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Gaidulis G, Padala M. Computational Modeling of the Subject-Specific Effects of Annuloplasty Ring Sizing on the Mitral Valve to Repair Functional Mitral Regurgitation. Ann Biomed Eng 2023; 51:1984-2000. [PMID: 37344691 PMCID: PMC10826925 DOI: 10.1007/s10439-023-03219-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 04/21/2023] [Indexed: 06/23/2023]
Abstract
Surgical repair of functional mitral regurgitation (FMR) that occurs in nearly 60% of heart failure (HF) patients is currently performed with undersizing mitral annuloplasty (UMA), which lacks short- and long-term durability. Heterogeneity in valve geometry makes tailoring this repair to each patient challenging, and predictive models that can help with planning this surgery are lacking. In this study, we present a 3D echo-derived computational model, to enable subject-specific, pre-surgical planning of the repair. Three computational models of the mitral valve were created from 3D echo data obtained in three pigs with HF and FMR. An annuloplasty ring model in seven sizes was created, each ring was deployed, and post-repair valve closure was simulated. The results indicate that large annuloplasty rings (> 32 mm) were not effective in eliminating regurgitant gaps nor in restoring leaflet coaptation or reducing leaflet stresses and chordal tension. Smaller rings (≤ 32 mm) restored better systolic valve closure in all investigated cases,but excessive valve tethering and restricted motion of the leaflets were still present. This computational study demonstrates that for effective correction of FMR, the extent of annular reduction differs between subjects, and overly reducing the annulus has deleterious effects on the valve.
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Affiliation(s)
- Gediminas Gaidulis
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center at Emory University Hospital Midtown, Atlanta, USA
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, USA
| | - Muralidhar Padala
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center at Emory University Hospital Midtown, Atlanta, USA.
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, USA.
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2
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Zhan-Moodie S, Xu D, Suresh KS, He Q, Onohara D, Kalra K, Guyton RA, Sarin EL, Padala M. Papillary muscle approximation reduces systolic tethering forces and improves mitral valve closure in the repair of functional mitral regurgitation. JTCVS OPEN 2021; 7:91-104. [PMID: 35299626 PMCID: PMC8924981 DOI: 10.1016/j.xjon.2021.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background Undersizing mitral annuloplasty (UMA) to repair functional mitral regurgitation (FMR) lacks durability, as it forces leaflet coaptation without relieving the subleaflet tethering forces. In this biomechanical study, we demonstrate that papillary muscle approximation (PMA) before UMA can drastically relieve tethering forces and improve valve function, without the need for significant annular downsizing. Methods An ex vivo model of FMR was used, in which pig mitral valves were geometrically perturbed to induce FMR, and the repairs were performed. Nine pig mitral valves were studied in the following sequence: normal (baseline), FMR, true-sized annuloplasty to 30 mm (true-sized ring [TSR]), and undersized annuloplasty to 26 mm (down-sized ring [DSR]), along with concomitant PMA at both ring sizes. Mitral regurgitation, valve kinematics, and chordal forces were measured and compared among the groups. Results FMR geometry induced a mean regurgitant fraction of 16.31 ± 7.33% compared with 0% at baseline. TSR reduced the regurgitant fraction to 6.05 ± 5.63%, whereas DSR reduced it to 5.06 ± 6.76%. The addition of PMA before the use of these rings reduced the mean regurgitant fraction to 3.87 ± 6.79% with the TSR (TSR + PMA) and 3.71 ± 6.25% with the DSR (DSR + PMA). Mean peak anterior and posterior marginal chordal forces were elevated to 0.09 ± 0.1 N and 0.12 ± 0.1 N, respectively, with FMR and were not reduced by annuloplasty of either sizes. The addition of PMA significantly reduced these forces to 0.23 ± 0.02 N and 0.51 ± 0.04 N. Conclusions This biomechanical study demonstrates that PMA relieves tethering forces, and concomitantly with annuloplasty it mobilizes the leaflets to achieve physiological valve closure. Such a result could be achieved without the need for extensive annular downsizing.
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Pasrija C, Quinn R, Ghoreishi M, Eperjesi T, Lai E, Gorman RC, Gorman JH, Gorman RC, Pouch A, Cortez FV, D'Ambra MN, Gammie JS. A Novel Quantitative Ex Vivo Model of Functional Mitral Regurgitation. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2021; 15:329-337. [PMID: 32830572 DOI: 10.1177/1556984520930336] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Durability of mitral valve (MV) repair for functional mitral regurgitation (FMR) remains suboptimal. We sought to create a highly reproducible, quantitative ex vivo model of FMR that functions as a platform to test novel repair techniques. METHODS Fresh swine hearts (n = 10) were pressurized with air to a left ventricular pressure of 120 mmHg. The left atrium was excised and the altered geometry of FMR was created by radially dilating the annulus and displacing the papillary muscle tips apically and radially in a calibrated fashion. This was continued in a graduated fashion until coaptation was exhausted. Imaging of the MV was performed with a 3-dimensional (3D) structured-light scanner, which records 3D structure, texture, and color. The model was validated using transesophageal echocardiography in patients with normal MVs and severe FMR. RESULTS Compared to controls, the anteroposterior diameter in the FMR state increased 32% and the annular area increased 35% (P < 0.001). While the anterior annular circumference remained fixed, the posterior circumference increased by 20% (P = 0.026). The annulus became more planar and the tenting height increased 56% (9 to 14 mm, P < 0.001). The median coaptation depth significantly decreased (anterior leaflet: 5 vs 2 mm; posterior leaflet: 7 vs 3 mm, P < 0.001). The ex vivo normal and FMR models had similar characteristics as clinical controls and patients with severe FMR. CONCLUSIONS This novel quantitative ex vivo model provides a simple, reproducible, and inexpensive benchtop representation of FMR that mimics the systolic valvular changes of patients with FMR.
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Affiliation(s)
- Chetan Pasrija
- 12264 Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Rachael Quinn
- 12264 Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mehrdad Ghoreishi
- 12264 Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Thomas Eperjesi
- 6572 Department of Surgery, University of Pennsylvania, PA, USA
| | - Eric Lai
- 6572 Department of Surgery, University of Pennsylvania, PA, USA
| | - Robert C Gorman
- 6572 Department of Surgery, University of Pennsylvania, PA, USA
| | - Joseph H Gorman
- 6572 Department of Surgery, University of Pennsylvania, PA, USA
| | - Robert C Gorman
- 6572 Department of Surgery, University of Pennsylvania, PA, USA
| | - Alison Pouch
- 6572 Department of Surgery, University of Pennsylvania, PA, USA
| | - Felino V Cortez
- 12264 Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Michael N D'Ambra
- 12264 Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - James S Gammie
- 12264 Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
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Abstract
PURPOSE OF REVIEW The review summarizes the key parameters that can aid in determining the optimal treatment of ischemic mitral regurgitation (IMR). RECENT FINDINGS Left ventricular (LV) and mitral valve (MV) parameters are important for surgical planning and risk stratification in IMR. Although LV dimensions is one of the main parameters used in the guidelines, volumes more accurately depict LV remodelling. Furthermore, wall motion abnormalities and wall motion score index can also be useful for surgical planning in treatment of IMR. Viability is best measured with cardiac magnetic resonance, but it is not feasible in certain centres. In contrast, measurement of strain with echocardiography is an emerging and feasible tool for estimating viability. MV leaflet tethering and pattern measured with echocardiography are also useful for MV surgery. Anterior leaflet excursion angle can identify patients in whom undersized ring annuloplasty is potentially unsuitable. SUMMARY Treatment of IMR relies on accurate parameters that can determine the optimal surgical approach. In some patients, lack of viable myocardium suggests inadequacy of revascularization and thus, an adjunctive left ventricular reconstruction may be necessary. Degree and pattern of MV leaflet tethering can indicate whether ring annuloplasty, which is the most common repair technique, is sufficient or an adjunctive sub-valvular intervention is beneficial.
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Hagendorff A, Knebel F, Helfen A, Stöbe S, Haghi D, Ruf T, Lavall D, Knierim J, Altiok E, Brandt R, Merke N, Ewen S. Echocardiographic assessment of mitral regurgitation: discussion of practical and methodologic aspects of severity quantification to improve diagnostic conclusiveness. Clin Res Cardiol 2021; 110:1704-1733. [PMID: 33839933 PMCID: PMC8563569 DOI: 10.1007/s00392-021-01841-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 03/08/2021] [Indexed: 12/28/2022]
Abstract
The echocardiographic assessment of mitral valve regurgitation (MR) by characterizing specific morphological features and grading its severity is still challenging. Analysis of MR etiology is necessary to clarify the underlying pathological mechanism of the valvular defect. Severity of mitral regurgitation is often quantified based on semi-quantitative parameters. However, incongruent findings and/or interpretations of regurgitation severity are frequently observed. This proposal seeks to offer practical support to overcome these obstacles by offering a standardized workflow, an easy means to identify non-severe mitral regurgitation, and by focusing on the quantitative approach with calculation of the individual regurgitant fraction. This work also indicates main methodological problems of semi-quantitative parameters when evaluating MR severity and offers appropriateness criteria for their use. It addresses the diagnostic importance of left-ventricular wall thickness, left-ventricular and left atrial volumes in relation to disease progression, and disease-related complaints to improve interpretation of echocardiographic findings. Finally, it highlights the conditions influencing the MR dynamics during echocardiographic examination. These considerations allow a reproducible, verifiable, and transparent in-depth echocardiographic evaluation of MR patients ensuring consistent haemodynamic plausibility of echocardiographic results.
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Affiliation(s)
- Andreas Hagendorff
- Department of Cardiology, Klinik und Poliklinik für Kardiologie, University of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany.
| | - Fabian Knebel
- Department of Cardiology, University of Berlin, Charité Universitätsmedizin Berlin, Campus Mitte, Medizinische Klinik mit Schwerpunkt Kardiologie und Angiologie, Charitéplatz 1, 10117, Berlin, Germany
| | - Andreas Helfen
- Department of Cardiology, Katholisches Klinikum Lünen Werne GmbH, St-Marien-Hospital Lünen, Altstadtstrasse 23, 44534, Lünen, Germany
| | - Stephan Stöbe
- Department of Cardiology, Klinik und Poliklinik für Kardiologie, University of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
| | - Dariush Haghi
- Kardiologische Praxisklinik Ludwigshafen, Akademische Lehrpraxis der Universität Mannheim, Ludwig-Guttmann-Strasse 11, 67071, Ludwigshafen, Germany
| | - Tobias Ruf
- Department of Cardiology, Center of Cardiology, Heart Valve Center, University Medical Center Mainz, University of Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Daniel Lavall
- Department of Cardiology, Klinik und Poliklinik für Kardiologie, University of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
| | - Jan Knierim
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Ertunc Altiok
- Department of Cardiology, University of Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Roland Brandt
- Department of Cardiology, Kerckhoff Heart Center, Benekestr. 2-8, 61231, Bad Nauheim, Germany
| | - Nicolas Merke
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Sebastian Ewen
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Kirrberger Str, IMED, 66421, Homburg, Germany
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6
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Fatima H, Matyal R, Mahmood F, Baribeau Y, Khabbaz KR. Ischemic Mitral Regurgitation: To Fix or Not to Fix. J Cardiothorac Vasc Anesth 2020; 34:2532-2535. [PMID: 32540246 DOI: 10.1053/j.jvca.2020.04.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 04/10/2020] [Accepted: 04/20/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Huma Fatima
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA
| | - Robina Matyal
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA
| | - Feroze Mahmood
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA
| | - Yanick Baribeau
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA
| | - Kamal R Khabbaz
- Department of Surgery, Division of Cardiac Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Calafiore AM, Totaro A, Testa N, Sacra C, Calvo E, Di Mauro M. Association of tethering of the second-order chords and prolapse of the first-order chords of the anterior leaflet: A risk factor for early and late repair failure. J Card Surg 2020; 35:916-919. [PMID: 32073685 DOI: 10.1111/jocs.14469] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND AIM Second-order chord tethering of the anterior leaflet is a risk factor for failure of posterior leaflet prolapse repair. MATERIALS AND METHODS We describe two cases of second-order chord tethering of the anterior leaflet associated with severe mitral regurgitation due to prolapse or chordal rupture of the anterior leaflet, causing early and late failure of repair. RESULTS We described two cases where this phenomenon happened. CONCLUSIONS Our cases demonstrate that the second-order chords of the prolapsing AL can be tethered and that this aspect should be carefully evaluated before surgery, as it can progress over time, affecting the results of surgical repair.
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Affiliation(s)
| | - Antonio Totaro
- Department of Cardiovascular Diseases, Gemelli Molise, Campobasso, Italy
| | - Nicola Testa
- Department of Cardiovascular Diseases, Gemelli Molise, Campobasso, Italy
| | - Cosimo Sacra
- Department of Cardiovascular Diseases, Gemelli Molise, Campobasso, Italy
| | - Eugenio Calvo
- Department of Cardiovascular Diseases, Gemelli Molise, Campobasso, Italy
| | - Michele Di Mauro
- Division of Cardiac Surgery, Gabriele d'Annunzio University, Chieti, Italy
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8
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Pang PYK, Huang MJ, Tan TE, Lim SL, Naik MJ, Chao VTT, Sin YK, Lim CH, Chua YL. Restrictive mitral valve annuloplasty for chronic ischaemic mitral regurgitation: outcomes of flexible versus semi-rigid rings. J Thorac Dis 2020; 11:5096-5106. [PMID: 32030226 DOI: 10.21037/jtd.2019.12.04] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Restrictive mitral annuloplasty is the mainstay of surgical correction of chronic ischaemic mitral regurgitation (CIMR). Long-term data on the various types of annuloplasty rings is limited. The aim of this study was to investigate the clinical and echocardiographic outcomes of restrictive mitral annuloplasty in patients with CIMR, comparing the use of flexible versus semi-rigid annuloplasty rings. Methods A retrospective review was conducted for 133 patients with CIMR who underwent restrictive mitral annuloplasty at our institution between 1999 and 2015. Patient demographics and postoperative outcomes were analyzed. Results Mean age was 61.9±9.2 years and 103 patients (77.4%) were male. All patients underwent coronary artery bypass grafting, with a mean of 3.3±0.8 grafts. Flexible rings was implanted in 39 patients (29.3%, group F) and semi-rigid rings in 94 (70.7%, group R). Preoperative New York Heart Association class was III/IV in 104 patients (78.2%). Mean preoperative left ventricular ejection fraction was 28.8%±10.2%. Preoperative mitral regurgitation was moderate in 51 patients (38.3%) and severe in 82 (61.7%). In-hospital mortality occurred in 11 patients (8.3%). Overall survival at 1, 5 and 10 years were, respectively, 86.4%, 69.7% and 45.9%. At 10 years, overall survival (group F 53.1%, group R 40.0%, P=0.330) and freedom from moderate to severe MR (group F 53.1%, group R 53.8%, P=0.725) did not differ significantly. Freedom from hospitalization for heart failure was 59.3%. Left ventricular reverse remodelling, defined as a reduction of left ventricular end-systolic volume index >15%, occurred more commonly in Group R (51.1%) compared to Group F (23.1%), P=0.003. Conclusions Restrictive mitral annuloplasty was associated with an operative mortality of 8.3%. Heart failure symptoms and significant MR recur in approximately 40% of patients after 10 years. Survival remained suboptimal and was not influenced by the type of annuloplasty ring.
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Affiliation(s)
- Philip Y K Pang
- Department of Cardiothoracic Surgery, National Heart Centre Singapore, Singapore
| | - Ming Jie Huang
- Department of Cardiothoracic Surgery, National Heart Centre Singapore, Singapore
| | - Teing Ee Tan
- Department of Cardiothoracic Surgery, National Heart Centre Singapore, Singapore
| | - See Lim Lim
- Department of Cardiothoracic Surgery, National Heart Centre Singapore, Singapore
| | - Madhava J Naik
- Department of Cardiothoracic Surgery, National Heart Centre Singapore, Singapore
| | - Victor T T Chao
- Department of Cardiothoracic Surgery, National Heart Centre Singapore, Singapore
| | - Yoong Kong Sin
- Department of Cardiothoracic Surgery, National Heart Centre Singapore, Singapore
| | - Chong Hee Lim
- Department of Cardiothoracic Surgery, National Heart Centre Singapore, Singapore.,C H Lim Thoracic Cardiovascular Surgery, Mount Elizabeth Medical Centre, Singapore
| | - Yeow Leng Chua
- Department of Cardiothoracic Surgery, National Heart Centre Singapore, Singapore
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9
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Kim J, Palumbo MC, Khalique OK, Rong LQ, Sultana R, Das M, Jantz J, Nagata Y, Devereux RB, Wong SC, Bergman GW, Levine RA, Ratcliffe MB, Weinsaft JW. Transcatheter MitraClip repair alters mitral annular geometry - device induced annular remodeling on three-dimensional echocardiography predicts therapeutic response. Cardiovasc Ultrasound 2019; 17:31. [PMID: 31878931 PMCID: PMC6933704 DOI: 10.1186/s12947-019-0181-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 12/11/2019] [Indexed: 01/05/2023] Open
Abstract
Background Echocardiography (echo) is widely used to guide therapeutic decision-making for patients being considered for MitraClip. Relative utility of two- (2D) and three-dimensional (3D) echo predictors of MitraClip response, and impact of MitraClip on mitral annular geometry, are uncertain. Methods The study population comprised patients with advanced (> moderate) MR undergoing MitraClip. Mitral annular geometry was quantified on pre-procedural 2D transthoracic echocardiography (TTE) and intra-procedural 3D transesophageal echocardiography (TEE); 3D TEE was used to measure MitraClip induced changes in annular geometry. Optimal MitraClip response was defined as ≤mild MR on follow-up (mean 2.7 ± 2.5 months) post-procedure TTE. Results Eighty patients with advanced MR underwent MitraClip; 41% had optimal response (≤mild MR). Responders had smaller pre-procedural global left ventricular (LV) end-diastolic size and mitral annular diameter on 2D TTE (both p ≤ 0.01), paralleling smaller annular area and circumference on 3D TEE (both p = 0.001). Mitral annular size yielded good diagnostic performance for optimal MitraClip response (AUC 0.72, p < 0.01). In multivariate analysis, sub-optimal MitraClip response was independently associated with larger pre-procedural mitral annular area on 3D TEE (OR 1.93 per cm2/m2 [CI 1.19–3.13], p = 0.007) and global LV end-diastolic volume on 2D TTE (OR 1.29 per 10 ml/m2 [CI 1.02–1.63], p = 0.03). Substitution of 2D TTE derived mitral annular diameter for 3D TEE data demonstrated a lesser association between pre-procedural annular size (OR 5.36 per cm/m2 [CI 0.95–30.19], p = 0.06) and sub-optimal MitraClip response. Matched pre- and post-procedural TEE analyses demonstrated MitraClip to acutely decrease mitral annular area and circumference (all p < 0.001) as well as mitral tenting height, area, and volume (all p < 0.05): Magnitude of MitraClip induced reductions in mitral annular circumference on intra-procedural 3D TEE was greater among patients with, compared to those without, sub-optimal MitraClip response (>mild MR) on followup TTE (p = 0.017); greater magnitude of device-induced annular reduction remained associated with sub-optimal MitraClip response even when normalized for pre-procedure annular circumference (p = 0.028). Conclusions MitraClip alters mitral annular geometry as quantified by intra-procedural 3D TEE. Pre-procedural mitral annular dilation and magnitude of device-induced reduction in mitral annular size on 3D TEE are each associated with sub-optimal therapeutic response to MitraClip.
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Affiliation(s)
- Jiwon Kim
- Department of Medicine (Cardiology), Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10021, USA.
| | - Maria Chiara Palumbo
- Department of Medicine (Cardiology), Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10021, USA.,Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Omar K Khalique
- Division of Cardiology, Columbia University Medical Center, New York, NY, USA
| | - Lisa Q Rong
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Razia Sultana
- Department of Medicine (Cardiology), Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10021, USA
| | - Mukund Das
- Department of Medicine (Cardiology), Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10021, USA
| | - Jennifer Jantz
- Department of Medicine (Cardiology), Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10021, USA
| | - Yasfumi Nagata
- Division of Cardiology -Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard B Devereux
- Department of Medicine (Cardiology), Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10021, USA
| | - Shing Chiu Wong
- Department of Medicine (Cardiology), Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10021, USA
| | - Geoffrey W Bergman
- Department of Medicine (Cardiology), Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10021, USA
| | - Robert A Levine
- Division of Cardiology -Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Mark B Ratcliffe
- Department of Bioengineering, University of California, San Francisco, USA.,Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Jonathan W Weinsaft
- Department of Medicine (Cardiology), Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10021, USA
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10
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Gasior T, Gavazzoni M, Taramasso M, Zuber M, Maisano F. Direct Percutaneous Mitral Annuloplasty in Patients With Functional Mitral Regurgitation: When and How. Front Cardiovasc Med 2019; 6:152. [PMID: 31788478 PMCID: PMC6855240 DOI: 10.3389/fcvm.2019.00152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 10/07/2019] [Indexed: 11/13/2022] Open
Abstract
Mitral regurgitation (MR) is a frequent valvular disease among patients deemed too high risk for surgery. Echocardiography along with CT is the primary diagnostic tool for MR and offers a comprehensive 3D assessment in patient selection and screening for the optimal treatment method. The direct percutaneous mitral annuloplasty addresses the underlying mechanisms of functional MR with a less invasive, catheter-based approach. The here-described techniques proved a sufficient safety profile, delivered significant MR reduction in most of the cases, and were associated with a notable improvement of symptoms. Although long-term outcome assessment is needed to support these early reports, the percutaneous mitral annuloplasty is likely to set a new standard of treatment in the forthcoming future.
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Affiliation(s)
- Tomasz Gasior
- University Heart Center, University Hospital Zurich, Zurich, Switzerland.,Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Mara Gavazzoni
- University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Maurizio Taramasso
- University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Michel Zuber
- University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Francesco Maisano
- University Heart Center, University Hospital Zurich, Zurich, Switzerland
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11
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Functional Mitral Valve Regurgitation. CURRENT CARDIOVASCULAR RISK REPORTS 2019. [DOI: 10.1007/s12170-019-0624-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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12
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Results of Left Ventricular Reconstruction With and Without Mitral Valve Surgery. Ann Thorac Surg 2019; 109:753-761. [PMID: 31472132 DOI: 10.1016/j.athoracsur.2019.07.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 06/22/2019] [Accepted: 07/05/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND This study aims to compare the midterm outcomes of left ventricular reconstruction with those of left ventricular reconstruction plus mitral valve surgery in patients with left ventricular aneurysm due to anterior myocardial infarction and moderate mitral regurgitation. METHODS A total of 523 patients (75 who underwent left ventricular reconstruction plus mitral valve surgery and 448 who underwent left ventricular reconstruction) with concomitant moderate mitral regurgitation were included in the study population. All-cause mortality was considered the primary endpoint. Major adverse cardiovascular and cerebrovascular events, including death, myocardial infarction, stroke, and subsequent mitral valve surgery, were considered secondary endpoints. Multivariable proportional hazards Cox regression models were used to assess the associations between groups and outcomes. In the sensitivity analysis we excluded patients who did not undergo coronary artery bypass graft and repeated the statistical analysis above. RESULTS The median follow-up time among all patients was 41 months. There was no significant difference between the left ventricular reconstruction plus mitral valve surgery and the left ventricular reconstruction groups with regard to all-cause mortality (P = .208) and major adverse cardiovascular and cerebrovascular events (P = .817) after adjustment for covariates. In the sensitivity analysis there was no significant difference between the left ventricular reconstruction plus mitral valve surgery and left ventricular reconstruction groups with regard to all-cause mortality (P = .158) and major adverse cardiovascular and cerebrovascular events (P = .651) after adjustment for covariates. CONCLUSIONS The clinical outcomes of left ventricular reconstruction are comparable with those of left ventricular reconstruction plus mitral valve surgery in patients with left aneurysm and moderate mitral regurgitation.
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Hagendorff A, Doenst T, Falk V. Echocardiographic assessment of functional mitral regurgitation: opening Pandora's box? ESC Heart Fail 2019; 6:678-685. [PMID: 31347297 PMCID: PMC6676284 DOI: 10.1002/ehf2.12491] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 06/11/2019] [Indexed: 12/26/2022] Open
Abstract
Two recent trials of transcatheter mitral-valve repair in patients with functional mitral regurgitation (FMR) presented opposing results for the MitraClip® compared to medical therapy alone. The conflicting results gave rise to intensive discussions about assessment of mitral valve regurgitation (MR). A recent editorial viewpoint provided a potential explanation presenting a new pathophysiologic concept. However, the echocardiographic characterization of both trials' patients is inconsistent and the discussed concepts appear to suffer from plausibility weaknesses. It is well conceivable that limitations in the echocardiographic assessment of the trial patients introduced a bias regarding the selection of patients with severe (or less severe) MR that may be a more plausible explanation for the differences in outcome. We here illustrate our viewpoint regarding the two MitraClip trials and also illustrate the difficulties in assessing functional MR properly. It may indeed be "opening Pandora's box", but we will also make an attempt to provide a solution.
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Affiliation(s)
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Volkmar Falk
- Department of Cardiac Surgery, German Heart Center, Berlin, Germany
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Choudhary SK. "RFEF" & mitral regurgitation jet direction: surrogate markers for likelihood of left ventricle reverse remodelling in patients with moderate chronic ischemic mitral regurgitation. Indian J Thorac Cardiovasc Surg 2019; 35:148-149. [PMID: 33060998 PMCID: PMC7525447 DOI: 10.1007/s12055-018-0765-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 10/18/2018] [Accepted: 10/24/2018] [Indexed: 10/27/2022] Open
Affiliation(s)
- Shiv Kumar Choudhary
- The Department of Cardiothoracic & Vascular Surgery, All India Institute of Medical Science, New Delhi, 110029 India
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Sielicka A, Sarin EL, Shi W, Sulejmani F, Corporan D, Kalra K, Thourani VH, Sun W, Guyton RA, Padala M. Pathological Remodeling of Mitral Valve Leaflets from Unphysiologic Leaflet Mechanics after Undersized Mitral Annuloplasty to Repair Ischemic Mitral Regurgitation. J Am Heart Assoc 2018; 7:e009777. [PMID: 30571381 PMCID: PMC6404183 DOI: 10.1161/jaha.118.009777] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 10/03/2018] [Indexed: 01/24/2023]
Abstract
Background Undersized ring annuloplasty is a commonly used surgical repair for ischemic mitral regurgitation, in which annular downsizing corrects regurgitation, but alters valve geometry and elevates tissue stresses. In this study, we investigated if unphysiological leaflet kinematics after annuloplasty might cause pathogenic biological remodeling of the mitral valve leaflets, and if preserving physiologic leaflet kinematics with a better technique can moderate such adverse remodeling. Methods and Results Twenty-nine swine were induced with ischemic mitral regurgitation, and survivors were assigned to groups: 7 underwent annuloplasty, 12 underwent annuloplasty with papillary-muscle approximation, 6 underwent papillary-muscle approximation, and 3 were sham controls. Pre-and post-surgery leaflet kinematics were measured, and valve tissue was explanted after 3 months to assess biological changes. Anterior leaflet excursion was unchanged across groups, but persistent tethering was observed with annuloplasty. Posterior leaflet was vertically immobile after annuloplasty, better mobile with the combined approach, and substantially ( P=0.0028) mobile after papillary-muscle approximation. Procollagen-1 was higher in leaflets from annuloplasty compared with the other groups. Heat shock protein-47 and lysyl oxidase were higher in groups receiving annuloplasty compared with sham. α- SMA was elevated in leaflets from animals receiving an annuloplasty, indicating activation of quiescent valve interstitial cells, paralleled by elevated transforming growth factor-β expression. Conclusions This is the first study to demonstrate that surgical valve repairs that impose unphysiological leaflet mechanics have a deleterious, pathological impact on valve biology. Surgeons may need to consider restoring physiologic leaflet stresses as well as valve competence, while also exploring pharmacological methods to inhibit the abnormal signaling cascades.
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Affiliation(s)
- Alicja Sielicka
- Structural Heart Research & Innovation LaboratoryCarlyle Fraser Heart CenterEmory University Hospital MidtownAtlantaGA
| | - Eric L. Sarin
- Structural Heart Research & Innovation LaboratoryCarlyle Fraser Heart CenterEmory University Hospital MidtownAtlantaGA
- Department of Cardiothoracic SurgeryInova Heart and Vascular InstituteFairfaxVA
| | - Weiwei Shi
- Structural Heart Research & Innovation LaboratoryCarlyle Fraser Heart CenterEmory University Hospital MidtownAtlantaGA
| | - Fatiesa Sulejmani
- Wallace H. Coulter Department of Biomedical EngineeringGeorgia Institute of TechnologyAtlantaGA
| | - Daniella Corporan
- Structural Heart Research & Innovation LaboratoryCarlyle Fraser Heart CenterEmory University Hospital MidtownAtlantaGA
| | - Kanika Kalra
- Structural Heart Research & Innovation LaboratoryCarlyle Fraser Heart CenterEmory University Hospital MidtownAtlantaGA
| | - Vinod H. Thourani
- Structural Heart Research & Innovation LaboratoryCarlyle Fraser Heart CenterEmory University Hospital MidtownAtlantaGA
- Department of Cardiac SurgeryMedStar Heart and Vascular Institute and Georgetown UniversityWashingtonDC
| | - Wei Sun
- Wallace H. Coulter Department of Biomedical EngineeringGeorgia Institute of TechnologyAtlantaGA
| | - Robert A. Guyton
- Structural Heart Research & Innovation LaboratoryCarlyle Fraser Heart CenterEmory University Hospital MidtownAtlantaGA
- Division of Cardiothoracic SurgeryJoseph P. Whitehead Department of SurgeryEmory University School of MedicineAtlantaGA
| | - Muralidhar Padala
- Structural Heart Research & Innovation LaboratoryCarlyle Fraser Heart CenterEmory University Hospital MidtownAtlantaGA
- Division of Cardiothoracic SurgeryJoseph P. Whitehead Department of SurgeryEmory University School of MedicineAtlantaGA
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Malhotra AK, Evans AS, Weiner MM, Ramakrishna H. Ischemic Mitral Regurgitation: A Paradigm Shift in Surgical Management? J Cardiothorac Vasc Anesth 2018; 32:580-585. [DOI: 10.1053/j.jvca.2017.05.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Indexed: 11/11/2022]
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17
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Mitral valve annuloplasty versus replacement for severe ischemic mitral regurgitation. Sci Rep 2018; 8:1537. [PMID: 29367688 PMCID: PMC5784087 DOI: 10.1038/s41598-018-19909-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 01/08/2018] [Indexed: 11/09/2022] Open
Abstract
Although practice guidelines recommend surgery for patients with severe chronic ischemic mitral regurgitation (CIMR), they do not specify whether to repair or replace the mitral valve. 436 consecutive patients with severe CIMR were eligible for inclusion in the study, of which 316 (72.5%) underwent mitral valve annuloplasty (MVA) whereas 120 (27.5%) received mitral valve replacement (MVR). At 59 months (interquartile range, 37–85 months) follow-up, though the left ventricle end-diastolic diameter was markedly larger (P = 0.019) in the MVA group than in the MVR group, no significant difference was observed in overall survival, freedom from cardiac death, or avoidance of major adverse cardiac or cerebrovascular events (MACCE). MVA provides better results in freedom from cardiac death in subgroups of age ≥65years and left ventricular ejection fraction (EF) ≥50% (P = 0.014 and P = 0.016, respectively), whereas MVR was associated with a lower risk of MACCE in subgroups of age <65years, EF <50% and left ventricular inferior basal wall motion abnormality (BWMA) (all P < 0.05). In conclusion, MVR is a suitable management of patients with severe CIMR, and it is more favorable to ventricular remodeling. The choice of MVA or MVR should depend on major high-risk clinical factors.
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Mitral valve repair for functional regurgitation: Do not miss the last piece of the puzzle! J Thorac Cardiovasc Surg 2017; 154:1258-1259. [PMID: 28651942 DOI: 10.1016/j.jtcvs.2017.05.073] [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: 05/23/2017] [Accepted: 05/23/2017] [Indexed: 11/21/2022]
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Kron IL, LaPar DJ, Acker MA, Adams DH, Ailawadi G, Bolling SF, Hung JW, Lim DS, Mack MJ, O'Gara PT, Parides MK, Puskas JD. 2016 update to The American Association for Thoracic Surgery (AATS) consensus guidelines: Ischemic mitral valve regurgitation. J Thorac Cardiovasc Surg 2017; 153:e97-e114. [DOI: 10.1016/j.jtcvs.2017.01.031] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 01/31/2017] [Indexed: 01/06/2023]
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20
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Topographic mapping of left ventricular regional contractile injury in ischemic mitral regurgitation. J Thorac Cardiovasc Surg 2016; 154:149-158.e1. [PMID: 28109612 DOI: 10.1016/j.jtcvs.2016.11.055] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 10/28/2016] [Accepted: 11/01/2016] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Restrictive leaflet tethering resulting from regional left ventricular (LV) contractile injury causes ischemic mitral regurgitation (MR). We hypothesized that 3-dimensional LV topographic mapping by MRI-based multiparametric strain analysis could characterize the regional contractile injury patterns that differentiate ischemic coronary artery disease patients who have ischemic MR from those who do not. METHODS Magnetic resonance imaging-based multiparametric strain data were calculated for 15,300 LV grid points in 100 normal volunteers. Strain parameters from ischemic MR (n = 10) and ischemic no-MR (n = 36) patients were then normalized to this normal human strain database with z score quantification of standard deviation from the normal mean. Mean multiparametric strain z scores were calculated for 18 LV subregions (basilar/mid/apical levels; 6 LV regions). Mean strain z scores for papillary muscle-related (basilar/mid levels of anterolateral, posterolateral, and posterior) and nonpapillary muscle-related (all other) subregions were compared between ischemic MR and ischemic no-MR groups. RESULTS Across all patients, contractile injury was greater in the papillary muscle-related regions compared with the nonpapillary regions (P = .007). In the papillary regions, contractile injury was greater in the ischemic MR group compared with the no-MR group (z scores, 1.91 ± 1.13 vs 1.20 ± 1.01, respectively; P < .001). Strain values in the nonpapillary muscle-related subregions were not different between the 2 groups (1.31 ± 1.04 vs 1.20 ± 1.03; P = .301). CONCLUSIONS Multiparametric strain analysis demonstrated severe normalized contractile injury in the papillary muscle-related LV subregions in patients with ischemic MR. The mean degree of normalized injury approached 2 standard deviations and was significantly worse than the levels seen in ischemic no-MR patients.
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Wijdh-den Hamer IJ, Bouma W, Lai EK, Levack MM, Shang EK, Pouch AM, Eperjesi TJ, Plappert TJ, Yushkevich PA, Hung J, Mariani MA, Khabbaz KR, Gleason TG, Mahmood F, Acker MA, Woo YJ, Cheung AT, Gillespie MJ, Jackson BM, Gorman JH, Gorman RC. The value of preoperative 3-dimensional over 2-dimensional valve analysis in predicting recurrent ischemic mitral regurgitation after mitral annuloplasty. J Thorac Cardiovasc Surg 2016; 152:847-59. [PMID: 27530639 DOI: 10.1016/j.jtcvs.2016.06.040] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 05/05/2016] [Accepted: 06/10/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Repair for ischemic mitral regurgitation with undersized annuloplasty is characterized by high recurrence rates. We sought to determine the value of pre-repair 3-dimensional echocardiography over 2-dimensional echocardiography in predicting recurrence at 6 months. METHODS Intraoperative transesophageal 2-dimensional echocardiography and 3-dimensional echocardiography were performed in 50 patients undergoing undersized annuloplasty for ischemic mitral regurgitation. Two-dimensional echocardiography annular diameter and tethering parameters were measured in the apical 2- and 4-chamber views. A customized protocol was used to assess 3-dimensional annular geometry and regional leaflet tethering. Recurrence (grade ≥2) was assessed with 2-dimensional transthoracic echocardiography at 6 months. RESULTS Preoperative 2- and 3-dimensional annular geometry were similar in all patients with ischemic mitral regurgitation. Preoperative 2- and 3-dimensional leaflet tethering were significantly higher in patients with recurrence (n = 13) when compared with patients without recurrence (n = 37). Multivariate logistic regression revealed preoperative 2-dimensional echocardiography posterior tethering angle as an independent predictor of recurrence with an optimal cutoff value of 32.0° (area under the curve, 0.81; 95% confidence interval, 0.68-0.95; P = .002) and preoperative 3-dimensional echocardiography P3 tethering angle as an independent predictor of recurrence with an optimal cutoff value of 29.9° (area under the curve, 0.92; 95% confidence interval, 0.84-1.00; P < .001). The predictive value of the 3-dimensional geometric multivariate model can be augmented by adding basal aneurysm/dyskinesis (area under the curve, 0.94; 95% confidence interval, 0.87-1.00; P < .001). CONCLUSIONS Preoperative 3-dimensional echocardiography P3 tethering angle is a stronger predictor of ischemic mitral regurgitation recurrence after annuloplasty than preoperative 2-dimensional echocardiography posterior tethering angle, which is highly influenced by viewing plane. In patients with a preoperative P3 tethering angle of 29.9° or larger (especially when combined with basal aneurysm/dyskinesis), chordal-sparing valve replacement should be strongly considered.
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Affiliation(s)
- Inez J Wijdh-den Hamer
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa; Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Wobbe Bouma
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa; Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Eric K Lai
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa
| | - Melissa M Levack
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa
| | - Eric K Shang
- Department of Surgery, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa
| | - Alison M Pouch
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa
| | - Thomas J Eperjesi
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa
| | - Theodore J Plappert
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa
| | - Paul A Yushkevich
- Department of Radiology, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa
| | - Judy Hung
- Department of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Massimo A Mariani
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Kamal R Khabbaz
- Department of Cardiothoracic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | | | - Feroze Mahmood
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Michael A Acker
- Department of Surgery, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
| | - Albert T Cheung
- Department of Anesthesia, Stanford University, Stanford, Calif
| | - Matthew J Gillespie
- Department of Cardiology, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa
| | - Benjamin M Jackson
- Department of Surgery, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa
| | - Joseph H Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa; Department of Surgery, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa
| | - Robert C Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa; Department of Surgery, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa.
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Kron IL, Acker MA, Adams DH, Ailawadi G, Bolling SF, Hung JW, Lim DS, LaPar DJ, Mack MJ, O'Gara PT, Parides MK, Puskas JD. 2015 The American Association for Thoracic Surgery Consensus Guidelines: Ischemic mitral valve regurgitation. J Thorac Cardiovasc Surg 2016; 151:940-56. [DOI: 10.1016/j.jtcvs.2015.08.127] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 08/03/2015] [Accepted: 08/19/2015] [Indexed: 12/01/2022]
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Surgical ventricular restoration plus mitral valve repair in patients with ischaemic heart failure: risk factors for early and mid-term outcomes. Eur J Cardiothorac Surg 2016; 49:e72-8; discussion e78-9. [DOI: 10.1093/ejcts/ezv478] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 12/04/2015] [Indexed: 11/14/2022] Open
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Acker MA, Dagenais F, Goldstein D, Kron IL, Perrault LP. Severe ischemic mitral regurgitation: Repair or replace? J Thorac Cardiovasc Surg 2015; 150:1425-7. [DOI: 10.1016/j.jtcvs.2015.09.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 09/03/2015] [Indexed: 11/27/2022]
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25
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Suh YJ, Chang BC, Im DJ, Kim YJ, Hong YJ, Hong GR, Kim YJ. Assessment of mitral annuloplasty ring by cardiac computed tomography: Correlation with echocardiographic parameters and comparison between two different ring types. J Thorac Cardiovasc Surg 2015; 150:1082-90. [DOI: 10.1016/j.jtcvs.2015.07.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Revised: 06/25/2015] [Accepted: 07/03/2015] [Indexed: 01/20/2023]
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Crudeli E, Lazzeri C, Stefàno P, Chiostri M, Blanzola C, Rossi A, Olivo G, Pace SD, Gensini GF, Valente S. Age as a Prognostic Factor in Patients with Acute Coronary Syndrome undergoing Urgent/Emergency Cardiac Surgery. Heart Lung Circ 2015; 24:845-53. [PMID: 25769662 DOI: 10.1016/j.hlc.2015.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 02/09/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND Patients presenting with acute coronary syndrome (ACS) who require urgent/emergency coronary artery bypass grafting (CABG) are increasing, as is the complexity of their clinical characteristics, one of which is advanced age. We evaluated the prognostic role of age in patients undergoing urgent/emergency cardiac surgery for ACS. METHODS From January to December 2013, 452 consecutive patients underwent CABG at our institution. Among these, 213 presented with ACS, were enrolled in the study and divided into tertiles of age: First: 40-65 years old (n=73), Second: 66-74 (n=70), Third: 75-89 (n=70). Patients were followed post-operatively for 30 days. RESULTS No differences between tertiles were found for baseline clinical and angiographic characteristics. Off-pump interventions were 67.6%. Older patients more frequently required an associate intervention to CABG for a mechanical complication of ACS. Overall 30-day all-cause mortality was 4.7% (n=10); 0.6% (n=1) in patients undergoing isolated CABG (n=168, 78.9%). The STEMI diagnosis was an independent risk factor for 30-day mortality, and age was not. CONCLUSIONS The 30-day mortality rate of older ACS patients who undergo urgent/emergency CABG is comparable to that of younger ones. Pre-operative risk assessment should rely on evaluation of the clinical complexity of each patient independent of their chronological age, to customise the therapeutic strategy.
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Affiliation(s)
- Elena Crudeli
- Heart and Vessel Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Chiara Lazzeri
- Heart and Vessel Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Pierluigi Stefàno
- Heart and Vessel Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Marco Chiostri
- Heart and Vessel Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Claudio Blanzola
- Heart and Vessel Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Alessandra Rossi
- Heart and Vessel Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Giuseppe Olivo
- Heart and Vessel Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Stefano Del Pace
- Heart and Vessel Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Gian Franco Gensini
- Heart and Vessel Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Serafina Valente
- Heart and Vessel Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
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Dudzinski DM, Hung J. Echocardiographic assessment of ischemic mitral regurgitation. Cardiovasc Ultrasound 2014; 12:46. [PMID: 25416497 PMCID: PMC4277822 DOI: 10.1186/1476-7120-12-46] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 10/10/2014] [Indexed: 12/13/2022] Open
Abstract
Ischemic mitral regurgitation is an important consequence of LV remodeling after myocardial infarction. Echocardiographic diagnosis and assessment of ischemic mitral regurgitation are critical to gauge its adverse effects on prognosis and to attempt to tailor rational treatment strategy. There is no single approach to the echocardiographic assessment of ischemic mitral regurgitation: standard echocardiographic measures of mitral regurgitation severity and of LV dysfunction are complemented by assessments of displacement of the papillary muscles and quantitative indices of mitral valve deformation. Development of novel approaches to understand mitral valve geometry by echocardiography may improve understanding of the mechanism, clinical trajectory, and reparability of ischemic mitral regurgitation.
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Affiliation(s)
| | - Judy Hung
- Echocardiography Laboratory, Cardiology Division, Massachusetts General Hospital, Boston, MA 02114, USA.
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Predicting recurrent mitral regurgitation after mitral valve repair for severe ischemic mitral regurgitation. J Thorac Cardiovasc Surg 2014; 149:752-61.e1. [PMID: 25500293 DOI: 10.1016/j.jtcvs.2014.10.120] [Citation(s) in RCA: 158] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 10/14/2014] [Accepted: 10/30/2014] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The Cardiothoracic Surgical Trials Network recently reported no difference in the primary end point of left ventricular end-systolic volume index at 1 year postsurgery in patients randomized to repair (n = 126) or replacement (n = 125) for severe ischemic mitral regurgitation. However, patients undergoing repair experienced significantly more recurrent mitral regurgitation than patients undergoing replacement (32.6% vs 2.3%). We examined whether baseline echocardiographic and clinical characteristics could identify those who will develop moderate/severe recurrent mitral regurgitation or die. METHODS Our analysis includes 116 patients who were randomized to and received mitral valve repair. Logistic regression was used to estimate a model-based probability of recurrence or death from baseline factors. Receiver operating characteristic curves were constructed from these estimated probabilities to determine classification cut-points maximizing accuracy of prediction based on sensitivity and specificity. RESULTS Of the 116 patients, 6 received a replacement before leaving the operating room; all other patients had mild or less mitral regurgitation on intraoperative echocardiogram after repair. During the 2-year follow-up period, 76 patients developed moderate/severe mitral regurgitation or died (53 mitral regurgitation recurrences, 13 mitral regurgitation recurrences and death, and 10 deaths). The mechanism for recurrent mitral regurgitation was largely mitral valve leaflet tethering. Our model (including age, body mass index, sex, race, effective regurgitant orifice area, basal aneurysm/dyskinesis, New York Heart Association class, history of coronary artery bypass grafting, percutaneous coronary intervention, or ventricular arrhythmias) yielded an area under the receiver operating characteristic curve of 0.82. CONCLUSIONS The model demonstrated good discrimination in identifying patients who will survive 2 years without recurrent mitral regurgitation after mitral valve repair. Although our results require validation, they offer a clinically relevant risk score for selection of surgical candidates for this procedure.
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29
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Zeng X, Nunes MCP, Dent J, Gillam L, Mathew JP, Gammie JS, Ascheim DD, Moquete E, Hung J. Asymmetric versus symmetric tethering patterns in ischemic mitral regurgitation: geometric differences from three-dimensional transesophageal echocardiography. J Am Soc Echocardiogr 2014; 27:367-75. [PMID: 24513242 DOI: 10.1016/j.echo.2014.01.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Ischemic mitral regurgitation (IMR) results from mitral leaflet tethering from left ventricular remodeling. Heterogeneity in local or global left ventricular remodeling can result in differential tethering patterns and affect mitral valve function and the degree of mitral regurgitation. The aims of this study were to compare mitral valve geometry in asymmetric and symmetric tethering patterns using three-dimensional transesophageal echocardiography and to examine the impact of tethering pattern on IMR severity. METHODS Sixty-two patients with moderate or greater IMR underwent three-dimensional transesophageal echocardiography for the assessment of mitral valve geometry. Symmetric and asymmetric tethering patterns were determined by mitral regurgitation jet direction and coaptation of the mitral leaflets. The ratio of posterior to anterior leaflet tethering angle was a measure of tethering pattern (the higher the ratio, the more asymmetric the pattern). Overall tethering degree was assessed by tenting volume (TV). RESULTS Compared with the symmetric group, the asymmetric group had less annular dilatation, greater annular heights (10.3 ± 1.9 vs 8.5 ± 1.9 mm, P < .01), greater ratios of posterior to anterior leaflet tethering angle (3.19 ± 0.88 vs 1.95 ± 0.46, P < .01), and smaller TVs with more posterior displacement of the coaptation line. Vena contracta normalized to TV was greater in the asymmetric group (0.38 ± 0.24 vs 0.19 ± 0.13 cm/mL, P < .01). Multivariate analysis showed that both ratio of posterior to anterior leaflet tethering angle (β = 0.46, P < .001) and TV (β = 0.41, P = .001) were predictors of IMR severity. CONCLUSIONS Differences in mitral valve geometry are observed between asymmetric and symmetric tethering patterns in IMR. IMR degree is affected by both the pattern of tethering and the total degree of tethering. For the same degree of tethering, an asymmetric pattern is associated with increased MR severity. The pattern of mitral leaflet tethering may be considered in therapeutic decision making.
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Affiliation(s)
- Xin Zeng
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Boston, Massachusetts
| | - Maria Carmo P Nunes
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Boston, Massachusetts
| | - John Dent
- Cardiovascular Division, University of Virginia, Charlottesville, Virginia
| | - Linda Gillam
- Cardiovascular Medicine, Atlantic Health System, Morristown, New Jersey
| | - Joseph P Mathew
- Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - James S Gammie
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Deborah D Ascheim
- Department of Health Evidence and Policy, Mount Sinai School of Medicine, New York, New York; Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ellen Moquete
- Department of Health Evidence and Policy, Mount Sinai School of Medicine, New York, New York
| | - Judy Hung
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Boston, Massachusetts.
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Magne J, Pibarot P. Left Ventricular Systolic Function in Ischemic Mitral Regurgitation: Time to Look beyond Ejection Fraction. J Am Soc Echocardiogr 2013; 26:1130-1134. [DOI: 10.1016/j.echo.2013.08.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Gelsomino S, van Garsse L, Lucà F, Parise O, Cheriex E, Rao CM, Gensini GF, Maessen J. Left ventricular strain in chronic ischemic mitral regurgitation in relation to mitral tethering pattern. J Am Soc Echocardiogr 2013; 26:370-380.e11. [PMID: 23415836 DOI: 10.1016/j.echo.2013.01.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Indexed: 11/17/2022]
Abstract
BACKGROUND The aim of this retrospective study was to explore whether different tethering patterns in chronic ischemic mitral regurgitation have different distributions of left ventricular (LV) systolic longitudinal, circumferential, and radial strain before and after mitral valve repair. METHODS Sixty-one patients with chronic ischemic mitral regurgitation who underwent mitral repair were divided on the basis of the preoperative anterior/posterior tethering angle ratio (cutoff value, 0.76). There were 29 patients with symmetric (group 1) and 32 with asymmetric (group 2) preoperative tethering patterns. Assessment of longitudinal peak systolic strain was performed offline by applying speckle-tracking imaging to the apical two-chamber, three-chamber, and four-chamber views of the left ventricle. Peak systolic radial and circumferential strain was obtained from short-axis views at the basal, middle, and apical levels. Twenty healthy subjects served as controls. RESULTS In group 1, baseline LV strain was impaired in all LV segments, with the worst values in the anterolateral, anterior, and inferolateral segments at the midventricular and basal levels. In contrast, asymmetric patients showed higher values in the inferior and inferoseptal walls and values closer to normal in the other segments. After surgery, all strain measurements showed significant improvements in all LV segments in group 2, whereas in Group 1, strain worsened in the inferoseptal, inferior, and anteroseptal walls and did not change in the other segments. CONCLUSIONS Patients with baseline symmetric tethering patterns showed more extensive abnormal strain, which was observed in all LV segments and was not reverted by surgery. These findings require confirmation in additional larger studies.
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Affiliation(s)
- Sandro Gelsomino
- Department of Heart and Vessels, Careggi Hospital, Florence, Italy.
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van Garsse L, Gelsomino S, Cheriex E, Lucà F, Rao CM, Parise O, Gensini GF, Maessen J. Tethering Symmetry Reflects Advanced Left Ventricular Mechanical Dyssynchrony in Patients With Ischemic Mitral Regurgitation Undergoing Restrictive Mitral Valve Repair. Ann Thorac Surg 2012; 94:1418-28. [DOI: 10.1016/j.athoracsur.2012.05.099] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Revised: 05/22/2012] [Accepted: 05/25/2012] [Indexed: 11/30/2022]
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van Garsse L, Gelsomino S, Lucà F, Parise O, Cheriex E, Rao CM, Gensini GF, Maessen JG. Left atrial strain and strain rate before and following restrictive annuloplasty for ischaemic mitral regurgitation evaluated by two-dimensional speckle tracking echocardiography. Eur Heart J Cardiovasc Imaging 2012; 14:534-43. [PMID: 23053854 DOI: 10.1093/ehjci/jes206] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS We retrospectively evaluated left atrial (LA) strain and strain rate (SR) before and after undersized mitral ring annuloplasty (UMRA) for chronic ischaemic mitral regurgitation (CIMR) with two-dimensional speckle-tracking echocardiography. METHODS AND RESULTS Left atrial volumes, LA reservoir, LA conduit, LA contractile phases, and LA ejection fraction (LAEF) were measured in 95 CIMR patients who underwent coronary bypass grafting and UMRA. Left atrial peak global strain (ε), LA reservoir (SRp), LA conduit (SRE), and LA contractile phase (SRA) strain rates were obtained at the baseline and at the follow-up (median 41.5 months, interquartile range 23-61). Based on the recurrence of mitral regurgitation (MR) at the follow-up, the patients were divided into two groups: patients with (group MR+, n = 30) or without (group MR-, n = 65) recurrent MR. Twenty age-and gender-matched healthy adults were controls. In the MR- group, baseline ε (P < 0.001), SRP (P < 0.001), SRE (P < 0.001), and SRA (P < 0.001) were enhanced, while in MR+ group, ε (P < 0.001), SRP (P = 0.03), SRE (P = 0.03), and SRA (P = 0.003) were worse than controls. At the follow-up, none of these indices changed in the MR+ group while all returned to normal values in patients belonging to the MR- group. Left atrial deformation correlated with corresponding volumetric parameters. Furthermore, we found a direct correlation between SRE and early peak diastolic velocity (E) (ρ = 0.52, P = 0.02) and E-wave deceleration time (ρ = 0.50, P = 0.02). Finally, there was a strong correlation between ε, SRP, and SRA (ρ = 0.72, P < 0.001 and ρ = 0.79, P < 0.001, respectively) and SRE (ρ = 0.69, P < 0.001 and ρ = 0.71, P < 0.001, respectively). Finally, ε, SRP, and SRE (all, P < 0.001) were co-factors associated to recurrent MR. CONCLUSION Left atrial peak global strain, peak systolic SR, and peak early diastolic SR were cofactors associated to recurrent MR. The assessment of LA strain and SR, in addition to other echocardiographic parameters, can be helpful in detecting patients undergoing UMRA who are unlikely to benefit from annuloplasty.
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Affiliation(s)
- Leen van Garsse
- Department of Cardiothoracic Surgery, University Hospital, Maastricht, The Netherlands
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van Garsse L, Gelsomino S, Parise O, Lucà F, Cheriex E, Lorusso R, Vizzardi E, Rao CM, Gensini GF, Maessen J. Systolic Papillary Muscle Dyssynchrony Predicts Recurrence of Mitral Regurgitation in Patients with Ischemic Cardiomyopathy (ICM) Undergoing Mitral Valve Repair. Echocardiography 2012; 29:1191-200. [DOI: 10.1111/j.1540-8175.2012.01789.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Leen van Garsse
- Department of Cardiothoracic Surgery; University Hospital; Maastricht; The Netherlands
| | | | - Orlando Parise
- Department of Heart and Vessels; Careggi Hospital; Florence; Italy
| | - Fabiana Lucà
- Department of Heart and Vessels; Careggi Hospital; Florence; Italy
| | - Emile Cheriex
- Department of Cardiothoracic Surgery; University Hospital; Maastricht; The Netherlands
| | | | | | | | | | - Jos Maessen
- Department of Cardiothoracic Surgery; University Hospital; Maastricht; The Netherlands
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Unger P, Magne J, Dedobbeleer C, Lancellotti P. Ischemic mitral regurgitation: not only a bystander. Curr Cardiol Rep 2012; 14:180-9. [PMID: 22203438 DOI: 10.1007/s11886-011-0241-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Ischemic mitral regurgitation (MR) is a common complication of left ventricular (LV) dysfunction related to chronic coronary artery disease. This complex multifactorial disease involves global and regional LV remodeling, as well as dysfunction and distortion of the components of the mitral valve including the chordae, the annulus, and the leaflets. Its occurrence is associated with a poor prognosis. The suboptimal results obtained with the most commonly used surgical strategy, involving mitral valve annuloplasty with coronary bypass grafting, emphasize the need to develop alternative surgical techniques targeting the causal mechanisms of the disease. A comprehensive preoperative assessment of mitral valve configuration and LV geometry and function and an accurate quantification of MR severity at rest and during exercise may contribute to improve risk stratification and to tailor the surgical strategy according to the individual characteristics of the patient.
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Affiliation(s)
- Philippe Unger
- Cardiology Department, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.
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Yoshida K, Obase K. Assessment of Mitral Valve Complex by Three-Dimensional Echocardiography: Therapeutic Strategy for Functional Mitral Regurgitation. J Cardiovasc Ultrasound 2012; 20:69-76. [PMID: 22787522 PMCID: PMC3391630 DOI: 10.4250/jcu.2012.20.2.69] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2012] [Revised: 05/31/2012] [Accepted: 05/31/2012] [Indexed: 12/04/2022] Open
Abstract
The mitral valve complex is consisted of annulus, leaflets, chordae tendineae, papillary muscle (PMs) and surrounding left ventricle. Functional mitral regurgitation (MR) results from left ventricular remodeling such as dilatation or distortion, which displaces the PMs and then tethers the mitral leaflets, restricting leaflet coaptation. Undersized annuloplasty, which has been widely accepted as a simple and effective procedure for functional MR, sometimes worsens the tethering of posterior leaflet and induces recurrent MR. In order to overcome such problems, several additional procedures to the simple annuloplasty have been produced. Three dimensional echocardiography plays an essential role to understand the geometry of mitral valve complex and contributes greatly to decision making of the surgical strategy in functional MR and its postoperative assessment.
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Affiliation(s)
- Kiyoshi Yoshida
- Department of Cardiology, Kawasaki Medical School, Kurashiki, Japan
| | - Kikuko Obase
- Department of Cardiology, Kawasaki Medical School, Kurashiki, Japan
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