Left atrial reverse remodeling and functional improvement after mitral valve repair in degenerative mitral regurgitation: a real-time 3-dimensional echocardiography study

Mitral Valve Repair for Mitral Regurgitation in Patients With Marfan Syndrome

BACKGROUND

There is concern about the durability of mitral valve repair (MVr) for mitral regurgitation (MR) in Marfan patients due to limited long-term data. Furthermore, a detailed time course of changes in cardiac function after MVr in Marfan patients has not been reported. We examined repair techniques, postoperative cardiac function, and outcomes of MVr in Marfan patients.

METHODS AND RESULTS

We retrospectively reviewed 29 Marfan patients (mean [±SD] age 27.4±14.8 years) who underwent MVr at The University of Tokyo Hospital from 2010 to 2022. The mean follow-up period was 5.2±3.2 years. The causes of MR were isolated anterior leaflet prolapse in 25% of patients, isolated posterior leaflet prolapse in 11%, and bileaflet prolapse in 64%. Echocardiographic findings showed significant decreases in left ventricular (LV) diastolic and left atrial diameters 1 week after MVr. LV systolic diameter was significantly decreased 3 years after MVr, and LV ejection fraction initially declined before subsequently increasing. The in-hospital and 30-day mortality rates were 0%. At 5 years, the overall survival rate was 94% and the rate of freedom from MR was 84%.

CONCLUSIONS

The mid- to long-term outcomes after MVr in Marfan patients were satisfactory, supporting the durability of MVr in these patients. Postoperative cardiac reverse remodeling occurred in a phased manner in Marfan patients, similar to that in patients with degenerative MR.

Pre-operative left atrial size and functions are predictors of left atrial reverse remodelling after mitral valvuloplasty for myxomatous mitral valve disease in dogs

OBJECTIVES

The objective of this study was to determine alterations in left atrial size, function, and determinants of left atrial reverse remodelling (LARR) after mitral valvuloplasty (MVP) in dogs with myxomatous mitral valve disease.

ANIMALS

Thirty-seven dogs undergoing MVP were included in this study.

MATERIALS AND METHODS

Echocardiographic parameters, including left atrial (LA) strain, were evaluated at baseline, during the early postoperative period (within two weeks), and at one and three months postoperatively. Patients were divided into two groups based on the attainment of LARR, defined as a left atrial-to-aortic root ratio (LA:Ao) < 1.6 at three months. The predictors of LARR were analysed using univariate logistic regression analysis.

RESULTS

Left atrial-to-aortic root ratio significantly decreased in the early postoperative period (median: 1.68; lower and upper quartiles: 1.54-1.92) compared to that in baseline (2.41; 2.00-2.80), with a further significant reduction observed at three months (1.46; 1.34-1.63). Left atrial reverse remodelling was achieved in 27 (73%) patients. Baseline left atrial-to-aortic root ratio was higher, and peak atrial longitudinal strain and peak atrial contraction strain (PACS) were lower in the non-LARR group than in the LARR group. Among the baseline parameters, PACS was the strongest predictor of LARR (area under the curve: 0.837).

CONCLUSIONS

Following MVP, the LA size decreased in the early postoperative period and continued to decrease over three months of follow-up. A low PACS score was the most reliable predictor of inadequate LARR. Further studies are necessary to determine the relationship between LARR, prognosis, and the optimal timing for surgical intervention.

Atrial cardiomyopathy revisited-evolution of a concept: a clinical consensus statement of the European Heart Rhythm Association (EHRA) of the ESC, the Heart Rhythm Society (HRS), the Asian Pacific Heart Rhythm Society (APHRS), and the Latin American Heart Rhythm Society (LAHRS)

AIMS

The concept of "atrial cardiomyopathy" (AtCM) had been percolating through the literature since its first mention in 1972. Since then, publications using the term were sporadic until the decision was made to convene an expert working group with representation from four multinational arrhythmia organizations to prepare a consensus document on atrial cardiomyopathy in 2016 (EHRA/HRS/APHRS/SOLAECE expert consensus on atrial cardiomyopathies: definition, characterization, and clinical implication). Subsequently, publications on AtCM have increased progressively.

METHODS AND RESULTS

The present consensus document elaborates the 2016 AtCM document further to implement a simple AtCM staging system (AtCM stages 1-3) by integrating biomarkers, atrial geometry, and electrophysiological changes. However, the proposed AtCM staging needs clinical validation. Importantly, it is clearly stated that the presence of AtCM might serve as a substrate for the development of atrial fibrillation (AF) and AF may accelerates AtCM substantially, but AtCM per se needs to be viewed as a separate entity.

CONCLUSION

Thus, the present document serves as a clinical consensus statement of the European Heart Rhythm Association (EHRA) of the ESC, the Heart Rhythm Society (HRS), the Asian Pacific Heart Rhythm Society (APHRS), and the Latin American Heart Rhythm Society (LAHRS) to contribute to the evolution of the AtCM concept.

Association between Mitral Valve Mean Pressure Gradient and Atrial Fibrillation in Patients with Rheumatic Mitral Stenosis: A Cross-Sectional Study

INTRODUCTION

Atrial fibrillation (AF) often occurs in patients with rheumatic mitral stenosis (RMS) and is associated with adverse clinical outcomes. Mitral valve mean pressure gradient (MVMPG) is utilized as an indicator to assess the severity of mitral stenosis and its hemodynamic implications. The aim of this study was to investigate the association between MVMPG and AF in individuals with RMS.

METHODS

We conducted a retrospective analysis of medical records from 360 consecutive patients diagnosed with RMS at the First Affiliated Hospital of Wenzhou Medical University between January 2018 and January 2023. Using both univariate and multivariate logistic regression models, the relationship between MVMPG and AF was evaluated. Restricted cubic splines were employed to test for linearity, and stratified and interaction analyses were performed to evaluate the stability of this relationship among different subgroups.

RESULTS

Based on the MVMPG levels, 360 RMS patients in total were categorized into three groups for the analysis: Q1 (<5 mm Hg), Q2 (5-10 mm Hg), and Q3 (>10 mm Hg). The average age was 60.6 years (Q1: 66.1, Q2: 61.9, Q3: 55.8), and 70.8% were female. The prevalence of AF was 39.6%, 56.5%, and 63.2% in Q1, Q2, and Q3, respectively. After adjusting for potential confounders, a significant association between MVMPG and AF was observed. In Q2, there was a 119% increase in AF (OR 2.19, 95% CI: 1.01-4.75), while in Q3, there was a 238% increase (OR 3.38, 95% CI: 1.39-8.19), compared to Q1. The relationship between MVMPG and AF was linear (p = 0.503). These results remained consistent in each subgroup analysis.

CONCLUSION

Our study reveals a significant positive association between MVMPG and AF in patients with RMS, which holds important clinical implications. It is necessary to conduct further research.

Effect of cryothermic and radiofrequency Cox-Maze IV ablation on atrial size and function assessed by 2D and 3D echocardiography, a randomized trial. To freeze or to burn

BACKGROUND

Atrial linear scars in Cox-Maze IV procedures are achieved using Cryothermy (Cryo) or radiofrequency (RF) techniques. The subsequent postoperative left atrial (LA) reverse remodelling is unclear. We used 2- and 3-dimensional echocardiography (2-3DE) to compare the impact of Cryo and RF procedures on LA size and function 1 year after Cox-maze IV ablation concomitant with Mitral valve (MV) surgery.

METHODS

Seventy-two patients with MV disease and AF were randomized to Cryo (n = 35) or RF (n = 37) ablation. Another 33 patients were enroled without ablation (NoMaze). All patients underwent an echocardiogram the day before and 1 year after surgery. The LA function was assessed on 2D strain by speckle tracking and 3DE.

RESULTS

Forty-two ablated patients recovered sinus rhythm (SR) 1 year after surgery. They had comparable left and right systolic ventricular function, LA volume index (LAVI), and 2D reservoir strain before surgery. At follow-up, the 3DE extracted reservoir and booster function were higher after RF (37 ± 10% vs. 26 ± 6%; p < 0.001) than Cryo ablation (18 ± 9 vs. 7 ± 4%; p < 0.001), while passive conduit function was comparable between groups (24 ± 11 vs. 20 ± 8%; p = 0.17). The extent of LAVI reduction depended on the duration of AF preoperatively.

CONCLUSIONS

SR restoration after MV surgery and maze results in LA size reduction irrespective of the energy source used. Compared to RF, the extension of ablation area produced by Cryo implies a structural LA remodelling affecting LA systolic function.

The predictive value of changes in left atrial volume index for rehospitalization in heart failure with preserved ejection fraction

AIMS

Left atrial volume index (LAVI) is an adequate analysis to predicate the left ventricle (LV) filling pressures, providing a powerful predictive marker of LV diastolic dysfunction. LAVI is a dynamic morphophysiological marker, and whether LAVI changes can predicate clinical outcomes in HF with preserved ejection fraction (HFpEF) is unknown.

METHODS

HFpEF patients were retrospectively studied from the First Affiliated Hospital of Dalian Medical University. Patients were classified into deteriorated, stable and improved groups according to the change in LAVI. Rehospitalization was defined as the main endpoint, the composite outcome of rehospitalization or all-cause death was defined as the secondary endpoint.

RESULTS

A total of 409 patients were included. In this cohort, the percentage of deteriorated, stable, and improved LAVI were 99 (24.2%), 235 (57.4%), and 75 (18.4%), respectively. During the 22 months follow-up period, 168 patients (41.1%) were rehospitalized, 31 patients (7.5%) died and 182 patients (44.5%) experienced a composite outcome. Multivariate Cox regression showed that compared to improved LAVI, those with deteriorated and stable LAVI experienced higher risk of rehospitalization. Logistic regression showed atrial fibrillation (AF) and higher creatinine were independent predictors of deteriorated LAVI, whereas the use of loop diuretics, calcium channel blockers (CCB), and high level of high-density lipoprotein cholesterol (HDL-C) were significantly associated with improved LAVI.

CONCLUSIONS

Change in LAVI provides a powerful and dynamic morphophysiological marker of LV filling status and can be used to evaluate the rehospitalization in HFpEF patients.

Late plasma exosome microRNA-21-5p depicts magnitude of reverse ventricular remodeling after early surgical repair of primary mitral valve regurgitation

Introduction

Primary mitral valve regurgitation (MR) results from degeneration of mitral valve apparatus. Mechanisms leading to incomplete postoperative left ventricular (LV) reverse remodeling (Rev-Rem) despite timely and successful surgical mitral valve repair (MVR) remain unknown. Plasma exosomes (pEXOs) are smallest nanovesicles exerting early postoperative cardioprotection. We hypothesized that late plasma exosomal microRNAs (miRs) contribute to Rev-Rem during the late postoperative period.

Methods

Primary MR patients (n = 19; age, 45-71 years) underwent cardiac magnetic resonance imaging and blood sampling before (T0) and 6 months after (T1) MVR. The postoperative LV Rev-Rem was assessed in terms of a decrease in LV end-diastolic volume and patients were stratified into high (HiR-REM) and low (LoR-REM) LV Rev-Rem subgroups. Isolated pEXOs were quantified by nanoparticle tracking analysis. Exosomal microRNA (miR)-1, -21-5p, -133a, and -208a levels were measured by RT-qPCR. Anti-hypertrophic effects of pEXOs were tested in HL-1 cardiomyocytes cultured with angiotensin II (AngII, 1 μM for 48 h).

Results

Surgery zeroed out volume regurgitation in all patients. Although preoperative pEXOs were similar in both groups, pEXO levels increased after MVR in HiR-REM patients (+0.75-fold, p = 0.016), who showed lower cardiac mass index (-11%, p = 0.032). Postoperative exosomal miR-21-5p values of HiR-REM patients were higher than other groups (p < 0.05). In vitro, T1-pEXOs isolated from LoR-REM patients boosted the AngII-induced cardiomyocyte hypertrophy, but not postoperative exosomes of HiR-REM. This adaptive effect was counteracted by miR-21-5p inhibition.

Summary/Conclusion

High levels of miR-21-5p-enriched pEXOs during the late postoperative period depict higher LV Rev-Rem after MVR. miR-21-5p-enriched pEXOs may be helpful to predict and to treat incomplete LV Rev-Rem after successful early surgical MVR.

Myocardial fibrosis in asymptomatic patients undergoing surgery for mitral and aortic valve regurgitation

BACKGROUND

Chronic heart valve regurgitation induces left ventricular (LV) volume overload, leading to the development of hypertrophy and progressive dilatation of the ventricle to maintain physiological cardiac output. In order to prevent potential irreversible LV structural changes, the identification of the best timing for treatment is pivotal.

OBJECTIVE

To assess the presence and extent of fibrosis in myocardial tissue in asymptomatic patients with valvular heart disease (VHD) and preserved LV dimensions and function undergoing cardiac surgery.

METHODS

Thirty-nine patients were enrolled. Sixteen patients were affected by aortic or mitral regurgitation: they were all asymptomatic, undergoing valve surgery according to VHD European Society of Cardiology guidelines. Twenty-three patients with end-stage nonischemic dilated cardiomyopathy (DCM) and severe LV dysfunction undergoing cardiac surgery for implantation of a durable left ventricular assist device (LVAD) served as controls. During surgery, VHD patients underwent three myocardial biopsies at the level of the septum, the lateral wall and LV apex, while in LVAD patients the coring of the apex of the LV was used. For both groups, the tissue samples were analyzed on one section corresponding to the apical area. All slides were stained with hematoxylin and eosin and Masson's trichrome staining and further digitalized. The degree of fibrosis was then calculated as a percentage of the total area.

RESULTS

Of 39 patients, 23 met the inclusion criteria: 12 had mitral or aortic insufficiency with a preserved ejection fraction and 11 had idiopathic dilated cardiomyopathy. Quantitative analysis of apical sections revealed a myocardial fibrosis amount of 10 ± 6% in VHD patients, while in LVAD patients the mean apical myocardial fibrosis rate was 38 ± 9%. In VHD patients, fibrosis was also present in the lateral wall (9 ± 4%) and in the septum (9 ± 6%).

CONCLUSION

Our case series study highlights the presence of tissue remodeling with fibrosis in asymptomatic patients with VHD and preserved LV function. According to our results, myocardial fibrosis is present at an early stage of the disease, well before developing detectable LV dysfunction and symptoms. Since the relationship between the progressive magnitude of myocardial fibrosis and potential prognostic implications are not yet defined, further studies on this topic are warranted.

Left Atrial Remodeling after Mitral Valve Repair for Primary Mitral Regurgitation: Evolution over Time and Prognostic Significance

Left atrial (LA) dilatation is associated with worse outcomes in primary mitral regurgitation (MR). However, the effects of mitral valve repair on LA size and its prognostic implications are not well known. In the current study, LA volume index (LAVi) and LA reservoir strain (LASr) were evaluated immediately before and after surgery, and during long-term follow-up in 226 patients undergoing mitral valve repair for primary MR (age 62 ± 13 years, 66% male). Mean LAVi was reduced significantly after surgery and at long-term follow-up (from 56 ± 28 to 38 ± 21 to 32 ± 17 mL/m2; p < 0.001). LASr reduced significantly after surgery but increased again during the long-term (from 23.6 ± 9.4 to 11.5 ± 5.0 to 17.3 ± 7.5%; p < 0.001). Age, pre-operative LAVi, MR severity, and postoperative transmitral pressure gradient were associated with LA reverse remodeling by the long-term check-up. During a median follow-up of 72 (40−114) months, 43 (19%) patients died. Patients with LAVi ≥ 42 mL/m2 at long-term follow-up showed significant higher mortality rates compared to patients with LAVI < 42 mL/m2 (p < 0.001), even after adjusting for clinical covariates. In conclusion, significant LA reverse remodeling was observed both immediately and at long-term follow-up after mitral valve repair. LA dilatation at long term follow-up after surgery was still associated with all-cause mortality.

Blood Pressure Trajectories for 16 Years and the Development of Left Ventricular Hypertrophy and Increased Left Atrial Size: The Korean Genome and Epidemiology Study

Background

Elevated single blood pressure (BP) measurement can be associated with the development of hypertension-mediated target organ damage including left ventricular hypertrophy (LVH) and left atrial (LA) enlargement (LAE). However, long-term patterns of BP and their effects on LVH and LAE are poorly understood. We evaluated the association between the BP trajectories and the presence of LVH and LAE.

Methods

We analyzed a total of 2,565 participants (1,267 males, 47.8 ± 6.7 years old) from the first biennial examination (2001-2002) of the Korean Genome and Epidemiology Study. The presence of LVH and LAE was identified by echocardiography performed at the 8^th biennial examination (2015-2016). Latent mixture modeling was used to identify trajectories in mid-BP ((systolic BP + diastolic BP)/2) over time. Linear logistic regression was used for assessing BP trajectories with the outcomes.

Results

We identified 4 distinct mid-BP trajectories: group 1 (lowest, 20.9%, n = 536), group 2 (36.2%, n = 928), group 3 (32.3%, n = 828), and group 4 (highest, 10.6%, n = 273). Compared with the lowest group, trajectories with elevated mid-BP had greater odds ratios having LVH and LAE by multivariable-adjusted regression models. Adjusted odd ratios for LVH were 2.033 (95% CI = 1.462–2.827, P < 0.001) for group 2, 3.446 (95% CI = 2.475–4.797, P < 0.001) for group 3, and 4.940 (95% CI = 3.318–7.356, P < 0.001) for group 4. Adjusted odd ratios for LAE were 1.200 (95% CI = 0.814–1.769, P = 0.358) for group 2, 1.599 (95% CI = 1.084–2.360, P = 0.018) for group 3, and 1.944 (95% CI = 1.212–3.118, P = 0.006) for group 4.

Conclusions

Higher long-term mid-BP was an independent risk factor of cardiac structural changes such as LVH and LAE among middle-aged population.

Stage-based approach to predict left ventricular reverse remodeling after mitral repair

Background

Although predictors of reverse left ventricular (LV) remodeling postmitral valve repair are critical for guiding perioperative decision‐making, there remains a paucity of randomized, prospective data to support the criteria that potential predictor variables must meet.

Methods and Results

The CAMRA CardioLink‐2 randomized trial allocated 104 patients to either leaflet resection or preservation strategies for mitral repair. The correlation of indexed left ventricular end‐systolic volume (LVESVI), indexed left ventricular end‐diastolic volume (LVEDVI), and left ventricular ejection fraction (LVEF) were tested with univariate analysis and subsequently with multivariate analysis to determine independent predictors of reverse remodeling at discharge and at 12 months postoperatively. At discharge, both LVESVI and LVEDVI were independently associated with their preoperative values (p < .001 for both) and LVEF by preoperative LVESVI (p < .001). Mitral ring size was favorably associated with the change in LVESVI (p < .05) and LVEF (p < .01) from predischarge to 12 months, while the mean mitral valve gradient after repair was adversely associated with the change in LVESVI (p < .05) and LVEDVI (p < .05). No significant associations were found between reverse remodeling and coaptation height nor mitral repair technique.

Conclusions

Beyond confirming the lack of impact of mitral repair technique on reverse remodeling, this investigation suggests that recommending surgery before significant LV dilatation or dysfunction, as well as higher postoperative mitral valve hemodynamic performance, may enhance remodeling capacity following mitral repair.

Left atrial disease and left atrial reverse remodelling across different stages of heart failure development and progression: a new target for prevention and treatment

The left atrium is a dynamic chamber with peculiar characteristics. Stressors and disease mechanisms may deeply modify its structure and function, leading to left atrial remodelling and disease. Left atrial disease is a predictor of poor outcomes. It may be a consequence of left ventricular systolic and diastolic dysfunction and neurohormonal and inflammatory activation and/or actively contribute to the progression and clinical course of heart failure through multiple mechanisms such as left ventricular filling and development of atrial fibrillation and subsequent embolic events. There is growing evidence that therapy may improve left atrial function and reverse left atrial remodelling. Whether this translates into changes in patient's prognosis is still unknown. In this review we report current data about changes in left atrial size and function across different stages of development and progression of heart failure. At each stage, drug therapies, lifestyle interventions and procedures have been associated with improvement in left atrial structure and function, namely a reduction in left atrial volume and/or an improvement in left atrial strain function, a process that can be defined as left atrial reverse remodelling and, in some cases, this has been associated with improvement in clinical outcomes. Further evidence is still needed mainly with respect of the possible role of left atrial reverse remodelling as an independent mechanism affecting the patient's clinical course and as regards better standardization of clinically meaningful changes in left atrial measurements. Summarizing current evidence, this review may be the basis for further studies.

Mitral repair with leaflet preservation versus leaflet resection and ventricular reverse remodeling from a randomized trial

OBJECTIVES

In the Canadian Mitral Research Alliance (CAMRA) Trial CardioLink-2 leaflet resection versus preservation techniques for posterior leaflet prolapse was investigated and no difference was shown in their effect on mean mitral gradient at peak exercise at 12 months postoperatively. The purpose of this subanalysis was to evaluate the effect of the 2 strategies on left ventricular (LV) reverse remodeling after repair.

METHODS

A total of 104 patients were randomized to either a leaflet resection or leaflet preservation strategy. Echocardiograms, performed at baseline (preoperative), predischarge, and 12 months postoperatively, were analyzed in a blinded fashion at a core laboratory.

RESULTS

All patients underwent successful mitral repair. At discharge, 3 patients showed moderate mitral regurgitation, whereas the remainder showed mild or less regurgitation. Compared with the baseline echocardiogram, the indexed end diastolic volume was reduced at the discharge echocardiogram (P < .0001) and was further reduced at the 12-month echocardiogram (P = .01). In contrast, the indexed end systolic volume did not significantly change from baseline assessed at the predischarge echocardiogram (P = .32) but improved at 12 months postoperatively (P < .0001), resulting in a corresponding improvement in ejection fraction at 12 months (P < .0001). The type of mitral repair strategy had no significant effect on LV reverse remodeling trends.

CONCLUSIONS

The mitral repair strategies used did not influence postoperative LV reverse remodeling, which occurred in stages. Although LV end diastolic dimensions recovered before discharge, improvements in LV end systolic dimension were evident 12 months after repair.

Prevention of Pathological Atrial Remodeling and Atrial Fibrillation: JACC State-of-the-Art Review

Atrial enlargement in response to pathological stimuli (e.g., hypertension, mitral valve disease) and physiological stimuli (exercise, pregnancy) can be comparable in magnitude, but the diseased enlarged atria is associated with complications such as atrial fibrillation (AF), whereas physiological atrial enlargement is not. Pathological atrial enlargement and AF is also observed in a small percentage of athletes undergoing extreme/intense endurance sport and pregnant women with preeclampsia. Differences between physiological and pathological atrial enlargement and underlying mechanisms are poorly understood. This review describes human and animal studies characterizing atrial enlargement under physiological and pathological conditions and highlights key knowledge gaps and clinical challenges, including: 1) the limited ability of atria to reverse remodel; and 2) distinguishing physiological and pathological enlargement via imaging/biomarkers. Finally, this review discusses how targeting distinct molecular mechanisms underlying physiological and pathological atrial enlargement could provide new therapeutic and diagnostic strategies for preventing or reversing atrial enlargement and AF.

Tricuspid regurgitation after transcatheter mitral valve repair: Clinical course and impact on outcome

Objectives

The aim of this study was to determine the course of tricuspid regurgitation (TR) after transcatheter mitral valve repair (TMVR), identify predictors for severe TR after TMVR and determine the association of severe TR after TMVR with outcome.

Background

TR is often present in patients with symptomatic mitral regurgitation (MR) and is associated with increased morbidity and mortality. The clinical course of TR after TMVR has not been clearly determined.

Methods

Patients that underwent TMVR between 2009 and 2017 were included. Clinical data were compared between patients with and without severe TR at 6 months after TMVR. Multivariate logistic regression analysis was performed to identify predictors for severe TR after TMVR. Survival analysis was done for both groups, using the Kaplan–Meier method.

Results

A total of 146 patients were included (mean age 76 years, 51% male, 79% New York Heart Association class ≥3 and 29% severe TR at baseline).

Advanced age, atrial fibrillation (AF), right ventricular (RV) dysfunction, and limited procedural MR reduction were revealed as independent predictors for severe TR after TMVR. Survival of patients with severe TR after TMVR was 58% after 2 years compared to 82% for those with non, mild or moderate TR.

Conclusions

Severe TR after TMVR is common in patients at advanced age, those with AF, RV dysfunction and limited MR reduction during TMVR and is associated with impaired survival. As the associated parameters are indicators of longstanding MR, research investigating the benefits of earlier intervention in MR should be initiated.

Predictive Value of Pre-Operative 2D and 3D Transthoracic Echocardiography in Patients Undergoing Mitral Valve Repair: Long Term Follow Up of Mitral Valve Regurgitation Recurrence and Heart Chamber Remodeling

The “ideal” management of asymptomatic severe mitral regurgitation (MR) in valve prolapse (MVP) is still debated. The aims of this study were to identify pre-operatory parameters predictive of residual MR and of early and long-term favorable remodeling after MVP repair. We included 295 patients who underwent MV repair for MVP with pre-operatory two- and three-dimensional transthoracic echocardiography (2DTTE and 3DTTE) and 6-months (6M) and 3-years (3Y) follow-up 2DTTE. MVP was classified by 3DTTE as simple or complex and surgical procedures as simple or complex. Pre-operative echo parameters were compared to post-operative values at 6M and 3Y. Patients were divided into Group 1 (6M-MR < 2) and Group 2 (6M-MR ≥ 2), and predictors of MR ≥ 2 were investigated. MVP was simple in 178/295 pts, and 94% underwent simple procedures, while in only 42/117 (36%) of complex MVP a simple procedure was performed. A significant relation among prolapse anatomy, surgical procedures and residual MR was found. Post-operative MR ≥ 2 was present in 9.8%: complex MVP undergoing complex procedures had twice the percentage of MR ≥ 2 vs. simple MVP and simple procedures. MVP complexity resulted independent predictor of 6M-MR ≥ 2. Favorable cardiac remodeling, initially found in all cases, was maintained only in MR < 2 at 3Y. Pre-operative 3DTTE MVP morphology identifies pts undergoing simple or complex procedures predicting MR recurrence and favorable cardiac remodeling.

The value of three-dimensional echocardiography in risk stratification in pulmonary arterial hypertension: a cross-sectional study

To explore the value of right ventricular (RV) parameters detected by three-dimensional echocardiography (3DE) in risk stratification in pulmonary arterial hypertension (PAH) patients. We prospectively recruited 130 pulmonary hypertension patients from National Center for Cardiovascular Diseases, Fuwai Hospital. Each participant was performed a transthoracic echocardiography and 3DE parameters were measured using an off-line software (4D RV Function 2.0, TomTec). Patients were classified into low, intermediate-high risk group based on 2015 ESC Guidelines. A total of 91 PAH patients (34 ± 12 years old, 25 males) were enrolled, among which, 42 were classified into low risk group, while 49 were intermediate-high risk group. Compared with low-risk patients, those with intermediate-high risk had significantly larger 3DE-RV volumes, worse ejection fraction (EF) and tricuspid annular plane systolic excursion, and decreased longitudinal strain (LS). Receive operating characteristic curves illustrated all the 3DE parameters were able to predict intermediate-high risk stratification, especially 3D-RVEF (area under curve, 0.82, 95% CI 0.73-0.91, P < 0.001). And 3D-RVEF < 26.39% had a 81.6% sensibility and 73.8% specificity to predict intermediate-high risk stratification. Univariate and multivariate Logistic regression analyses identified 3D-RV end-diastolic (OR 1.02, 95% CI 1.01-1.03, P = 0.002) and end-systolic (OR 1.03, 95% CI 1.01-1.04, P < 0.001) volumes, 3D-RVEF (OR 0.82, 95% CI 0.75-0.90, P < 0.001) and LS of free wall (OR 1.17, 95% CI 1.05-1.31, P = 0.005) as independent predictors of intermediate-high risk stratification. In conclusion, RV volumes, EF and free wall strain detected by 3DE were independent predictors of intermediate-high risk stratification in PAH patients, among which, RVEF showed the best predictive capacity.

Preoperative left atrial volume index is associated with postoperative outcomes in mitral valve repair for chronic mitral regurgitation

OBJECTIVE

To assess determinants of left atrial reverse remodeling after mitral valve repair and to evaluate the impact of preoperative left atrial volume on postoperative outcomes.

METHODS

We reviewed the records of 720 patients who underwent mitral valve repair from September 2008 to July 2015 and had preoperative measurement of left atrial volume index. We analyzed the association of preoperative left atrial volume index on early and late outcomes, and determined which baseline characteristics are associated with left atrial reverse remodeling, as measured by changes in left atrial volume index in 512 patients who had at least 1 postoperative measurement.

RESULTS

The median (interquartile range) preoperative left atrial volume index was 54.0 (44.0-66.0) mL/m². Preoperative left atrial volume index, age, body mass index, and atrial fibrillation were independently associated with the degree of left atrial reverse remodeling over the follow-up period. Reverse remodeling was greatest in patients with higher baseline left atrial volume index (P < .001), but less reverse remodeling was observed in patients with advanced age (P < .001), preoperative atrial fibrillation (P < .001), and extreme values of body mass index (P = .004), although these effects were moderately attenuated when limiting the analysis to 6-month follow-up. Secondary analysis demonstrated marginally significant effects of preoperative left atrial volume index on risks of early postoperative atrial fibrillation (P = .030) and late mortality (P = .077) after adjusting for age and sex.

CONCLUSIONS

In patients with degenerative mitral valve regurgitation who had mitral valve repair, preoperative left atrial volume index was associated with extent of left atrial reverse remodeling, risk of early postoperative atrial fibrillation, and late mortality. The majority of reverse remodeling occurs within the first month after operation and is greatest in younger patients.

Prognostic Impact of Left Atrial Function Following Transcatheter Mitral Valve Repair

Background

Left atrial (LA) function predicts clinical outcome in a variety of cardiovascular diseases. However, limited data are available in the setting of mitral regurgitation. The aim of the present study was to assess potential changes in LA ejection fraction (LAEF) and its prognostic value in patients following transcatheter mitral valve repair using the MitraClip.

Methods and Results

A total of 88 consecutive patients undergoing MitraClip implantation with complete echocardiography at baseline and follow‐up between 3 and 6 months postprocedure were enrolled. LAEF improved in 58% of the population. Change in LAEF was associated with residual mitral regurgitation, residual transmitral gradient and left ventricular ejection fraction changes. Compared with their counterparts, patients with residual mitral regurgitation ≥grade 2 (change in LAEF, −6% [Interquartile [IQR], −9–1%] versus 4% [IQR, −5–15%]; P=0.05) and with residual transmitral gradient ≥5 mm Hg (change in LAEF, −2% [IQR, −9–9%] versus 5% [IQR, −4–16%]; P=0.03) showed a decline in LAEF, respectively. Furthermore, LAEF significantly correlated with changes in left ventricular ejection fraction (r=0.40; P=0.001). With regards to clinical outcome, heart failure symptoms as assessed by New York Heart Association class were more severe in patients with worsened LAEF at follow‐up. Finally, LAEF change was identified as an independent predictor of all‐cause mortality (hazard ratio, 0.94; 95% CI, 0.90–0.98 [P=0.008]).

Conclusions

The present analysis showed that changes in LA function in patients undergoing MitraClip implantation are associated with important measures including residual mitral regurgitation, elevated transmitral gradient, and left ventricular function. Importantly, LA function alterations represent a strong predictor for all‐cause mortality.

Incremental Value of Left Atrial Geometric Remodeling in Predicting Late Atrial Fibrillation Recurrence After Pulmonary Vein Isolation: A Cardiovascular Magnetic Resonance Study

Background Left atrial ( LA ) enlargement is a marker for increased risk of atrial fibrillation ( AF ). However, LA remodeling is a complex process that is poorly understood, and LA geometric remodeling may also be associated with the development of AF . We sought to determine whether LA spherical remodeling or its temporal change predict late AF recurrence after pulmonary vein isolation ( PVI ). Methods and Results Two hundred twenty-seven consecutive patients scheduled for their first PVI for paroxysmal or persistent AF who underwent cardiovascular magnetic resonance before and within 6 months after PVI were retrospectively identified. The LA sphericity index was computed as the ratio of the measured LA maximum volume to the volume of a sphere with maximum LA length diameter. During mean follow-up of 25 months, 88 patients (39%) experienced late recurrence of AF . Multivariable Cox regression analyses identified an increased pre- PVI LA sphericity index as an independent predictor of late AF recurrence (hazard ratio, 1.32; 95% confidence interval, 1.07-1.62, P=0.009). Patients in the highest LA sphericity index tertile were at highest risk of late recurrence (highest versus lowest: 59% versus 28%; P<0.001). The integration of the LA sphericity index to the LA minimum volume index and passive emptying fraction provided important incremental prognostic information for predicting late AF recurrence post PVI (categorical net reclassification improvement, 0.43; 95% confidence interval, 0.16-0.69, P=0.001). Conclusions The assessment of pre- PVI LA geometric remodeling provides incremental prognostic information regarding late AF recurrence and may be useful to identify those for whom PVI has reduced success or for whom more aggressive ablation or medications may be useful.

3D Experimental and Computational Analysis of Eccentric Mitral Regurgitant Jets in a Mock Imaging Heart Chamber

Mitral valve regurgitation (MR) is a disorder of the heart in which the mitral valve does not close properly. This causes an abnormal leaking of blood backwards from the left ventricle into the left atrium during the systolic contractions of the left ventricle. Noninvasive assessment of MR using echocardiography is an ongoing challenge. In particular, a major problem are eccentric or Coanda regurgitant jets which hug the walls of the left atrium and appear smaller in the color Doppler image of regurgitant flow. This manuscript presents a comprehensive investigation of Coanda regurgitant jets and the associated intracardiac flows by using a combination of experimental and computational approaches. An anatomically correct mock heart chamber connected to a pulsatile flow loop is used to generate the physiologically relevant flow conditions, and the influence of two clinically relevant parameters (orifice aspect ratio and regurgitant volume) on the onset of Coanda effect is studied. A two parameter bifurcation diagram showing transition to Coanda jets is obtained, indicating that: (1) strong wall hugging jets occur in long and narrow orifices with moderate to large regurgitant volumes, and (2) short orifices with moderate to large regurgitant volumes produce strong 3D flow features such as vortex rolls, giving rise to the velocities that are orthogonal to the 2D plane associated with the apical color Doppler views, making them "invisible" to the single plane color Doppler assessment of MR. This is the first work in which the presence of vortex rolls in the left atrium during regurgitation is reported and identified as one of the reasons for under-estimation of regurgitant volume. The results of this work can be used for better design of imaging strategies in noninvasive assessment of MR, and for better understanding of LA remodeling that may be associated with the presence of maladapted vortex dynamics. This introduces a new concept in clinical imaging, which emphasizes that the quality and not only the quantity of regurgitant flow matters in the assessment of severity of mitral valve regurgitation.

Role of Left Atrial Reservoir Strain Rate in Left Atrial Remodeling in Severe Mitral Regurgitation

Background:

Impaired left atrial (LA) reservoir deformation has been found to be associated with poor functional capacity and outcomes in severe chronic mitral regurgitation (MR). Among patients with primary MR (valve incompetence due to mitral valve pathology), we focus on Carpentier II classification (prolapse or flail mitral valve) and aim to investigate determinants for decreased LA reservoir deformation and its impact on LA remodeling in severe MR.

Methods:

Among 159 consecutive patients with severe chronic Carpentier II MR (left ventricular ejection fraction ≥ 60%), 55 underwent follow-up echocardiography, which was compared with their baseline study. We used the change of LA volume index as the rapidity of LA remodeling, LA eccentricity index as LA sphericity, and peak LA reservoir strain as well as reservoir strain rate (LASR_R) derived from two-dimensional speckle-tracking echocardiography as LA reservoir function.

Results:

Older age, elongated left atrium, increased LA volume index, as well as reduced left ventricular global longitudinal strain and LA ejection fraction all linked to a poor baseline LASR_R (all p < 0.001). A second echocardiography during a mean follow-up of 15.3 ± 8.3 months revealed an enlarged left atrium (increased interval change of LA volume index; p < 0.001). In multivariate analysis, only the difference between the baseline and follow-up LASR_R values (Δ: LASR_R; odds ratio (OR) 0.037, 95% confidence interval (CI) 0.003–0.496, p = 0.013) predicted accelerated LA remodeling. A poor baseline LASR_R was significantly associated with its profound deterioration during the follow-up period (β: = -0.424, p = 0.002).

Conclusion:

In severe chronic Carpentier II MR, a reduced follow-up LASR_R predicted future accelerated LA remodeling. Patients with a poor baseline LASR_R are at a higher risk of its deterioration.

Time course of left atrial reverse remodelling after mitral valve surgery and the impact of left ventricular global longitudinal strain in patients with chronic severe mitral regurgitation

OBJECTIVES

We aimed to investigate the time course of left atrial (LA) reverse remodelling (LARR) after mitral valve (MV) surgery in patients with chronic severe mitral regurgitation (MR) and examine the impact of left ventricular (LV) mechanical function on LARR.

METHODS

A total of 140 patients (73 males, age 54 ± 16 years) with chronic severe MR undergoing MV surgery were analysed. All patients underwent two-dimensional, Doppler and speckle-tracking echocardiography before and after surgery (1 week, 6 months and 12 months).

RESULTS

There was a significant decrease in LA volume from 137.8 ± 85.5 to 89.7 ± 54.6 ml (-32.1 ± 16.7%, P < 0.001) at 1 week after surgery. LA volume further decreased to 77.4 ± 52.4 ml (-9.9 ± 13.4%, P < 0.001) at 6 months but increased to 79.7 ± 62.4 ml (3.6 ± 11.9%, P = 0.002) at 12 months after surgery. Patients with good LARR (a reduction of ≥25% in LA volume) showed lower LV global longitudinal strain (LV-GLS) than those with poor LARR (P = 0.032). In simple correlation, age (r = 0.19, P = 0.026), preoperative LA volume (r = -0.28, P = 0.001) and preoperative LV-GLS (r = 0.28, P = 0.001) showed significant correlations with the % change in LA volume, whereas no correlations were observed with preoperative LV ejection fraction, global circumferential and radial strain. In multivariate analyses, preoperative LV-GLS (β = 0.24, P = 0.014) was an independent determinant for early LARR along with age and preoperative LA volume.

CONCLUSIONS

The majority of LARR after MV surgery occurred during the early postoperative period. LV-GLS, age and LA volume at surgery determined the degree of early LARR after MV surgery in patients with chronic severe MR.

Right Atrial Evaluation in Patients With Pulmonary Hypertension: A Real-time 3-Dimensional Transthoracic Echocardiographic Study

OBJECTIVES

The purpose of this study was to investigate the changes in the morphologic characteristics and performance of the right atrium (RA) that occur secondary to structural remodeling of the right ventricle (RV) in patients with pulmonary hypertension by real-time 3-dimensional echocardiography (3DE).

METHODS

Comprehensive 2-dimensional echocardiography and real-time 3DE were performed in 112 patients and 30 healthy control participants. Patients with pulmonary hypertension were divided into 3 subgroups: 1, normal RV dimension (n = 34); 2, RV enlargement and preserved systolic function (n = 36); and 3, RV enlargement and systolic dysfunction (n = 42).

RESULTS

Patients had larger RA volume parameters and lower RA passive emptying fractions than controls (P< .01). The RA active emptying fraction was higher in patient groups 1 (mean ± SD, 45.5% ± 10.7%) and 2 (40.1% ± 4.0%) and lower in group 3 (19.3% ± 4.3%) compared to controls (35.4% ± 3.5%). The RA total emptying fraction was similar between groups 1 and 2 (59.3% ± 9.7% and 52.6% ± 3.4%, respectively) but was significantly lower in group 3 compared to controls (26.8% ± 5.1% versus 55.2% ± 5.1%). Right atrial volume and phasic function were substantially affected by RV structure and function.

CONCLUSIONS

Real-time 3DE is a feasible, repeatable, and noninvasive method for accessing cyclic RA volume and function changes, such as those that occur with varying RV status in patients with pulmonary hypertension.

Preoperative left ventricular ejection fraction and left atrium reverse remodeling after mitral regurgitation surgery

Background

Left atrium enlargement has been associated with cardiac events in patients with mitral regurgitation (MR). Left atrium reverse remodeling (LARR) occur after surgical correction of MR, but the preoperative predictors of this phenomenon are not well known. It is therefore important to identify preoperative predictors for postoperative LARR.

Methods

We enrolled 62 patients with chronic severe MR (prolapse or flail leaflet) who underwent successful mitral valve surgery (repair or replacement); all with pre- and postoperative echocardiography. LARR was defined as a reduction in left atrium volume index (LAVI) of ≥25%. Stepwise multiple regression analysis was used to identify independent predictors of LARR.

Results

LARR occurred in 46 patients (74.2%), with the mean LAVI decreasing from 85.5 mL/m² to 49.7 mL/m² (p <0.001). These patients had a smaller preoperative left ventricular systolic volume (p =0.022) and a higher left ventricular ejection fraction (LVEF) (p =0.034). LVEF was identified as the only preoperative variable significantly associated with LARR (odds ratio, 1.086; 95% confidence interval, 1.002–1.178). A LVEF cutoff value of 63.5% identified patients with LARR of ≥25% with a sensitivity of 71.7% and a specificity of 56.3%.

Conclusions

LARR occurs frequently after mitral valve surgery and is associated with preoperative LVEF higher than 63.5%.

Effects of 5 days of head-down bed rest, with and without short-arm centrifugation as countermeasure, on cardiac function in males (BR-AG1 study)

This study examined cardiac remodeling and functional changes induced by 5 days of head-down (−6°) bed rest (HDBR) and the effectiveness of short-arm centrifugation (SAC) in preventing them in males. Twelve healthy men (mean age: 33 ± 7) were enrolled in a crossover design study (BR-AG1, European Space Agency), including one sedentary (CTRL) and two daily SAC countermeasures (SAC1, 30 min continuously; SAC2, 30 min intermittently) groups. Measurements included plasma and blood volume and left ventricular (LV) and atrial (LA) dimensions by transthoracic echocardiography (2- and 3-dimensional) and Doppler inflows. Results showed that 5 days of HDBR had a major impact on both the geometry and cardiac function in males. LV mass and volume decreased by 16 and 14%, respectively; LA volume was reduced by 36%; Doppler flow and tissue Doppler velocities were reduced during early filling by 18 and 12%, respectively; and aortic flow velocity time integral was decreased by 18% with a 3% shortening of LV ejection time. These modifications were presumably due to decreased physiological loading and dehydration, resulting in reduced plasma and blood volume. All these changes were fully reversed 3 days after termination of HDBR. Moreover, SAC was not able to counteract these changes, either when applied continuously or intermittently.

Left atrial asynchrony and mechanical function in patients with mitral stenosis before and immediately after percutaneous balloon mitral valvuloplasty: a real time three-dimensional echocardiography study

OBJECTIVE

This study evaluated the feasibility of assessing left atrium (LA) function and asynchrony in patients with rheumatic mitral stenosis (MS) before and immediately after percutaneous balloon mitral valvuloplasty (PBMV) by real time three-dimensional echocardiography (RT3DE).

METHODS

Thirty patients with rheumatic MS who underwent PBMV and 30 controls were enrolled. RT3DE was used to measure LA volume and function, the standard deviation of time to the minimal systolic volume divided into 16 segments, 12 segments, or 6 segments (Tmsv 16-SD, Tmsv 12-SD, Tmsv 6-SD), and the maximum differences (Tmsv 16-Dif, 12-Dif, 6-Dif) in RT3DE derived values in MS patients before and 2 days after PBMV were obtained and compared with those of normal controls. The associations between the LA asynchrony and heart volume, function, mitral valve area (MVA), maximum mitral valve gradient (MVGmax ), mean mitral valve gradient (MVGmean), and mean LA pressure (MLAP) were investigated.

RESULTS

Left atrium asynchrony indexes were significantly larger, and LA function parameters were significantly lower in the MS group than in the controls (P < 0.05 for all). Of all the LA asynchrony indexes, LA Tmsv16-SD was most significantly correlated with the LA volume and function parameters, MVGmax , MVGmean , and MLAP (P < 0.05 for all). LA asynchrony indexes and LA volume significantly deceased, and LA function significantly increased post-PBMV (P < 0.05).

CONCLUSION

Real time three-dimensional echocardiography is a reliable and reproducible method to quantify LA function and asynchrony. RT3DE revealed a significant, early improvement in LA function and asynchrony in MS patients after PBMV.

Three-dimensional echocardiography of the mitral valve: lessons learned

Three-dimensional echocardiography has markedly improved our understanding of normal and pathologic mitral valve (MV) mechanics. Qualitative and quantitative analysis of three-dimensional (3D) data on the mitral valve could have a clinical impact on diagnosis, patient referral, surgical strategies, annuloplasty ring design and evaluation of the immediate and long-term surgical outcome. This review covers the contribution of 3D echocardiography in the diagnosis of MV disease, its role in selecting and monitoring surgical procedures, and in the assessment of surgical outcomes. Moreover, advantages of this technique versus the standard 2D modality, as well as future applications of advanced analysis techniques, will be reviewed.

Left atrium reverse remodeling in patients with mitral valve stenosis after percutaneous valvuloplasty: a 2- and 3-dimensional echocardiographic study

INTRODUCTION AND OBJECTIVES

The left atrium is clinically relevant in patients with mitral valve stenosis. The objective of this study was to analyze the effects of percutaneous balloon valvuloplasty on left atrium volumes and the left atrium emptying fraction in symptomatic mitral valve stenosis patients using 2-dimensional and real-time 3 -dimensional transthoracic echocardiography.

METHODS

We carried out a prospective study of 28 consecutive symptomatic mitral valve stenosis patients, aged 22-72 (39 [11.5]) years, 24/28 (85.6%) women, who underwent to percutaneous balloon valvuloplasty between March 2009 and May 2011. Patients underwent 2- and 3-dimensional transthoracic and transesophageal echocardiography (atrial fibrillation) and invasive mitral valve area measurement. Echocardiographic analysis was performed before, 72 h after and 12 months after percutaneous balloon valvuloplasty. The following parameters were analyzed: a) mitral valve area (2-dimensional planimetry, pressure half-time, 3-dimensional echocardiography, invasive hemodynamic measurement); b) indexed left atrium maximum and indexed minimum volumes, and c) left atrium emptying fraction.

RESULTS

The 3-dimensional parameters of the mitral valve stenosis patients before and 72 h and 12 months after percutaneous balloon valvuloplasty were as follows: a) mitral valve area: 0.9 (0.1) cm(2); 1.8 (0.2) cm(2) (P<.001); 1.7 (0.2) cm(2) (P<.001); b) left atrium maximum volumes: 49.9 (12) mL/m(2); 42 (11.4) mL/m(2) (P<.001); 40.3 (10.2) mL/m(2) (P<.001), and c) left atrium emptying fraction: 30.1 (9.4%); 40.6 (7.4%) (P<.001); 44.1 (8%) (P<.001), respectively.

CONCLUSIONS

In symptomatic mitral valve stenosis patients who underwent percutaneous balloon valvuloplasty analysis by 2- and 3-dimensional echocardiography, improvements in left atrium reverse remodeling and left atrium emptying fraction were observed 72 h and 12 months after the procedure.

Changes in left ventricular morphology and function after mitral valve surgery

Degenerative mitral valve disease is the leading cause of mitral regurgitation in North America. Surgical intervention has hinged on the symptoms and ventricular changes that develop as compensatory ventricular remodeling occurs. In the present study, we sought to characterize the temporal response of left ventricular (LV) morphology and function to mitral valve surgery for degenerative disease and to identify the preoperative factors that influence reverse remodeling. From 1986 to 2007, 2,778 patients with isolated degenerative mitral valve disease underwent valve repair (n = 2,607 [94%]) or replacement (n = 171 [6%]) and had ≥1 postoperative transthoracic echocardiogram; 5,336 transthoracic echocardiograms were available for analysis. Multivariate longitudinal repeated-measures analysis was performed to identify the factors associated with reverse remodeling. The LV dimensions decreased in the first year after surgery (end-diastolic from 5.7 ± 0.80 to 4.9 ± 1.4 cm; end-systolic from 3.4 ± 0.71 to 3.1 ± 1.4 cm). The LV mass index decreased from 139 ± 44 to 112 ± 73 g/m(2). The reduction in LV hypertrophy was less pronounced in patients with greater preoperative left heart enlargement (p <0.0001) and a greater preoperative LV mass (p <0.0001). The postoperative LV ejection fraction initially decreased from 58 ± 7.0% to 53 ± 20%, increased slightly during the first postoperative year, and was negatively influenced by preoperative heart failure symptoms (p <0.0001) and a lower preoperative LV ejection fraction (p <0.0001). The risk-adjusted response of LV morphology and function to valve repair and replacement was similar (p >0.2). In conclusion, a positive response toward normalization of LV morphology and function after mitral valve surgery is greatest in the first year. The best response occurs when surgery is performed before left heart dilation, LV hypertrophy, or LV dysfunction develop.