Prevalence of Unsuspected and Significant Mitral and Aortic Regurgitation

Expert proposal to analyze the combination of aortic and mitral regurgitation in multiple valvular heart disease by comprehensive echocardiography

The assessment of valvular pathologies in multiple valvular heart disease by echocardiography remains challenging. Data on echocardiographic assessment-especially in patients with combined aortic and mitral regurgitation-are rare in the literature. The proposed integrative approach using semi-quantitative parameters to grade the severity of regurgitation often yields inconsistent findings and results in misinterpretation. Therefore, this proposal aims to focus on a practical systematic echocardiographic analysis to understand the pathophysiology and hemodynamics in patients with combined aortic and mitral regurgitation. The quantitative approach of grading the regurgitant severity of each compound might be helpful in elucidating the scenario in combined aortic and mitral regurgitation. To this end, both the individual regurgitant fraction of each valve and the total regurgitant fraction of both valves must be determined. This work also outlines the methodological issues and limitations of the quantitative approach by echocardiography. Finally, we present a proposal that enables verifiable assessment of regurgitant fractions. The overall interpretation of echocardiographic results includes the symptomatology of patients with combined aortic and mitral regurgitation and the individual treatment options with respect to their individual risk. In summary, a reproducible, verifiable, and transparent in-depth echocardiographic investigation might ensure consistent hemodynamic plausibility of the quantitative results in patients with combined aortic and mitral regurgitation.

Prevalence and Risk Factors of Mitral, Tricuspid, and Aortic Regurgitation: A Population-Based Study from Rural Northeast China

The population-based studies on the epidemiologic features of valvular regurgitation in Northeast China are scarce. We aim to estimate the prevalence and risk factors of mitral regurgitation (MR), tricuspid regurgitation (TR), and aortic regurgitation (AR) in a general population from rural Northeast China. Valvular regurgitation was assessed by color flow Doppler echocardiography in a population-based survey of 11,278 participants aged ≥35 years in rural areas of Liaoning Province during 2012 to 2013. The prevalence of mild or greater MR and TR were 1.6% and 1.5%, respectively. Trace or greater AR was present in 4.1% of the participants. In the multivariable regression model, older age, left atrial dimension, low left ventricular (LV) ejection fraction, and fasting plasma glucose were associated with higher risk of MR in men, whereas only older age and left atrial dimension increased the risk in women. Body mass index was found to be a protective factor for MR in women (odds ratio 0.847, 95% confidence interval 0.741 to 0.969). TR was independently associated with age, heart rate, low LV ejection fraction, current drinking status, and high-density lipoprotein cholesterol. The risk for AR significantly increased with age in both genders. LV mass index and aortic dimension increased the risk of AR in males, and females with higher LV mass index and high-density lipoprotein cholesterol had an increased risk for AR. In both genders, systolic blood pressure presented as a risk factor for AR, while diastolic blood pressure as a protective factor. In this large Chinese population-based study, we found remarkably low prevalence of valvular regurgitation, adding evidence for estimating disease burden and making policy strategies in Northeast China.

Transcatheter Edge-to-Edge Repair for a Patient With Severe Mitral Regurgitation of Carpentier IIIa Classification

Whether patients diagnosed with mitral regurgitation of Carpentier class IIIa (rheumatic origin) can possibly be treated with balloon mitral commissurotomy followed by transcatheter edge-to-edge repair remains unclear. Here, we report on such a case who was successfully treated with balloon mitral commissurotomy and then transcatheter edge-to-edge repair without aggravating mitral stenosis. (Level of Difficulty: Intermediate.).

Sex Differences in Epidemiology, Morphology, Mechanisms, and Treatment of Mitral Valve Regurgitation

Sex-related disparities have been recognized in incidence, pathological findings, pathophysiological mechanisms, and diagnostic pathways of non-rheumatic mitral regurgitation. Furthermore, access to treatments and outcomes for surgical and interventional therapies among women and men appears to be different. Despite this, current European and US guidelines have identified common diagnostic and therapeutic pathways that do not consider patient sex in decision-making. The aim of this review is to summarize the current evidence on sex-related differences in non-rheumatic mitral regurgitation, particularly regarding incidence, imaging modalities, surgical-derived evidence, and outcomes of transcatheter edge-to-edge repair, with the goal of informing clinicians about sex-specific challenges to consider when making treatment decisions for patients with mitral regurgitation.

Incidence of heart valve disease in women treated with the ergot-derived dopamine agonist bromocriptine

BACKGROUND

Ergot-derived dopamine agonists are thought to induce fibrotic changes in cardiac valve leaflets. We sought to determine the incidence of heart valve disease in women treated with bromocriptine compared with age and sex matched controls from the background population.

METHODS

In nationwide Danish registries we identified female patients treated with bromocriptine in the period 1995-2018. Patients were included at date of second redeemed prescription and were matched 1:5 with controls from the background population based on age, sex and year of inclusion by use of incidence density sampling. The outcomes were hospital admission for or outpatient diagnosis of heart valve disease, and death as competing risk. Incidence rates, cumulative incidence curves, and adjusted cox-proportional hazard models adjusted for cardiovascular risk factors were used to assess outcomes in bromocriptine users versus controls.

RESULTS

A total of 3035 female bromocriptine users and 15,175 matched controls were included. Median age at inclusion was 32 years (Q1-Q3, 28-37 years). Both bromocriptine users and controls had few comorbidities and low use of concomitant pharmacotherapy. Within 10 years of follow-up, 11 patients (0.34%, 95% CI 0.13-0.55%) and 44 controls (0.29%, 95% CI 0.20-0.37) met the primary endpoint of heart valve disease, p = 0.63. The adjusted cox regression analysis yielded a hazard ratio of 0.96 (95% confidence interval (CI) 0.55-1.69, p = 0.89).

CONCLUSIONS

Treatment initiation with ergot-derived dopamine agonist bromocriptine in younger women with few comorbidities, was associated with a low absolute long-term risk of heart valve disease, not significantly different from the risk in age and sex matched population controls. Thus, indicating a low clinical yield of pre-treatment echocardiographic screening in this patient population in accordance with current guidelines.

Aortic root dimensions as a correlate for aortic regurgitation's severity

To evaluate the prevalence of aortic regurgitation (AR) and associations between the individual aortic root components and AR severity in the general population. The study included the first 10,000 participants of the population-based Hamburg City Health Study (HCHS) of whom 8259 subjects, aged 62.23 ± 8.46 years (51.3% females), enrolled 2016-2018, provided echocardiographic data. 69 subjects with bicuspid valves and 23 subjects with moderate/severe aortic stenosis were excluded. Aortic root dimensions were measured using state-of-the-art cardiac ultrasound, including the aortic annulus, sinus of Valsalva, sinotubular junction (STJ), and ascending aorta, in diastole and systole. The distribution of AR was: 932 (11.4%) mild, 208 (2.5%) moderate, and 20 (0.24%) severe. Patients with moderate or severe AR were predominantly male at advanced age who had hypertension, coronary artery disease, atrial fibrillation, and renal dysfunction. Increasing AR severity correlated with higher absolute and indexed aortic root diameters (e.g., end-diastolic sinus of Valsalva for no-mild-moderate-severe AR in mm ± standard deviation: 34.06 ± 3.81; 35.65 ± 4.13; 36.13 ± 4.74; 39.67 ± 4.61; p < 0.001). In binary logistic regression analysis, all aortic root components showed significant associations with moderate/severe AR. Mid-systolic STJ showed the strongest association with moderate/severe AR (OR 1.33, 95% confidence interval 1.25-1.43, p < 0.001). AR was prevalent in 14.2%, of whom 2.8% showed moderate/severe AR. All assessed aortic root diameters correlated with the prevalence and severity of AR. STJ diameter had the strongest association with moderate/severe AR possibly reflecting the pathophysiological impact of an increasingly dilated STJ in the context of an ageing aorta.

Characteristics and outcomes of MitraClip in octogenarians: Evidence from 1853 patients in the GIOTTO registry

BACKGROUND

We aimed at appraising features and outcomes of patients undergoing MitraClip treatment according to their age.

METHODS

We queried the prospective GIse registry Of Transcatheter treatment of mitral valve regurgitaTiOn (GIOTTO) multicenter registry dataset including 19 Italian centers performing MitraClip implantation, distinguishing patients <80 vs ≥80 years of age.

RESULTS

In total, 1853 patients were included, 751 (40.5%) octogenarians and 1102 (59.5%) non-octogenarians. Several baseline and procedural features were significantly different, including gender, regurgitation etiology, and functional class (all p < 0.05). In-hospital outcomes were similarly satisfactory, with death occurring in 18 (2.4%) and 32 (2.9%, p = 0.561), respectively, and improvement in mitral regurgitation in 732 (97.4%) and 1078 (97.8%, p = 0.746), respectively. After a mean follow-up of 15 months, death occurred in 152 (20.2%) and 264 (24.0%), and cardiac death in 85 (11.3%) and 138 (12.5%), respectively (both p > 0.05). Rehospitalization for heart failure and the composite of cardiac death or rehospitalization for heart failure were significantly less common in octogenarians: 63 (8.4%) vs 156 (14.2%, p < 0.001), and 125 (16.6%) vs 242 (22.0%, p = 0.005), respectively. Multivariable analysis showed that these differences were largely due to confounding features, as after adjustment for baseline, clinical and imaging characteristics no significant difference was found for the above clinical endpoints.

CONCLUSIONS

Transcatheter mitral valve repair with the MitraClip in carefully selected octogenarians appears feasible and safe, and is associated with favorable clinical outcomes at mid-term follow-up.

Aortic Stenosis, Aortic Regurgitation and Arterial Hypertension

BACKGROUND

Hypertension (HT) is an important risk factor for cardiovascular disease and might precipitate pathology of the aortic valve.

OBJECTIVE

To investigate the association of HT with aortic dysfunction (including both aortic regurgitation and stenosis) and the impact of antihypertensive treatment on the natural course of underlying aortic disease.

METHODS

We performed a systematic review of the literature for all relevant articles assessing the correlation between HT and phenotype of aortic disease.

RESULTS

Co-existence of HT with aortic stenosis and aortic regurgitation is highly prevalent in hypertensive patients and predicts a worse prognosis. Certain antihypertensive agents may improve haemodynamic parameters (aortic jet velocity, aortic regurgitation volume) and remodeling of the left ventricle, but there is no strong evidence of benefit regarding clinical outcomes. Renin-angiotensin system inhibitors, among other vasodilators, are well-tolerated in aortic stenosis.

CONCLUSION

Several lines of evidence support a detrimental association between HT and aortic valve disease. Therefore, HT should be promptly treated in aortic valvulopathy. Despite conventional wisdom, specific vasodilators can be used with caution in aortic stenosis.

The Role of Arterial Hypertension in Mitral Valve Regurgitation

PURPOSE OF REVIEW

To review medical literature for evidence of association between hypertension and mitral regurgitation (MR) and summarize potential favorable effects of antihypertensive drugs on MR natural history and treatment.

RECENT FINDINGS

Hypertension and MR are common diseases affecting a large proportion of the general population. Contemporary evidence suggests that hypertension may worsen the progression and prognosis of MR through augmented mechanical stress and increased regurgitation volume. Renin-angiotensin axis inhibitors, beta-blockers, and vasodilators have been tested in order to prevent or decrease primary or secondary MR. Although antihypertensive agents may improve hemodynamic parameters and left ventricular remodeling in primary MR, there is no strong evidence of benefit on clinical outcomes. On the other hand, a beneficial effect of these drugs on secondary MR is better established. Moreover, there are no studies evaluating a possible benefit of lower blood pressure targets in MR. Randomized controlled trials are warranted to elucidate the precise role of antihypertensive therapy on treatment of MR.

The need for annual echocardiography to detect cabergoline-associated valvulopathy in patients with prolactinoma: a systematic review and additional clinical data

Present recommendations by the US Food and Drug Administration advise that patients with prolactinoma treated with cabergoline should have an annual echocardiogram to screen for valvular heart disease. Here, we present new clinical data and a systematic review of the scientific literature showing that the prevalence of cabergoline-associated valvulopathy is very low. We prospectively assessed 40 patients with prolactinoma taking cabergoline. Cardiovascular examination before echocardiography detected an audible systolic murmur in 10% of cases (all were functional murmurs), and no clinically significant valvular lesion was shown on echocardiogram in the 90% of patients without a murmur. Our systematic review identified 21 studies that assessed the presence of valvular abnormalities in patients with prolactinoma treated with cabergoline. Including our new clinical data, only two (0·11%) of 1811 patients were confirmed to have cabergoline-associated valvulopathy (three [0·17%] if possible cases were included). The probability of clinically significant valvular heart disease is low in the absence of a murmur. On the basis of these findings, we challenge the present recommendations to do routine echocardiography in all patients taking cabergoline for prolactinoma every 12 months. We propose that such patients should be screened by a clinical cardiovascular examination and that echocardiogram should be reserved for those patients with an audible murmur, those treated for more than 5 years at a dose of more than 3 mg per week, or those who maintain cabergoline treatment after the age of 50 years.

Valvular regurgitations may increase risk of arrhythmias in Nigerians with hypertensive heart failure

BACKGROUND

Hypertensive heart disease (HHD) is the commonest cause of sudden cardiac death among Nigerians. A high frequency and early onset of valvular regurgitations (VHD) in hypertensives, and greater concentric hypertrophy are also common in that population.

AIMS AND METHODS

To further investigate the relationship between VHD and cardiac arrhythmias and their correlates seen in the hypertensive spectrum and to test the hypothesis that VHD predisposes to cardiac arrhythmias in hypertensive heart failure (HHF). HHF patients (n = 14), HHD patients n = 23, and normotensive controls (n = 9) all underwent 24 h electrocardiogram Holter monitoring as well as two-dimensional and Doppler echocardiography. Participants in each patient category were classified according to the presence and severity of VHD or its absence (NVHD).

RESULTS

There were statistically significant differences in the mean supraventricular tachycardia (SVT) (P < 0.001 analysis of variance; ANOVA), the mean and median frequency of ventricular tachycardia episodes (P < 0.02 ANOVA), and couplets (P = 0.0002 ANOVA) between groups. HHF-VHD always had more SVT (81/24 versus 4.4/24 h; P = 0.016) and ventricular arrhythmias 69/24 versus 34/24 h (P < 0.02) than HHF-NVHD. Multivalvular regurgitations (three or more valves), higher left ventricular mass index (g/m2) [274 (24) versus 191(19); P < 0.001 ANOVA], and lower ejection fraction (EF; %) [29(3) versus 53(14)] in HHF-VHD were arrhythmogenic. Mean ventricular tachycardia/triplet frequency/24 h were HHF-VHD 69, HHF-NVHD 39, HHD-VHD 0.3, HHD-NVHD 6, and controls 0.2 (P < 0.02 ANOVA). Compared with 35% (10/27) of all VHD, 15.7% (3/19) of all NVHD participants had nonsustained ventricular tachycardia. The number of regurgitant valves was positively correlated with the frequency of the Lown class of the arrhythmias 0-IVB (r = 0.42, P = 0.003) and to ventricular tachycardia (r = 0.3, P = 0.04) (both n = 46).

CONCLUSION

Left ventricular hypertrophy (LVH) increased arrhythmias. But multivalvular regurgitations predisposes to greater SVT and complex ventricular arrhythmias, especially in HHF. Low EF and concentric LVH are correlates.

Hesr2 knockout mice develop aortic valve disease with advancing age

OBJECTIVE

Acquired heart diseases, such as valve disease, are major causes of human morbidity and mortality. However, the pathological mechanisms underlying these diseases are largely unknown. Our aim is to identify the role of the hairy and enhancer of split-related (Hesr)-2 gene in the adult heart.

METHODS AND RESULTS

Echocardiography detected heart dysfunctions indicative of aortic valve anomalies, stenosis, and regurgitation, in ≈59% of >12-month-old Hesr2 knockout survivor mice. Morphological and histological analyses revealed thickened semilunar valves with increased fibrotic areas, indicating that sclerotic degeneration of valves is the main cause of aortic valve disease. The expression of osteogenic genes, such as osteopontin and sclerostin, were upregulated in the mutants, and the overexpression of sclerostin in endothelial cells resulted in thickened semilunar valves with increased fibrotic areas, similar to that seen in the Hesr2 knockout mice, suggesting that Hesr2 can regulate osteogenic gene expression in valves. Reduced left ventricular function, which may be caused by increased ventricular interstitial fibrosis, and enlarged myocardial cell size without ventricular wall thickening were found in both aortic valve stenosis/regurgitation-positive (33%) and aortic valve stenosis/regurgitation-negative (38%) subpopulations in 12-month-old survivor mice. Dilated left ventricular internal dimensions were specifically detected in the aortic valve stenosis/regurgitation-positive subpopulation, thus suggesting that the degeneration of cardiomyocytes is influenced by irregular hemodynamics.

CONCLUSIONS

These data revealed that survivor mice lacking the Hesr2 gene exhibit fibrosis in the aortic valve and ventricle in adulthood, thus suggesting that Hesr2 plays an important role in maintaining the homeostasis of the aortic valve and ventricle.

Prevalence of valvular regurgitation in adolescent idiopathic scoliosis patients

Sixty-seven adolescent scoliosis patients with thoracic curve (Lenke type 1, 3, and 6) and 16 nonthoracic curve patients (Lenke type 5) were evaluated with color Doppler echocardiography to identify and compare the prevalence and frequency of valvular regurgitation. Regurgitation of one or more valves was detected in 36 thoracic curve patients (53.73%) and seven nonthoracic curve patients (43.75%). Regurgitation with tricuspid valve involvement was statistically significant in patients with thoracic curve (P=0.0216). Frequency of tricuspid valve involvement was statistically significant (28.57 vs. 83.33%, P=0.0076) in patients with thoracic curve. Those without cardiac disease had a higher incidence of valvular regurgitation.

Valvular regurgitation impact on left ventricular 2-dimensional and Doppler echocardiographic indices in patients with essential hypertension

BACKGROUND

Blacks have both a higher hypertension prevalence and accelerated cardiac end organ damage. Because blacks also have a higher prevalence of valvular heart disease, which occurs at a younger age than for whites, we further examined the contribution of valvular regurgitation to the severity of hypertensive heart disease in Nigerians.

METHODS

We evaluated and compared echocardiographic indexes in 75 essential hypertensive Nigerians with (n=48) and without (n=27) valvular regurgitations. Demographic and echocardiographic indices, as well as the types and severity of valvular lesions were compared between the groups using bivariate logistic regression and analysis of variance.

RESULTS

The 2 groups were of similar demographics, but those with regurgitations had larger cardiac size (p < .05), greater mass (147 +/- 31 vs. 122 +/- 32 g/m2, p = .01) higher volume (p < .01), and left atrial size (35.6 +/- 4.6 vs. 33.3 +/- 4.6 mm, p < .05). Atrial size, cardiac volume, and dimension were independent correlates/predictors of regurgitation occurrence. Relative wall thickness of at least 0.6 was more common in regurgitation patients. Cardiac mass was correlated to increasing age (r = 0.23, p = .043). The valvular lesions frequencies were aortic regurgitation, 8; mitral regurgitation, 22; and mixed, 18. The aortic orifice dimension was significantly different among the regurgitant cases, highest in aortic regurgitation (p = .001). Aortic orifice dimension increased with hypertension duration (p = .028).

CONCLUSIONS

Regurgitant lesions are common and occur early in hypertensive Africans. Apparently mild valvular regurgitation may accentuate preclinical concentric hypertrophy in hypertensive blacks.

The heart in sporadic inclusion body myositis: a study in 51 patients

The purpose of this study was to explore the prevalence and nature of cardiac abnormalities in sporadic inclusion body myositis (sIBM). Fifty-one sIBM patients were cross-sectionally studied using history-taking, physical examination, measurements of serum creatine kinase activity, the MB fraction (CK-MB), cardiac troponin T (cTnT) and I (cTnI), a 12-lead electrocardiogram (ECG) and 2-dimensional echocardiography. Present cardiac history was abnormal in 12 (24%) out of 51 patients, 12 (24%) patients had abnormalities on ECG, mostly aspecific, and in 12 (24%) patients the echocardiograph showed abnormalities. Elevated CK-MB was present in 42 (82%) patients and 40 (78%) had an elevated cTnT in the absence of acute cardiac pathology. In contrast, in one patient (2%) cTnI was elevated. There was no apparent association between elevated biomarkers, ECG or echocardiographic abnormalities. The prevalence of cardiac abnormalities in sIBM does not seem to be higher than would be expected in these elderly patients. Elevated CK-MB and cTnT levels are common, in contrast to cTnI, but do not reflect cardiac pathology.

Mutations of NPHP2 and NPHP3 in infantile nephronophthisis

Nephronophthisis is an autosomal recessive chronic tubulointerstitial disease that progresses to end-stage renal disease (ESRD) in about 10% of cases during infancy. Mutations in the INVS (NPHP2) gene were found in a few patients with infantile nephronophthisis. Mutations of NPHP3, known to be associated with adolescent nephronophthisis, were found in two patients with early-onset ESRD. Here we screened 43 families with infantile nephronophthisis (ESRD less than 5 years of age) for NPHP2 and NPHP3 mutations and determined genotype-phenotype correlations. In this cohort there were 16 families with NPHP2 mutations and NPHP3 mutations in seven. Three patients carried only one heterozygous mutation in NPHP3. ESRD arose during the first 2 years of life in 16 of 18 patients with mutations in NPHP2, but in only two patients with mutations in NPHP3. Renal morphology, characterized by hyper-echogenic kidneys on ultrasound and tubular lesions with interstitial fibrosis on histology, was similar in the two patient groups. The kidney sizes were highly diverse and ultrasound-visualized cysts were present in a minority of cases. Extra-renal anomalies were found in 80% of the entire cohort including hepatic involvement (50%), cardiac valve or septal defects (20%) and recurrent bronchial infections (18%). We show that NPHP3 mutations in both infantile and adolescent nephronophthisis point to a common pathophysiological mechanism despite their different clinical presentations.