardiovasc Magn Reson 2016; 18:79. [PMID: 27846845 PMCID: PMC5111188 DOI: 10.1186/s12968-016-0301-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 10/29/2016] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Functional mitral regurgitation is one of the severe complications of non-ischemic dilated cardiomyopathy (DCM). Non-contrast native T1 mapping has emerged as a non-invasive method to evaluate myocardial fibrosis. We sought to evaluate the potential relationship between papillary muscle T1 time and mitral regurgitation in DCM patients. METHODS Forty DCM patients (55 ± 13 years) and 20 healthy adult control subjects (54 ± 13 years) were studied. Native T1 mapping was performed using a slice interleaved T1 mapping sequence (STONE) which enables acquisition of 5 slices in the short-axis plane within a 90 s free-breathing scan. We measured papillary muscle diameter, length and shortening. DCM patients were allocated into 2 groups based on the presence or absence of functional mitral regurgitation. RESULTS Papillary muscle T1 time was significantly elevated in DCM patients with mitral regurgitation (n = 22) in comparison to those without mitral regurgitation (n = 18) (anterior papillary muscle: 1127 ± 36 msec vs 1063 ± 16 msec, p < 0.05; posterior papillary muscle: 1124 ± 30 msec vs 1062 ± 19 msec, p < 0.05), but LV T1 time was similar (1129 ± 38 msec vs 1134 ± 58 msec, p = 0.93). Multivariate linear regression analysis showed that papillary muscle native T1 time (β = 0.10, 95 % CI: 0.05-0.17, p < 0.05) is significantly correlated with mitral regurgitant fraction. Elevated papillary muscle T1 time was associated with larger diameter, longer length and decreased papillary muscle shortening (all p values <0.05). CONCLUSIONS In DCM, papillary muscle native T1 time is significantly elevated and related to mitral regurgitant fraction.
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Affiliation(s)
- Shingo Kato
- Department of Medicine (Cardiovascular Division), Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215 USA
- Department of Cardiology, Yokohama City University Hospital, Yokohama, Japan
| | - Shiro Nakamori
- Department of Medicine (Cardiovascular Division), Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215 USA
| | - Sébastien Roujol
- Biomedical Engineering Department, King’s College London, London, UK
| | - Francesca N. Delling
- Department of Medicine (Cardiovascular Division), Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215 USA
| | - Shadi Akhtari
- Department of Medicine (Cardiovascular Division), Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215 USA
| | - Jihye Jang
- Department of Medicine (Cardiovascular Division), Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215 USA
| | - Tamer Basha
- Department of Medicine (Cardiovascular Division), Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215 USA
- Biomedical Engineering Department, Cairo University, Giza, Egypt
| | - Sophie Berg
- Department of Medicine (Cardiovascular Division), Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215 USA
| | - Kraig V. Kissinger
- Department of Medicine (Cardiovascular Division), Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215 USA
| | - Beth Goddu
- Department of Medicine (Cardiovascular Division), Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215 USA
| | - Warren J. Manning
- Department of Medicine (Cardiovascular Division), Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215 USA
- Department of Radiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA USA
| | - Reza Nezafat
- Department of Medicine (Cardiovascular Division), Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215 USA
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SUDARSHAN VIDYAK, NG EYK, ACHARYA URAJENDRA, TAN RUSAN, CHOU SIAWMENG, GHISTA DHANJOON. INFARCTED LEFT VENTRICLE CLASSIFICATION FROM CROSS-SECTIONAL ECHOCARDIOGRAMS USING RELATIVE WAVELET ENERGY AND ENTROPY FEATURES. J MECH MED BIOL 2016. [DOI: 10.1142/s0219519416400091] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Parasternal and apical echocardiography images captured from different cross-sectional planes (short-axis and four chambers) convey significant information about the structure and function of infarcted Left Ventricular (LV) myocardium. Thus, features from these cross-sectional views of echocardiograms extracted using computer-aided techniques may aid in characterizing Myocardial Infarction (MI). Therefore, this paper proposes a new algorithm for automated MI characterization using features extracted from parasternal short axis and apical four chambers cross-sectional views of 160 subjects (80 with MI and 80 normal) echocardiograms. The Stationary Wavelet Transform (SWT) method is used to extract the Relative Wavelet Energy and Entropy (RWE and RWEnt) features from the two cross-sectional views of echocardiography images separately. These features are ranked and subjected to classification in two different steps: (i) the features from each view are separately ranked using entropy, t-test and Wilcoxon ranking tests and fed to the classifier, and (ii) later, the features from both the views are combined and ranked. Finally, these ranked features are subjected to the Support Vector Machine (SVM) classifier for characterization of normal and MI using a minimum number of features. The proposed method is able to identify MI with 95.0% of accuracy, 93.7% of sensitivity and 96.2% of specificity using 32 features extracted from parasternal short-axis view; an accuracy of 96.2%, sensitivity of 97.5% and specificity of 95.0% with 18 apical four chamber view features. The results show that by combining the features from both views enables the confirmation of MI LVs with an accuracy of 96.8%, sensitivity of 93.7% and specificity of 100% using 16 features extracted from only two frames. Software development is in progress which can be incorporated into the echocardiography ultrasound machine for automated detection of MI patients.
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Affiliation(s)
- VIDYA K. SUDARSHAN
- School of Mechanical and Aerospace Engineering, Nanyang Technological University, Singapore
- Department of Electronics and Computer Engineering, Ngee Ann Polytechnic, Singapore
| | - E. Y. K. NG
- School of Mechanical and Aerospace Engineering, Nanyang Technological University, Singapore
| | - U. RAJENDRA ACHARYA
- Department of Electronics and Computer Engineering, Ngee Ann Polytechnic, Singapore
- Department of Biomedical Engineering, Faculty of Engineering, University of Malaya, Malaysia
| | - RU SAN TAN
- Department of Cardiology, National Heart Centre, Singapore
| | - SIAW MENG CHOU
- School of Mechanical and Aerospace Engineering, Nanyang Technological University, Singapore
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6
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Sudarshan VK, Acharya UR, Ng EYK, Tan RS, Chou SM, Ghista DN. An integrated index for automated detection of infarcted myocardium from cross-sectional echocardiograms using texton-based features (Part 1). Comput Biol Med 2016; 71:231-40. [PMID: 26898671 DOI: 10.1016/j.compbiomed.2016.01.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 01/14/2016] [Accepted: 01/30/2016] [Indexed: 11/15/2022]
Abstract
Cross-sectional view echocardiography is an efficient non-invasive diagnostic tool for characterizing Myocardial Infarction (MI) and stages of expansion leading to heart failure. An automated computer-aided technique of cross-sectional echocardiography feature assessment can aid clinicians in early and more reliable detection of MI patients before subsequent catastrophic post-MI medical conditions. Therefore, this paper proposes a novel Myocardial Infarction Index (MII) to discriminate infarcted and normal myocardium using features extracted from apical cross-sectional views of echocardiograms. The cross-sectional view of normal and MI echocardiography images are represented as textons using Maximum Responses (MR8) filter banks. Fractal Dimension (FD), Higher-Order Statistics (HOS), Hu's moments, Gabor Transform features, Fuzzy Entropy (FEnt), Energy, Local binary Pattern (LBP), Renyi's Entropy (REnt), Shannon's Entropy (ShEnt), and Kapur's Entropy (KEnt) features are extracted from textons. These features are ranked using t-test and fuzzy Max-Relevancy and Min-Redundancy (mRMR) ranking methods. Then, combinations of highly ranked features are used in the formulation and development of an integrated MII. This calculated novel MII is used to accurately and quickly detect infarcted myocardium by using one numerical value. Also, the highly ranked features are subjected to classification using different classifiers for the characterization of normal and MI LV ultrasound images using a minimum number of features. Our current technique is able to characterize MI with an average accuracy of 94.37%, sensitivity of 91.25% and specificity of 97.50% with 8 apical four chambers view features extracted from only single frame per patient making this a more reliable and accurate classification.
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Affiliation(s)
- Vidya K Sudarshan
- School of Mechanical and Aerospace Engineering, Nanyang Technological University, Singapore; Department of Electronics and Computer Engineering, Ngee Ann Polytechnic, Singapore.
| | - U Rajendra Acharya
- Department of Electronics and Computer Engineering, Ngee Ann Polytechnic, Singapore; Department of Biomedical Engineering, Faculty of Engineering, University of Malaya, Malaysia
| | - E Y K Ng
- School of Mechanical and Aerospace Engineering, Nanyang Technological University, Singapore
| | - Ru San Tan
- Department of Cardiology, National Heart Centre, Singapore
| | - Siaw Meng Chou
- School of Mechanical and Aerospace Engineering, Nanyang Technological University, Singapore
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7
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Izumo M, Akashi YJ. Exercise echocardiography for structural heart disease. J Echocardiogr 2016; 14:21-9. [PMID: 26758899 DOI: 10.1007/s12574-016-0274-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 12/25/2015] [Accepted: 12/28/2015] [Indexed: 11/24/2022]
Abstract
Since the introduction of transcatheter structural heart intervention, the term "structural heart disease" has been widely used in the field of cardiology. Structural heart disease refers to congenital heart disease, valvular heart disease, and cardiomyopathy. In structural heart disease, valvular heart disease is frequently identified in the elderly. Of note, the number of patients who suffer from aortic stenosis (AS) and mitral regurgitation (MR) is increasing in developed countries because of the aging of the populations. Transcatheter aortic valve replacement and percutaneous mitral valve repair has been widely used for AS and MR, individually. Echocardiography is the gold standard modality for initial diagnosis and subsequent evaluation of AS and MR, although the difficulties in assessing patients with these diseases still remain. Here, we review the clinical usefulness and prognostic impact of exercise echocardiography on structural heart disease, particularly on AS and MR.
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Affiliation(s)
- Masaki Izumo
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan.
| | - Yoshihiro J Akashi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
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8
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Eitel I, Gehmlich D, Amer O, Wöhrle J, Kerber S, Lauer B, Pauschinger M, Schwab J, Birkemeyer R, Zimmermann R, Mende M, de Waha S, Desch S, Gutberlet M, Schuler G, Thiele H. Prognostic Relevance of Papillary Muscle Infarction in Reperfused Infarction as Visualized by Cardiovascular Magnetic Resonance. Circ Cardiovasc Imaging 2013; 6:890-8. [DOI: 10.1161/circimaging.113.000411] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ingo Eitel
- From the Department of Internal Medicine/Cardiology (I.E., D.G., O.A., S.d.W., S.D., G.S., H.T.) and Department of Diagnostic and Interventional Radiology (M.G.), University of Leipzig, Heart Center, Leipzig, Germany; Department of Internal Medicine II – Cardiology, University of Ulm, Ulm, Germany (J.W.); Herz- und Gefäß-Klinik Bad Neustadt, Bad Neustadt, Germany (S.K.); Zentralklinik Bad Berka, Bad Berka, Germany (B.L.); Klinikum Nürnberg, Medizinische Klinik/Kardiologie, Nürnberg, Germany (M.P., J
| | - Dörthe Gehmlich
- From the Department of Internal Medicine/Cardiology (I.E., D.G., O.A., S.d.W., S.D., G.S., H.T.) and Department of Diagnostic and Interventional Radiology (M.G.), University of Leipzig, Heart Center, Leipzig, Germany; Department of Internal Medicine II – Cardiology, University of Ulm, Ulm, Germany (J.W.); Herz- und Gefäß-Klinik Bad Neustadt, Bad Neustadt, Germany (S.K.); Zentralklinik Bad Berka, Bad Berka, Germany (B.L.); Klinikum Nürnberg, Medizinische Klinik/Kardiologie, Nürnberg, Germany (M.P., J
| | - Omran Amer
- From the Department of Internal Medicine/Cardiology (I.E., D.G., O.A., S.d.W., S.D., G.S., H.T.) and Department of Diagnostic and Interventional Radiology (M.G.), University of Leipzig, Heart Center, Leipzig, Germany; Department of Internal Medicine II – Cardiology, University of Ulm, Ulm, Germany (J.W.); Herz- und Gefäß-Klinik Bad Neustadt, Bad Neustadt, Germany (S.K.); Zentralklinik Bad Berka, Bad Berka, Germany (B.L.); Klinikum Nürnberg, Medizinische Klinik/Kardiologie, Nürnberg, Germany (M.P., J
| | - Jochen Wöhrle
- From the Department of Internal Medicine/Cardiology (I.E., D.G., O.A., S.d.W., S.D., G.S., H.T.) and Department of Diagnostic and Interventional Radiology (M.G.), University of Leipzig, Heart Center, Leipzig, Germany; Department of Internal Medicine II – Cardiology, University of Ulm, Ulm, Germany (J.W.); Herz- und Gefäß-Klinik Bad Neustadt, Bad Neustadt, Germany (S.K.); Zentralklinik Bad Berka, Bad Berka, Germany (B.L.); Klinikum Nürnberg, Medizinische Klinik/Kardiologie, Nürnberg, Germany (M.P., J
| | - Sebastian Kerber
- From the Department of Internal Medicine/Cardiology (I.E., D.G., O.A., S.d.W., S.D., G.S., H.T.) and Department of Diagnostic and Interventional Radiology (M.G.), University of Leipzig, Heart Center, Leipzig, Germany; Department of Internal Medicine II – Cardiology, University of Ulm, Ulm, Germany (J.W.); Herz- und Gefäß-Klinik Bad Neustadt, Bad Neustadt, Germany (S.K.); Zentralklinik Bad Berka, Bad Berka, Germany (B.L.); Klinikum Nürnberg, Medizinische Klinik/Kardiologie, Nürnberg, Germany (M.P., J
| | - Bernward Lauer
- From the Department of Internal Medicine/Cardiology (I.E., D.G., O.A., S.d.W., S.D., G.S., H.T.) and Department of Diagnostic and Interventional Radiology (M.G.), University of Leipzig, Heart Center, Leipzig, Germany; Department of Internal Medicine II – Cardiology, University of Ulm, Ulm, Germany (J.W.); Herz- und Gefäß-Klinik Bad Neustadt, Bad Neustadt, Germany (S.K.); Zentralklinik Bad Berka, Bad Berka, Germany (B.L.); Klinikum Nürnberg, Medizinische Klinik/Kardiologie, Nürnberg, Germany (M.P., J
| | - Matthias Pauschinger
- From the Department of Internal Medicine/Cardiology (I.E., D.G., O.A., S.d.W., S.D., G.S., H.T.) and Department of Diagnostic and Interventional Radiology (M.G.), University of Leipzig, Heart Center, Leipzig, Germany; Department of Internal Medicine II – Cardiology, University of Ulm, Ulm, Germany (J.W.); Herz- und Gefäß-Klinik Bad Neustadt, Bad Neustadt, Germany (S.K.); Zentralklinik Bad Berka, Bad Berka, Germany (B.L.); Klinikum Nürnberg, Medizinische Klinik/Kardiologie, Nürnberg, Germany (M.P., J
| | - Johannes Schwab
- From the Department of Internal Medicine/Cardiology (I.E., D.G., O.A., S.d.W., S.D., G.S., H.T.) and Department of Diagnostic and Interventional Radiology (M.G.), University of Leipzig, Heart Center, Leipzig, Germany; Department of Internal Medicine II – Cardiology, University of Ulm, Ulm, Germany (J.W.); Herz- und Gefäß-Klinik Bad Neustadt, Bad Neustadt, Germany (S.K.); Zentralklinik Bad Berka, Bad Berka, Germany (B.L.); Klinikum Nürnberg, Medizinische Klinik/Kardiologie, Nürnberg, Germany (M.P., J
| | - Ralf Birkemeyer
- From the Department of Internal Medicine/Cardiology (I.E., D.G., O.A., S.d.W., S.D., G.S., H.T.) and Department of Diagnostic and Interventional Radiology (M.G.), University of Leipzig, Heart Center, Leipzig, Germany; Department of Internal Medicine II – Cardiology, University of Ulm, Ulm, Germany (J.W.); Herz- und Gefäß-Klinik Bad Neustadt, Bad Neustadt, Germany (S.K.); Zentralklinik Bad Berka, Bad Berka, Germany (B.L.); Klinikum Nürnberg, Medizinische Klinik/Kardiologie, Nürnberg, Germany (M.P., J
| | - Rainer Zimmermann
- From the Department of Internal Medicine/Cardiology (I.E., D.G., O.A., S.d.W., S.D., G.S., H.T.) and Department of Diagnostic and Interventional Radiology (M.G.), University of Leipzig, Heart Center, Leipzig, Germany; Department of Internal Medicine II – Cardiology, University of Ulm, Ulm, Germany (J.W.); Herz- und Gefäß-Klinik Bad Neustadt, Bad Neustadt, Germany (S.K.); Zentralklinik Bad Berka, Bad Berka, Germany (B.L.); Klinikum Nürnberg, Medizinische Klinik/Kardiologie, Nürnberg, Germany (M.P., J
| | - Meinhard Mende
- From the Department of Internal Medicine/Cardiology (I.E., D.G., O.A., S.d.W., S.D., G.S., H.T.) and Department of Diagnostic and Interventional Radiology (M.G.), University of Leipzig, Heart Center, Leipzig, Germany; Department of Internal Medicine II – Cardiology, University of Ulm, Ulm, Germany (J.W.); Herz- und Gefäß-Klinik Bad Neustadt, Bad Neustadt, Germany (S.K.); Zentralklinik Bad Berka, Bad Berka, Germany (B.L.); Klinikum Nürnberg, Medizinische Klinik/Kardiologie, Nürnberg, Germany (M.P., J
| | - Suzanne de Waha
- From the Department of Internal Medicine/Cardiology (I.E., D.G., O.A., S.d.W., S.D., G.S., H.T.) and Department of Diagnostic and Interventional Radiology (M.G.), University of Leipzig, Heart Center, Leipzig, Germany; Department of Internal Medicine II – Cardiology, University of Ulm, Ulm, Germany (J.W.); Herz- und Gefäß-Klinik Bad Neustadt, Bad Neustadt, Germany (S.K.); Zentralklinik Bad Berka, Bad Berka, Germany (B.L.); Klinikum Nürnberg, Medizinische Klinik/Kardiologie, Nürnberg, Germany (M.P., J
| | - Steffen Desch
- From the Department of Internal Medicine/Cardiology (I.E., D.G., O.A., S.d.W., S.D., G.S., H.T.) and Department of Diagnostic and Interventional Radiology (M.G.), University of Leipzig, Heart Center, Leipzig, Germany; Department of Internal Medicine II – Cardiology, University of Ulm, Ulm, Germany (J.W.); Herz- und Gefäß-Klinik Bad Neustadt, Bad Neustadt, Germany (S.K.); Zentralklinik Bad Berka, Bad Berka, Germany (B.L.); Klinikum Nürnberg, Medizinische Klinik/Kardiologie, Nürnberg, Germany (M.P., J
| | - Matthias Gutberlet
- From the Department of Internal Medicine/Cardiology (I.E., D.G., O.A., S.d.W., S.D., G.S., H.T.) and Department of Diagnostic and Interventional Radiology (M.G.), University of Leipzig, Heart Center, Leipzig, Germany; Department of Internal Medicine II – Cardiology, University of Ulm, Ulm, Germany (J.W.); Herz- und Gefäß-Klinik Bad Neustadt, Bad Neustadt, Germany (S.K.); Zentralklinik Bad Berka, Bad Berka, Germany (B.L.); Klinikum Nürnberg, Medizinische Klinik/Kardiologie, Nürnberg, Germany (M.P., J
| | - Gerhard Schuler
- From the Department of Internal Medicine/Cardiology (I.E., D.G., O.A., S.d.W., S.D., G.S., H.T.) and Department of Diagnostic and Interventional Radiology (M.G.), University of Leipzig, Heart Center, Leipzig, Germany; Department of Internal Medicine II – Cardiology, University of Ulm, Ulm, Germany (J.W.); Herz- und Gefäß-Klinik Bad Neustadt, Bad Neustadt, Germany (S.K.); Zentralklinik Bad Berka, Bad Berka, Germany (B.L.); Klinikum Nürnberg, Medizinische Klinik/Kardiologie, Nürnberg, Germany (M.P., J
| | - Holger Thiele
- From the Department of Internal Medicine/Cardiology (I.E., D.G., O.A., S.d.W., S.D., G.S., H.T.) and Department of Diagnostic and Interventional Radiology (M.G.), University of Leipzig, Heart Center, Leipzig, Germany; Department of Internal Medicine II – Cardiology, University of Ulm, Ulm, Germany (J.W.); Herz- und Gefäß-Klinik Bad Neustadt, Bad Neustadt, Germany (S.K.); Zentralklinik Bad Berka, Bad Berka, Germany (B.L.); Klinikum Nürnberg, Medizinische Klinik/Kardiologie, Nürnberg, Germany (M.P., J
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9
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Silbiger JJ. Novel Pathogenetic Mechanisms and Structural Adaptations in Ischemic Mitral Regurgitation. J Am Soc Echocardiogr 2013; 26:1107-1117. [DOI: 10.1016/j.echo.2013.07.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Indexed: 10/26/2022]
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10
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Itoh A, Stephens EH, Ennis DB, Carlhall CJ, Bothe W, Nguyen TC, Swanson JC, Miller DC, Ingels NB. Contribution of myocardium overlying the anterolateral papillary muscle to left ventricular deformation. Am J Physiol Heart Circ Physiol 2011; 302:H180-7. [PMID: 22037187 DOI: 10.1152/ajpheart.00687.2011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Previous studies of transmural left ventricular (LV) strains suggested that the myocardium overlying the papillary muscle displays decreased deformation relative to the anterior LV free wall or significant regional heterogeneity. These comparisons, however, were made using different hearts. We sought to extend these studies by examining three equatorial LV regions in the same heart during the same heartbeat. Therefore, deformation was analyzed from transmural beadsets placed in the equatorial LV myocardium overlying the anterolateral papillary muscle (PAP), as well as adjacent equatorial LV regions located more anteriorly (ANT) and laterally (LAT). We found that the magnitudes of LAT normal longitudinal and radial strains, as well as major principal strains, were less than ANT, while those of PAP were intermediate. Subepicardial and midwall myofiber angles of LAT, PAP, and ANT were not significantly different, but PAP subendocardial myofiber angles were significantly higher (more longitudinal as opposed to circumferential orientation). Subepicardial and midwall myofiber strains of ANT, PAP, and LAT were not significantly different, but PAP subendocardial myofiber strains were less. Transmural gradients in circumferential and radial normal strains, and major principal strains, were observed in each region. The two main findings of this study were as follows: 1) PAP strains are largely consistent with adjacent LV equatorial free wall regions, and 2) there is a gradient of strains across the anterolateral equatorial left ventricle despite similarities in myofiber angles and strains. These findings point to graduated equatorial LV heterogeneity and suggest that regional differences in myofiber coupling may constitute the basis for such heterogeneity.
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Affiliation(s)
- Akinobu Itoh
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, California, USA
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11
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Madu EC, Baugh DS, Tulloch-Reid E, Potu C. Papillary Muscle Function Does Not Predict Mitral Regurgitation in Patients with Normal Left Ventricular Systolic Function: A Transesophageal Echocardiographic Study. ACTA ACUST UNITED AC 2011. [DOI: 10.4236/ijcm.2011.22030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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12
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Madu EC, D'Cruz IA. The vital role of papillary muscles in mitral and ventricular function: echocardiographic insights. Clin Cardiol 2009; 20:93-8. [PMID: 9034636 PMCID: PMC6655849 DOI: 10.1002/clc.4960200203] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
The two left ventricular (LV) papillary muscles are small structures but are vital to mitral valve competence. Partial or complete rupture, complicating acute myocardial infarction, causes severe or even catastrophic mitral regurgitation, potentially correctable by surgery. Papillary muscle dysfunction is a controversial topic in that the role of the papillary muscle itself, in causing mitral regurgitation post infarction, has been seriously questioned; it is less confusing if this syndrome is attributed not only to papillary muscle but also to adjacent LV wall ischemia or infarction. Papillary muscle calcification is easily and frequently detected on echocardiography, but its clinical significance remains uncertain. Papillary muscle hypertrophy accompanies LV hypertrophy of varied etiology and may have a significant role in producing dynamic late-systolic intra-LV obstruction in hypertrophic cardiomyopathy and other hyperdynamic hypertrophied LV chambers. All the above abnormalities can be adequately assessed by 2-D echocardiography and the Doppler modalities. In selected cases, transesophageal echocardiography can provide additional valuable data by improving visualization of papillary muscles and mitral apparatus.
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Affiliation(s)
- E C Madu
- Echocardiography Laboratory, University of Tennessee, Memphis 38163, USA
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13
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Quantitative measurement of mitral valve coaptation in functional mitral regurgitation: In vivo experimental study by real-time three-dimensional echocardiography. J Cardiol 2009; 53:94-101. [DOI: 10.1016/j.jjcc.2008.09.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2008] [Revised: 09/19/2008] [Accepted: 09/24/2008] [Indexed: 11/18/2022]
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14
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Pagel PS, Murphy RM, Iqbal Z, Gandhi SD, Markan S. Why the "Y"? A peculiar intraventricular structure associated with a posterior basal aneurysm. Diagnosis: isolated calcification of the distal posterior medial papillary muscle. J Cardiothorac Vasc Anesth 2008; 23:118-20. [PMID: 18834758 DOI: 10.1053/j.jvca.2007.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2007] [Indexed: 11/11/2022]
Affiliation(s)
- Paul S Pagel
- Anesthesia Service, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI 53295, USA.
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15
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Zhang H, Otsuji Y, Uemura T, Yu B, Takeuchi M, Hamasaki S, Miyata M, Kisanuki A, Minagoe S, Levine RA, Tei C. Different Mechanisms of Ischemic Mitral Regurgitation in Patients With Inferior and Anterior Myocardial Infarction. J Echocardiogr 2008. [DOI: 10.2303/jecho.6.74] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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17
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Otsuji Y, Levine RA, Takeuchi M, Sakata R, Tei C. Mechanism of Ischemic Mitral Regurgitation. J Cardiovasc Ultrasound 2008. [DOI: 10.4250/jcu.2008.16.1.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Yutaka Otsuji
- Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Robert A. Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Boston, USA
| | - Masaaki Takeuchi
- Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Ryuzo Sakata
- Department of Cardiovascular Surgery, Kagoshima University, Kagoshima, Japan
| | - Chuwa Tei
- Department of Cardiovascular Medicine, Kagoshima University, Kagoshima, Japan
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18
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Song JM, Qin JX, Kongsaerepong V, Shiota M, Agler DA, Smedira NG, McCarthy PM, Marc Gillinov A, Thomas JD, Shiota T. Determinants of Ischemic Mitral Regurgitation in Patients with Chronic Anterior Wall Myocardial Infarction: A Real Time Three-Dimensional Echocardiography Study. Echocardiography 2006; 23:650-7. [PMID: 16970716 DOI: 10.1111/j.1540-8175.2006.00284.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE We sought to elucidate the geometric determinants of ischemic mitral regurgitation (IMR) in patients with chronic anterior myocardial infarction (MI). MATERIALS AND METHODS In 16 patients with anterior MI only (Group A) and 18 patients with both anterior and inferoposterior MI (Group B), three parallel equidistant anteroposterior (AP) planes (medial, central, lateral) perpendicular to the mitral valvular commissure-commissure plane were generated. The systolic tenting area of the mitral valve (MVTa) and the angles between the annular plane and leaflets (anterior, Aalpha; posterior, Palpha) on the AP planes were measured. The left ventricular end-systolic and end-diastolic volumes, and end-diastolic and end-systolic mitral annular area (MAAs) were obtained. RESULT The regurgitant orifice area (ROA) was significantly smaller in Group A than Group B (0.08 +/- 0.09 vs 0.20 +/- 0.18 cm(2), P < 0.05). In the total of 34 patients, the medial MVTa (P < 0.001), MAAs (P < 0.05) and the spherical index (P < 0.05) were three independent determinants of ROA while the left ventricular volumes were not. MAAs was the only independent determinant of ROA in Group A, while the medial MVTa was in Group B. Palpha (P < 0.05) and MVTa (P = 0.06) tended to be larger in the medial than the lateral side in Group B, while no differences were found in Group A. CONCLUSION The geometry of the mitral valve apparatus was more important than the left ventricular volumes in determining the severity of IMR in patients with anterior MI. The posteromedial side tenting could play a critical role in causing significant IMR when the inferoposterior MI coexists with anterior MI.
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Affiliation(s)
- Jong-Min Song
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Nagasaki M, Nishimura S, Ohtaki E, Kasegawa H, Matsumura T, Nagayama M, Koyanagi T, Tohbaru T, Misu K, Asano R, Sumiyoshi T, Hosoda S. The echocardiographic determinants of functional mitral regurgitation differ in ischemic and non-ischemic cardiomyopathy. Int J Cardiol 2006; 108:171-6. [PMID: 15916824 DOI: 10.1016/j.ijcard.2005.04.028] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2004] [Revised: 03/08/2005] [Accepted: 04/20/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Functional mitral regurgitation (MR) is one of the common and severe complications in patients with dilated cardiomyopathy. The detailed mechanisms that cause functional MR remain to be elucidated. Using two-dimensional transthoracic echocardiography, we investigated the differences in major determinants of MR severity between ischemic cardiomyopathy (ICM) and non-ICM patients. METHODS We enrolled 103 patients (91 males; age 64+/-12 years) with significant left ventricular (LV) dilatation. They were divided into ICM group (n=69) with significant coronary disease, and non-ICM (n=34) group without coronary disease. We devised a novel and simple parameter; the short-axis sphericity index (SI), to evaluate global LV remodeling, and used coaptation depth (CD) and tenting area (TA) to evaluate mitral deformity. RESULTS In all cases, CD, TA and left atrium diameter (LAD) correlated positively with maximum regurgitation area (MRA) (r=0.54, 0.57, 0.57; P<0.0001). A negative correlation was observed between MRA and SI (r=-0.33, P=0.0008). There was no significant relationship between MRA and LV ejection fraction (EF). In non-ICM cases, SI tended to be lower with reduced EF. Multivariate stepwise linear regression analysis showed the following equations; ICM: MRA=-9.4+0.81CD+0.21LAD (r2=0.47, P<0.0001), non-ICM: MRA=-7.2+0.17LVDs (LV end systolic diameter) -8.7SI+0.27LAD (r2=0.63, P<0.0001). CONCLUSIONS The strongest determinants of functional MR severity differ in ICM and non-ICM. While LV diameter and SI (global LV remodeling index) mainly determine the severity in non-ICM, CD that reflects mitral deformity is the major determinant in ICM.
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Affiliation(s)
- Mika Nagasaki
- Sakakibara Heart Institute, Cardiology, 3-16-1 Asahi-Cho, Fuchu City Tokyo 183-0003, Japan
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Bursi F, Enriquez-Sarano M, Jacobsen SJ, Roger VL. Mitral regurgitation after myocardial infarction: a review. Am J Med 2006; 119:103-12. [PMID: 16443408 DOI: 10.1016/j.amjmed.2005.08.025] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2005] [Accepted: 08/12/2005] [Indexed: 10/25/2022]
Abstract
Mitral regurgitation after myocardial infarction is the result of multifactorial processes involving local and global left ventricular remodeling. The prevalence of mitral regurgitation varies from 11% to 59%. Published studies differ greatly in design, inclusion criteria, duration of follow-up, and technique of mitral regurgitation assessment. However, they consistently indicate that mitral regurgitation after myocardial infarction carries an adverse prognosis with increased risk of death and heart failure independently of previously known indicators of risk after myocardial infarction. Mitral regurgitation is often clinically silent; therefore, it should be systematically evaluated by echocardiography. Standard color Doppler imaging is a highly sensitive method to detect even mild degrees of ischemic mitral regurgitation. One unique advantage of echocardiography is that it accurately quantifies the severity of mitral regurgitation by measuring the effective regurgitant orifice area and the regurgitant volume using Doppler methodology. Therefore, the evaluation should include precise quantification of the degree of mitral regurgitation to best appraise the ensuing risk. Current medical options rely chiefly on angiotensin converting enzyme-inhibitors and beta-blocker therapy, and surgical approaches offer future promise. Both categories of therapeutic approaches should be evaluated by randomized controlled trials.
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Affiliation(s)
- Francesca Bursi
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA
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21
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A. Levine R, Otsuji Y, Schwammenthal E, Sakata R, Tei C. Ischemic Mitral Regurgitation: From New Understanding to New Solutions Role of Echocardiography. J Echocardiogr 2006. [DOI: 10.2303/jecho.4.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Hung J, Papakostas L, Tahta SA, Hardy BG, Bollen BA, Duran CM, Levine RA. Mechanism of recurrent ischemic mitral regurgitation after annuloplasty: continued LV remodeling as a moving target. Circulation 2005; 110:II85-90. [PMID: 15364844 DOI: 10.1161/01.cir.0000138192.65015.45] [Citation(s) in RCA: 252] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Patients who undergo ring annuloplasty for ischemic mitral regurgitation (MR) often have persistent or recurrent MR. This may relate to persistent leaflet tethering from left ventricle (LV) dilatation that is not relieved by ring annuloplasty. Therefore, the purpose of this study was to test the hypothesis that recurrent MR in patients after ring annuloplasty relates to continued LV remodeling. METHODS AND RESULTS Serial echoes were reviewed in 30 patients (aged 72+/-11 years) who showed recurrent MR late (47+/-27 months) versus early (3.8+/-5.8 months) after ring annuloplasty for ischemic MR during coronary artery bypass grafting without interval infarction. Patients with intrinsic mitral valve disease were excluded. Echocardiographic measures of MR (vena contracta and jet area/left atrial area) and LV remodeling (LV dimensions, volumes, and sphericity) were assessed at each stage. The degree of MR increased from mild to moderate, on average, from early to late postoperative stages, without significant change in LV ejection fraction. Changes in MR paralleled increases in LV volumes and sphericity index at end-systole and end-diastole. The only independent predictor of late postoperative MR was LV sphericity index at end-systole. CONCLUSIONS Recurrent MR late after ring annuloplasty is associated with continued LV remodeling, emphasizing its dynamic relation to the LV.
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Affiliation(s)
- Judy Hung
- Cardiac Ultrasound Laboratory-VBK 508, Massachusetts General Hospital, Boston, MA 02114, USA.
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Oishi Y, Mizuguchi Y, Tanaka H, Emi S, Ishimoto T, Nagase N, Oki T. Myocardial Strain Imaging is a Superior Method for Evaluating Papillry Muscle Contractility in Patients With Myocardial Infarction. J Echocardiogr 2005. [DOI: 10.2303/jecho.3.148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Khankirawatana B, Khankirawatana S, Mahrous H, Porter TR. Assessment of papillary muscle function using myocardial velocity gradient derived from tissue Doppler echocardiography. Am J Cardiol 2004; 94:45-9. [PMID: 15219507 DOI: 10.1016/j.amjcard.2004.03.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2003] [Revised: 03/04/2004] [Accepted: 03/04/2004] [Indexed: 11/23/2022]
Abstract
Papillary muscle (PM) function is vital to mitral valve competence. However, quantitative assessment of the function is difficult due to the complexity of the mitral apparatus. We hypothesized that myocardial velocity gradient (MVG) could be applied to assess PM function. We studied MVG-PM in 123 patients with left ventricular dysfunction (ejection fraction <40%) and 123 normal subjects throughout a systolic phase. MVG-PM in normal subjects was significantly higher than in patients with left ventricular dysfunction (3.6/s vs 1.4/s, p <0.001). MVG-PM reached its peak at early systole and correlated well with PM thickening (r = 0.89). MVG-PM in patients with left ventricular dysfunction correlated with the severity of apical tenting of the mitral valve (y = 0.8x - 0.07, r = 0.72). Patients with lower MVG-PM tended to have less severe mitral regurgitation (y = 0.03x + 0.3, r = 0.83). PM contractility can be quantitatively assessed by calculating the MVG derived from tissue Doppler imaging. PM dysfunction, indicated by lower MVG-PM, decreased mitral leaflet tethering, thus paradoxically decreasing mitral regurgitation severity. MVG is a useful tool in determining the role of PM in functional mitral regurgitation.
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Affiliation(s)
- Banthit Khankirawatana
- Department of Internal Medicine, Section of Cardiology, University of Nebraska Medical Center, Omaha, 68198-1165, USA.
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Arikawa K, Otsuji Y, Zhang H, Yu B, Uemura T, Hamasaki S, Biro S, Kisanuki A, Minagoe S, Tei C. Left Ventricular Remodeling is Less While Left Atrial Remodeling is Greater in Inferior Compared to Anterior Myocardial Infarction: Importance of Ischemic Mitral Regurgitation. J Echocardiogr 2004. [DOI: 10.2303/jecho.2.43] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Nesta F, Otsuji Y, Handschumacher MD, Messas E, Leavitt M, Carpentier A, Levine RA, Hung J. Leaflet concavity: a rapid visual clue to the presence and mechanism of functional mitral regurgitation. J Am Soc Echocardiogr 2003; 16:1301-8. [PMID: 14652610 DOI: 10.1067/j.echo.2003.09.003] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Repairing mitral regurgitation (MR) requires an understanding of its mechanism. Evaluating restricted leaflet closure in functional MR is challenging. Tenting area between leaflets and annulus in long-axis (LAX) views correlates with MR, but is positive even in control subjects; in the 4-chamber view, the incomplete mitral leaflet closure (IMLC) tenting pattern may be subtle and variable. We tested the hypothesis that leaflet concavity toward the left atrium in the LAX view, a rapid visual clue indicating abnormal tethering predominantly by intermediate chords, is a strong indicator of functional MR. We reviewed 90 patients: 40 with inferior myocardial infarction and ejection fraction > or = 50%; 40 with global left ventricular dysfunction and ejection fraction < 50%; and 10 control subjects. We assessed leaflet shape (concave or convex toward the left atrium) and maximum systolic proximal MR jet width in the LAX views. To quantify shape, we measured the leaflet concavity area between the anterior leaflet and a line connecting its ends. Conventional IMLC area was also assessed. Patients with leaflet concavity had significantly greater MR than those without this finding (jet width of 4.6 +/- 0.7 vs 0.5 +/- 0.1 mm, P <.0001), indicating mild-moderate versus trace MR, with differences comparable in those with inferior myocardial infarction and left ventricular dysfunction. Leaflet concavity area most strongly predicted MR by multivariate regression (R(2) = 0.7). Conventional IMLC area did not uniquely distinguish patients with or without MR and correlated more weakly with MR (R(2) = 0.30 vs 0.73). Mitral leaflet concavity in the LAX view provides rapid and reliable recognition of functional MR, with greater reliability than IMLC area. This shape, consistent with tethering by intermediate chords, may have implications for potential intervention.
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Affiliation(s)
- Francesca Nesta
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, 02114, USA
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Dagdelen S, Yuce M, Ergelen M, Pala S, Kýrma C. Quantitation of papillary muscle function with tissue and strain Doppler echocardiography measures papillary muscle contractile functions. Echocardiography 2003; 20:137-44. [PMID: 12848678 DOI: 10.1046/j.1540-8175.2003.03007.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
UNLABELLED It is well known that papillary muscle dysfunction may cause mitral regurgitation, however, there is not a standard technique to measure the papillary muscle function. The aim of this study is to investigate papillary muscle function by using tissue and strain rate Doppler echocardiography. METHOD A study group (SG) of 42 patients (12 females, 30 males, mean age: 53.8 +/- 10.9 years) with coronary artery disease who have segmental left ventricular dysfunction and mitral regurgitation, and as a control group (CG) 20 patients (6 females, 14 males, mean age 52.5 +/- 10.2 years) who have no coronary artery disease and mitral regurgitation were studied. A subgroup 20 patients (7 females, 13 males, mean age 42.5 +/- 7.5 years) who have rheumatic mitral regurgitation was included to the study. The patients who have left ventricular and mitral annular dilatation were not included into the study. Longitudinal wall motion of mid-inferior segment (one point) and posterior papillary muscle (two point) of the left ventricle was assessed by tissue and strain rate Doppler echocardiography from the apical two-chamber view. Systolic tissue velocity (Sm), strain rate (SR), and strain (S) were measured from the two points in all patients. RESULTS Comparing the one point values Sm, SR, and S were found less in SG than CG (respectively 4.2 +/- 1.4 vs 11.3 +/- 1.9 cm/sec, -1.0 +/- 0.4 vs -1.7 +/- 0.3 s-1, -13.5 +/- 5.0 vs -18.1 +/- 3.9%; P < 0.001 for all). Comparing the two point values Sm, SR and S were found less in SG than CG (respectively 2.8 +/- 1.2 vs 3.7 +/- 2.0 cm/sec, -0.8 +/- 0.4 vs -1.6 +/- 0.3 s-1, -9.7 +/- 4.6 vs -15.8 +/- 3.7%; P < 0.001 for all). Systolic mitral annulus, left ventricular systolic and diastolic dimensions were similar in two groups. Comparing the CG and subgroup, there were no significant differences with respect to Sm, SR, and S measured from the two points. CONCLUSIONS Papillary muscle function may be assessed quantitatively by using tissue and strain rate Doppler echocardiography. Tissue velocity, strain rate, and strain values were found decreased in dysfunctional papillary muscle.
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Kumanohoso T, Otsuji Y, Yoshifuku S, Matsukida K, Koriyama C, Kisanuki A, Minagoe S, Levine RA, Tei C. Mechanism of higher incidence of ischemic mitral regurgitation in patients with inferior myocardial infarction: quantitative analysis of left ventricular and mitral valve geometry in 103 patients with prior myocardial infarction. J Thorac Cardiovasc Surg 2003; 125:135-43. [PMID: 12538997 DOI: 10.1067/mtc.2003.78] [Citation(s) in RCA: 229] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The mechanism of higher incidence of ischemic mitral regurgitation in patients with inferior compared with anterior myocardial infarction despite less global left ventricular remodeling and dysfunction is controversial. We hypothesized that inferior myocardial infarction causes left ventricular remodeling, which displaces posterior papillary muscle away from its normal position, leading to ischemic mitral regurgitation. METHODS In 103 patients with prior myocardial infarction (61 anterior and 42 inferior) and 20 normal control subjects, we evaluated the grade of ischemic mitral regurgitation on the basis of the percentage of Doppler jet area, left ventricular end-diastolic and end-systolic volumes, midsystolic mitral annular area, and midsystolic leaflet-tethering distance between papillary muscle tips and the contralateral anterior mitral annulus, which were determined by means of quantitative echocardiography. RESULTS Global left ventricular dilatation and dysfunction were significantly less pronounced in patients with inferior myocardial infarction (left ventricular end-systolic volume: 52 +/- 18 vs 60 +/- 24 mL, inferior vs anterior infarction, P<.05; left ventricular ejection fraction: 51% +/- 9% vs 42% +/- 7%, P <.0001). However, the percentage of mitral regurgitation jet area and the incidence of significant regurgitation (percentage of jet area of 10% or greater) was greater in inferior infarction (percentage of jet area: 10.1% +/- 7.5% vs 4.4% +/- 7.0%, P =.0002; incidence: 16/42 (38%) vs 6/61 (10%), P <.0001). The mitral annulus (area = 8.2 +/- 1.2 cm2 in control subjects) was similarly dilated in both inferior and anterior myocardial infarction (9.7 +/- 1.7 vs. 9.5 +/- 2.3 cm2, no significant difference), and the anterior papillary muscle-tethering distance (33.8 +/- 2.6 mm in control subjects) was also similarly and mildly increased in both groups (35.2 +/- 2.4 vs 35.2 +/- 2.8 mm, no significant difference). However, the posterior papillary muscle-tethering distance (33.3 +/- 2.3 mm in control subjects) was significantly greater in inferior compared with anterior myocardial infarction (38.3 +/- 4.1 vs 34.7 +/- 2.9 mm, P =.0001). Multiple stepwise regression analysis identified the increase in posterior papillary muscle-tethering distance divided by body surface area as an independent contributing factor to the percentage of mitral regurgitation jet area (r2 = 0.70, P <.0001). CONCLUSIONS It is suggested that the higher incidence and greater severity of ischemic mitral regurgitation in patients with inferior compared with anterior myocardial infarction can be related to more severe geometric changes in the mitral valve apparatus with greater displacement of posterior papillary muscle caused by localized inferior basal left ventricular remodeling, which results in therapeutic implications for potential benefit of procedures, such as infarct plication and leaflet or chordal elongation, to reduce leaflet tethering.
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Affiliation(s)
- Toshiro Kumanohoso
- First Department of Internal Medicine, Department of Public Health, Kagoshima University School of Medicine, Kagoshima, Japan
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Abstract
Mitral valve regurgitation (MR) is a frequent Doppler echocardiographic finding in patients after acute myocardial infarction (AMI) and an independent predictor of long-term cardiovascular mortality. Reported risk factors include advanced age, prior myocardial infarction, infarct extension, and recurrent ischemia. During the early phase of AMI, transient ischemic MR is common and rarely causes hemodynamic compromise. However, when several chordae tendineae or a papillary muscle ruptures, acute left atrial and ventricular volume overload ensues, leading to abrupt hemodynamic deterioration with cardiogenic shock. Auscultation may be unrevealing due to decreased turbulence. Hence, the importance of a high index of suspicion for acute MR in any patient with acute pulmonary edema in the setting of AMI, especially if left ventricular systolic function is well preserved. Later, ventricular remodeling may lead to MR through annular dilatation or papillary muscle migration with malcoaptation of the leaflets. The widespread availability, ease of use and non-invasive nature of Doppler echocardiography have made it the standard diagnostic tool for detecting MR. Mechanical reperfusion of the infarct-related artery seems to be superior to fibrinolysis in decreasing its incidence acutely and in the long run. Nevertheless, when acute severe MR occurs, unless rapidly diagnosed and treated, this dreaded complication is associated with high morbidity and mortality. Prompt surgical intervention after hemodynamic stabilization is essential to ensure a good short-term and long-term prognosis. This review discusses the incidence, long-term prognosis, associated risk factors, complex pathophysiology, time of occurrence, clinical manifestations, diagnosis, and management of patients with MR after AMI.
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Affiliation(s)
- Yochai Birnbaum
- The Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas 77555-0553, USA.
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Otsuji Y, Kumanohoso T, Yoshifuku S, Matsukida K, Koriyama C, Kisanuki A, Minagoe S, Levine RA, Tei C. Isolated annular dilation does not usually cause important functional mitral regurgitation: comparison between patients with lone atrial fibrillation and those with idiopathic or ischemic cardiomyopathy. J Am Coll Cardiol 2002; 39:1651-6. [PMID: 12020493 DOI: 10.1016/s0735-1097(02)01838-7] [Citation(s) in RCA: 198] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES We sought to test whether isolated mitral annular (MA) dilation can cause important functional mitral regurgitation (MR). BACKGROUND Mitral annular dilation has been considered a primary cause of functional MR. Patients with functional MR, however, usually have both MA dilation and left ventricular (LV) dilation and dysfunction. Lone atrial fibrillation (AF) can potentially cause isolated MA dilation, offering a unique opportunity to relate MA dilation to leaflet function. METHODS Mid-systolic MA area, MR fraction, LV volumes and papillary muscle (PM) leaflet tethering length were compared by echocardiography among 18 control subjects, 25 patients with lone AF and 24 patients with idiopathic or ischemic cardiomyopathy (ICM). RESULTS Patients with lone AF had a normal LV size and function but MA dilation (isolated MA dialtion) significant and comparable to that of patients with ICM (MA AREA: 8.0 +/- 1.2 vs. 11.6 +/- 2.3 vs. 12.5 +/- 2.9 cm(2) [control vs. lone AF vs. ICM]; p < 0.001 for both lone AF and ICM). However, patients with lone AF had only modest MR, compared with that of patients with ICM (MR fraction: -3 +/- 8% vs. 3 +/- 9% vs. 36 +/- 25%; p < 0.001 for patients with ICM). Multivariate analysis identified PM tethering length, not MA dilation, as an independent primary contributor to MR. CONCLUSIONS Isolated annular dilation does not usually cause moderate or severe MR. Important functional MR also depends on LV dilation and dysfunction, leading to an altered force balance on the leaflets, which impairs coaptation.
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Affiliation(s)
- Yutaka Otsuji
- First Department of Internal Medicine, Kagoshima University School of Medicine, Japan.
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Levine RA, Hung J, Otsuji Y, Messas E, Liel-Cohen N, Nathan N, Handschumacher MD, Guerrero JL, He S, Yoganathan AP, Vlahakes GJ. Mechanistic insights into functional mitral regurgitation. Curr Cardiol Rep 2002; 4:125-9. [PMID: 11827635 DOI: 10.1007/s11886-002-0024-6] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Effective valve repair in patients with mitral regurgitation (MR) demands an understanding of its mechanism. In patients with ischemic heart disease and functional MR, which doubles late mortality, normal leaflets are apically displaced. This reflects an altered balance of forces acting on the leaflets: increased tethering forces restricting closure, resulting from an altered geometry of leaflet attachments, and decreased ventricular forces acting to close the leaflets. Extensive evidence confirms a central and predominant role of tethering as the final common pathway inducing functional MR; left ventricular (LV) pressure dynamically modulates the orifice area. Because ischemic MR is a disease of the entire mitral complex, including the remodeling LV, reducing annular size alone is often ineffective. Undersizing rings attempts to compensate for tethering; new and potentially more effective strategies directly address tethering by infarct plication, papillary muscle repositioning with a localized patch, or basal chordal cutting to increase coaptational surface area without prolapse. A comprehensive understanding of the valve in its ventricular context, therefore, provides new opportunities for successful valve repair in patients.
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Affiliation(s)
- Robert A Levine
- Massachusetts General Hospital, Department of Medicine, Non-Invasive Cardiology Laboratory VBK508, 55 Fruit Street, Boston, MA 02114, USA.
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Messas E, Guerrero JL, Handschumacher MD, Chow CM, Sullivan S, Schwammenthal E, Levine RA. Paradoxic decrease in ischemic mitral regurgitation with papillary muscle dysfunction: insights from three-dimensional and contrast echocardiography with strain rate measurement. Circulation 2001; 104:1952-7. [PMID: 11602500 DOI: 10.1161/hc4101.097112] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Ischemic mitral regurgitation (MR) was first ascribed to papillary muscle (PM) contractile dysfunction. Current theories include apical leaflet tethering caused by left ventricular (LV) distortion, but PM dysfunction is still postulated and commonly diagnosed. PM contraction, however, parallels apical tethering, suggesting the hypothesis that PM contractile dysfunction can actually diminish MR due to ischemic distortion of the inferior base alone. METHODS AND RESULTS We therefore occluded the proximal circumflex circulation in 7 sheep while maintaining PM perfusion, confirmed by contrast echocardiography. By 3D echocardiography, we measured the tethering distance between the ischemic medial PM tip and anterior annulus and LV ejection volume to give MR (by subtracting flowmeter LV outflow). In 6 sheep without initial MR, inferior ischemia alone produced PM tip retraction with restricted leaflet closure and mild-to-moderate MR (regurgitant fraction, 25.2+/-2.8%). Adding PM ischemia consistently decreased MR and tethering distance (5.2+/-0.3 to 1.4+/-0.3 mL; +3.8+/-0.5 mm to -2.2+/-0.7 mm axially relative to baseline; P<0.001) as PM strain rate decreased from +0.78+/-0.07 per second (contraction) to -0.42+/-0.06 per second (elongation, P<0.001) and leaflet tenting decreased. In one sheep, prolapse and MR resolved with inferior ischemia and recurred with PM ischemia. CONCLUSIONS PM contractile dysfunction can paradoxically decrease MR from inferobasal ischemia by reducing leaflet tethering to improve coaptation. This emphasizes the role of geometric factors in ischemic MR mechanism and potential therapy.
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Affiliation(s)
- E Messas
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Liel-Cohen N, Guerrero JL, Otsuji Y, Handschumacher MD, Rudski LG, Hunziker PR, Tanabe H, Scherrer-Crosbie M, Sullivan S, Levine RA. Design of a new surgical approach for ventricular remodeling to relieve ischemic mitral regurgitation: insights from 3-dimensional echocardiography. Circulation 2000; 101:2756-63. [PMID: 10851215 DOI: 10.1161/01.cir.101.23.2756] [Citation(s) in RCA: 141] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Mechanistic insights from 3D echocardiography (echo) can guide therapy. In particular, ischemic mitral regurgitation (MR) is difficult to repair, often persisting despite annular reduction. We hypothesized that (1) in a chronic infarct model of progressive MR, regurgitation parallels 3D changes in the geometry of mitral leaflet attachments, causing increased leaflet tethering and restricting closure; therefore, (2) MR can be reduced by restoring tethering geometry toward normal, using a new ventricular remodeling approach based on 3D echo findings. METHODS AND RESULTS We studied 10 sheep by 3D echo just after circumflex marginal ligation and 8 weeks later. MR, at first absent, became moderate as the left ventricle (LV) dilated and the papillary muscles shifted posteriorly and mediolaterally, increasing the leaflet tethering distance from papillary muscle tips to the anterior mitral annulus (P<0.0001). To counteract these shifts, the LV was remodeled by plication of the infarct region to reduce myocardial bulging, without muscle excision or cardiopulmonary bypass. Immediately and up to 2 months after plication, MR was reduced to trace-to-mild as tethering distance was decreased (P<0.0001). LV ejection fraction, global LV end-systolic volume, and mitral annular area were relatively unchanged. By multiple regression, the only independent predictor of MR was tethering distance (r(2)=0.81). CONCLUSIONS Ischemic MR in this model relates strongly to changes in 3D mitral leaflet attachment geometry. These insights from quantitative 3D echo allowed us to design an effective LV remodeling approach to reduce MR by relieving tethering.
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Affiliation(s)
- N Liel-Cohen
- Cardiac Ultrasound Laboratory and Cardiovascular Surgical Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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Otsuji Y, Gilon D, Jiang L, He S, Leavitt M, Roy MJ, Birmingham MJ, Levine RA. Restricted diastolic opening of the mitral leaflets in patients with left ventricular dysfunction: evidence for increased valve tethering. J Am Coll Cardiol 1998; 32:398-404. [PMID: 9708467 DOI: 10.1016/s0735-1097(98)00237-x] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES We tested the hypothesis that patients with incomplete systolic mitral leaflet closure (IMLC: apically displaced coaptation) also have restricted diastolic leaflet opening that is independent of mitral inflow volume and provides evidence supporting increased leaflet tethering. BACKGROUND Competing hypotheses for functional mitral regurgitation (MR) with IMLC include global left ventricular (LV) dysfunction per se (reduced leaflet closing force) versus geometric distortion of the mitral apparatus by LV dilation (augmented leaflet tethering). These are inseparable in systole, but restricted leaflet motion has also been observed in diastole, and attributed to reduced mitral inflow. METHODS Diastolic mitral leaflet excursion and orifice area were measured by two-dimensional echocardiography in 58 patients with global LV dysfunction, 36 with and 22 without IMLC, compared with 21 normal subjects. The biplane Simpson's method was used to calculate LV ejection volume, which equals mitral inflow volume in the absence of aortic regurgitation. RESULTS The diastolic mitral leaflet excursion angle was markedly reduced in patients with IMLC compared with those without IMLC, whose ventricles were smaller, and normal subjects (17 +/- 10 degrees vs. 58 +/- 13 degrees vs. 67 +/- 8 degrees, p < 0.0001). Excursion angle was dissociated from mitral inflow volume (r2 = 0.04); excursion was reduced in patients with IMLC despite a normal inflow volume in the larger ventricles with MR (60 +/- 25 vs. 61 +/- 12 ml in normal subjects, p = NS), and excursion was nearly normal in patients without IMLC despite reduced inflow volume (40 +/- 10 ml, p < 0.001 vs. normal subjects). The anterior leaflet when maximally open coincided well with the line connecting its attachments to the anterior annulus and papillary muscle tip (angular difference = 3 +/- 7 degrees vs. 25 +/- 9 degrees vs. 32 +/- 10 degrees in patients with and without IMLC vs. normal subjects, p < 0.0001). In patients with IMLC, the leaflet tip orifice was smaller in an anteroposterior direction but wider than in the other groups, giving a normal total area (6.8 +/- 1.8 vs. 7.1 +/- 1.2 vs. 6.9 +/- 0.8 cm2, p = NS). CONCLUSIONS Patients with LV dysfunction and systolic IMLC also have restricted diastolic leaflet excursion that is independent of inflow volume, coincides with the tethering line connecting the annulus and papillary muscle and reflects limitation of anterior motion relative to the posteriorly placed papillary muscles without a decrease in total orifice area. These observations are consistent with increased tethering by displaced mitral leaflet attachments in the dilated ventricles of patients with IMLC that can restrict both diastolic opening and systolic closure.
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Affiliation(s)
- Y Otsuji
- Massachusetts General Hospital, Department of Medicine, Harvard Medical School, Boston 02114-2698, USA
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Otsuji Y, Handschumacher MD, Schwammenthal E, Jiang L, Song JK, Guerrero JL, Vlahakes GJ, Levine RA. Insights from three-dimensional echocardiography into the mechanism of functional mitral regurgitation: direct in vivo demonstration of altered leaflet tethering geometry. Circulation 1997; 96:1999-2008. [PMID: 9323092 DOI: 10.1161/01.cir.96.6.1999] [Citation(s) in RCA: 415] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Recent advances in three-dimensional (3D) echocardiography allow us to address uniquely 3D scientific questions, such as the mechanism of functional mitral regurgitation (MR) in patients with left ventricular (LV) dysfunction and its relation to the 3D geometry of mitral leaflet attachments. Competing hypotheses include global LV dysfunction with inadequate leaflet closing force versus geometric distortion of the mitral apparatus by LV dilatation, which increases leaflet tethering and restricts closure. Because geometric changes generally accompany dysfunction, these possibilities have been difficult to separate. METHODS AND RESULTS We created a model of global LV dysfunction by esmolol and phenylephrine infusion in six dogs. initially with LV expansion limited by increasing pericardial restraint and then with the pericardium opened. The mid-systolic 3D relations of the papillary muscle (PM) tips and mitral valve were reconstructed. Despite severe LV dysfunction (ejection fraction, 18+/-6%), only trace MR developed when pericardial restraint limited LV dilatation; with the pericardium opened, moderate MR accompanied LV dilatation (end-systolic volume, 44+/-5 mL versus 12+/-5 mL control, P<.001). Mitral regurgitant volume and orifice area did not correlate with LV ejection fraction and dP/dt (global function) but did correlate with changes in the tethering distance from the PMs to the anterior annulus derived from the 3D reconstructions, especially PM shifts in the posterior and mediolateral directions, as well as with annular area (P<.0005). By multiple regression, only changes in the PM-to-annulus distance independently predicted MR volume and orifice area (R2=.82 to .85, P=2x10(-7) to 6x10(-8)). CONCLUSIONS LV dysfunction without dilatation fails to produce important MR. Functional MR relates strongly to changes in the 3D geometry of the mitral valve attachments at the PM and annular levels, with practical implications for approaches that would restore a more favorable configuration.
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Affiliation(s)
- Y Otsuji
- Massachusetts General Hospital, Department of Medicine, Harvard Medical School, Boston 02114, USA
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He S, Fontaine AA, Schwammenthal E, Yoganathan AP, Levine RA. Integrated mechanism for functional mitral regurgitation: leaflet restriction versus coapting force: in vitro studies. Circulation 1997; 96:1826-34. [PMID: 9323068 DOI: 10.1161/01.cir.96.6.1826] [Citation(s) in RCA: 272] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Functional mitral regurgitation in patients with ischemic or dilated ventricles has been related to competing factors: altered tension on the leaflets due to displacement of their papillary muscle and annular attachments, which restricts leaflet closure, versus global ventricular dysfunction with reduced transmitral pressure to close the leaflets. In vivo, however, geometric changes accompany dysfunction, making it difficult to study these factors independently. Functional mitral regurgitation also paradoxically decreases in midsystole, despite peak transmitral driving pressure, suggesting a change in the force balance acting to create a regurgitant orifice, with rising transmitral pressure counteracting forces that restrict leaflet closure. In vivo, this mechanism cannot be tested independently of annular contraction that could also reduce midsystolic regurgitation. METHODS AND RESULTS An in vitro model was developed that allows independent variation of papillary muscle position, annular size, and transmitral pressure, with direct regurgitant flow rate measurement, to test the hypothesis that functional mitral regurgitation reflects an altered balance of forces acting on the leaflets. Hemodynamic and echocardiographic measurements of excised porcine valves were made under physiological pressures and flows. Apical and posterolateral papillary muscle displacement caused decreased leaflet mobility and apical leaflet tethering or tenting with regurgitation, as seen clinically. It reproduced the clinically observed midsystolic decrease in regurgitant flow and orifice area as transmitral pressure increased. Tethering delayed valve closure, increased the early systolic regurgitant volume before complete coaptation, and decreased the duration of coaptation. Annular dilatation increased regurgitation for any papillary muscle position, creating clinically important regurgitation; conversely, increased transmitral pressure decreased regurgitant orifice area for any geometric configuration. CONCLUSIONS The clinically observed tented-leaflet configuration and dynamic regurgitant orifice area variation can be reproduced in vitro by altering the three-dimensional relationship of the annular and papillary muscle attachments of the valve so as to increase leaflet tension. Increased transmitral pressure acting to close the leaflets decreases the regurgitant orifice area. These results are consistent with a mechanism in which an altered balance of tethering versus coapting forces acting on the leaflets creates the regurgitant orifice.
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Affiliation(s)
- S He
- Institute for Bioengineering and Bioscience, Chemical Engineering Department, Georgia Institute of Technology, Atlanta 30332-0100, USA
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Tischler MD, Rothfeld J. Papillary muscle fractional shortening is a determinant of heart shape in patients with prior myocardial infarction. Am J Cardiol 1997; 80:204-6. [PMID: 9230161 DOI: 10.1016/s0002-9149(97)00319-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
To examine the relation between papillary muscle fractional shortening and heart shape, we performed quantitative echocardiography in 20 patients with prior myocardial infarction and 20 normal control subjects. Papillary muscle fractional shortening was markedly depressed in infarction patients and there was a high degree of correlation between papillary muscle fractional shortening and left ventricular shape, which was evident over a wide range of ejection fraction and shape.
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Affiliation(s)
- M D Tischler
- Cardiology Unit, Fletcher Allen Health Care and University of Vermont College of Medicine, Burlington 05401, USA
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Van Dantzig JM, Delemarre BJ, Koster RW, Bot H, Visser CA. Pathogenesis of mitral regurgitation in acute myocardial infarction: importance of changes in left ventricular shape and regional function. Am Heart J 1996; 131:865-71. [PMID: 8615303 DOI: 10.1016/s0002-8703(96)90166-0] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The pathogenesis of mitral regurgitation (MR) was determined by quantitative echocardiography in 188 patients with acute myocardial infarction (AMI) within 48 hours after admission. MR was classified, by using color Doppler, as significant (grades 3 to 4) or trivial (grades 0 to 2). Left ventricular (LV) function (global and regional), volume, and shape, as well as mitral valvular features, were measured and analyzed by stepwise logistic regression. Significant MR occurred in 25 (13%) patients. Univariately, recurrent infarction (p < 0.01), LV dilation (p < 0.001) and sphericity (p < 0.001), inferoposterolateral asynergy (p < 0.001), mitral annular dilatation (p < 0.005), and mitral leaflet restriction (p < 0.05) were associated with significant MR. In regression analysis, only recurrent infarction (odds ratio 5.08), LV sphericity index (odds ratio 1.12), and inferoposterolateral asynergy (odds ratio 6.07) were independently associated with significant MR, whereas none of the mitral valvular features examined had an independent association. In conclusion, changes in LV shape and regional function and not mitral valvular changes are prime determinants of significant MR after AMI.
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Affiliation(s)
- J M Van Dantzig
- Academic Medical Center, Department of Cardiology, Maastricht, The Netherlands
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Uemura H, Anderson RH, Ho SY, Devine WA, Neches WH, Smith A, Yagihara T, Kawashima Y. Left ventricular structures in atrioventricular septal defect associated with isomerism of atrial appendages compared with similar features with usual atrial arrangement. J Thorac Cardiovasc Surg 1995; 110:445-52. [PMID: 7637363 DOI: 10.1016/s0022-5223(95)70241-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
In patients with isomeric atrial appendages, regurgitation of atrioventricular valves is recognized clinically as one of the risk factors that militate against successful achievement of definitive repairs. To determine whether this reflected anatomic features, we investigated 91 specimens with atrioventricular septal defect that had a common atrioventricular valve and biventricular atrioventricular connections. Of these specimens, 35 had isomeric right appendages, 23 showed isomeric left appendages, and 33 had usual atrial arrangement. We measured either the size or location of the supporting papillary muscles and the circumference of the mural leaflet within the morphologically systemic ventricle, as well as the length of outlet, inlet, and so-called scooped dimensions of the muscular ventricular septum. Presence of a solitary papillary muscle, or deviation of the attachments of the papillary muscles, was more frequent in hearts with isomeric right appendages. Values for the diameter and lengths of the papillary muscles were significantly smaller in hearts with isomeric right appendages compared with those with usual atrial arrangement (p < 0.001), as were the distances between the papillary muscles (p < 0.002) and the circumference of the mural leaflet (p < 0.001). The proportional length of ventricular outlet was longer in the setting of isomeric right appendages than in the other groups (p < 0.001), whereas the extent of septal scooping showed no differences among these three groups. We conclude that these structural features could be factors in the known insufficiency of the common atrioventricular valve and the ventricular dysfunction in patients with isomeric right appendages.
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Affiliation(s)
- H Uemura
- National Heart and Lung Institute, Department of Pediatrics, London, United Kingdom
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