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Joury A, Duran A, Stewart M, Gilliland YE, Spindel SM, Qamruddin S. Prosthesis-patient mismatch following aortic and mitral valves replacement – A comprehensive review. Prog Cardiovasc Dis 2022; 72:84-92. [PMID: 35235847 DOI: 10.1016/j.pcad.2022.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 02/22/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Abdulaziz Joury
- Department of Cardiology, Ochsner Medical Center, New Orleans, LA, United States of America; King Salman Heart Center, King Fahad Medical City, Riyadh, Saudi Arabia.
| | - Antonio Duran
- Department of Cardiology, Ochsner Medical Center, New Orleans, LA, United States of America; Ochsner Clinical School, New Orleans, LA, United States of America.
| | - Merrill Stewart
- Department of Cardiology, Ochsner Medical Center, New Orleans, LA, United States of America; Ochsner Clinical School, New Orleans, LA, United States of America.
| | - Yvonne E Gilliland
- Department of Cardiology, Ochsner Medical Center, New Orleans, LA, United States of America; Ochsner Clinical School, New Orleans, LA, United States of America
| | - Stephen M Spindel
- Ochsner Clinical School, New Orleans, LA, United States of America; Division of Cardiothoracic Surgery, Ochsner Medical Center, New Orleans, LA, United States of America.
| | - Salima Qamruddin
- Department of Cardiology, Ochsner Medical Center, New Orleans, LA, United States of America; Ochsner Clinical School, New Orleans, LA, United States of America.
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Kitada Y, Arakawa M, Okamura H, Akiyoshi K, Hori D, Kimura N, Yamaguchi A. Impact of prosthesis-patient mismatch on late outcomes after bioprosthetic mitral valve replacement for mitral regurgitation. J Artif Organs 2021; 25:132-139. [PMID: 34665354 DOI: 10.1007/s10047-021-01299-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 10/06/2021] [Indexed: 10/20/2022]
Abstract
Negative impact of prosthesis-patient mismatch on long-term survival after valve replacement has been reported. However, the effect of prosthesis-patient mismatch after bioprosthetic mitral valve replacement has not yet been well examined. The purpose of this study was to investigate the effect of prosthesis-patient mismatch on late outcomes after bioprosthetic mitral valve replacement for mitral regurgitation. A total of 181 patients underwent bioprosthetic mitral valve replacement between April 2008 and December 2016. After excluding patients with mitral stenosis and those with incomplete data, 128 patients were included in the study. Postoperative transthoracic echocardiography was performed before discharge for all patients and the effective orifice area of bioprosthetic mitral valve was calculated using the formula: 220/pressure half-time, and the effective orifice area index was calculated by the formula: effective orifice area/body surface area. Prosthesis-patient mismatch was defined as a postoperative effective orifice area index ≤ 1.2 cm2/m2. The characteristics and outcomes were compared between the groups. There were 34 patients (26.6%) with prosthesis-patient mismatch and 94 patients (73.4%) without prosthesis-patient mismatch. There were no significant differences in the in-hospital mortality and morbidities. Multivariable analysis showed that prosthesis-patient mismatch was an independent predictor of late mortality (hazard ratio 3.38; 95% confidence interval 1.69-6.75; p = 0.001) and death from heart failure (hazard ratio 31.03, 95% confidence interval 4.49-214.40, p < 0.001). Prosthesis-patient mismatch at discharge after mitral valve replacement for mitral regurgitation was associated with long-term mortality and death from heart failure.
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Affiliation(s)
- Yuichiro Kitada
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, 1-847, Amanuma-cho, Omiya-ku, Saitama-shi, Saitama, 330-8503, Japan.
| | - Mamoru Arakawa
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, 1-847, Amanuma-cho, Omiya-ku, Saitama-shi, Saitama, 330-8503, Japan
| | - Homare Okamura
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, 1-847, Amanuma-cho, Omiya-ku, Saitama-shi, Saitama, 330-8503, Japan.
| | - Kei Akiyoshi
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, 1-847, Amanuma-cho, Omiya-ku, Saitama-shi, Saitama, 330-8503, Japan
| | - Daijiro Hori
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, 1-847, Amanuma-cho, Omiya-ku, Saitama-shi, Saitama, 330-8503, Japan
| | - Naoyuki Kimura
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, 1-847, Amanuma-cho, Omiya-ku, Saitama-shi, Saitama, 330-8503, Japan
| | - Atsushi Yamaguchi
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, 1-847, Amanuma-cho, Omiya-ku, Saitama-shi, Saitama, 330-8503, Japan
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Gopal A, Sharma T, Calkins JB. Safety of Phosphodiesterase-5 Inhibitors in Valvular Heart Disease. J Cardiovasc Pharmacol 2021; 78:372-376. [PMID: 34074904 DOI: 10.1097/fjc.0000000000001071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 05/16/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Erectile dysfunction is a common entity in clinical practice. Primary erectile dysfunction, not related to vasculopathy or psychiatric disorder, can be readily treated with phosphodiesterase inhibitors. These drugs have many physiologic effects that can alter a patient's hemodynamic profile considerably, especially in the presence of concomitant structural heart disease, specifically valvular heart disease. Although some contraindications to the use of PDE5 inhibitors in patients with cardiovascular disease are defined, the effect of these drugs in the presence of valvular heart disease is not well documented. The purpose of this review is to analyze the data regarding the safety of PDE5 inhibitors in patients with valvular heart disease.
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Affiliation(s)
- Aaron Gopal
- Division of Cardiology, Medical College of Georgia at Augusta University
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Xu F, Johnson EL, Wang C, Jafari A, Yang CH, Sacks MS, Krishnamurthy A, Hsu MC. Computational investigation of left ventricular hemodynamics following bioprosthetic aortic and mitral valve replacement. MECHANICS RESEARCH COMMUNICATIONS 2021; 112:103604. [PMID: 34305195 PMCID: PMC8301225 DOI: 10.1016/j.mechrescom.2020.103604] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
The left ventricle of the heart is a fundamental structure in the human cardiac system that pumps oxygenated blood into the systemic circulation. Several valvular conditions can cause the aortic and mitral valves associated with the left ventricle to become severely diseased and require replacement. However, the clinical outcomes of such operations, specifically the postoperative ventricular hemodynamics of replacing both valves, are not well understood. This work uses computational fluid-structure interaction (FSI) to develop an improved understanding of this effect by modeling a left ventricle with the aortic and mitral valves replaced with bioprostheses. We use a hybrid Arbitrary Lagrangian-Eulerian/immersogeometric framework to accommodate the analysis of cardiac hemodynamics and heart valve structural mechanics in a moving fluid domain. The motion of the endocardium is obtained from a cardiac biomechanics simulation and provided as an input to the proposed numerical framework. The results from the simulations in this work indicate that the replacement of the native mitral valve with a tri-radially symmetric bioprosthesis dramatically changes the ventricular hemodynamics. Most significantly, the vortical motion in the left ventricle is found to reverse direction after mitral valve replacement. This study demonstrates that the proposed computational FSI framework is capable of simulating complex multiphysics problems and can provide an in-depth understanding of the cardiac mechanics.
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Affiliation(s)
- Fei Xu
- Ansys Inc., Austin, TX 78746, USA
| | - Emily L. Johnson
- Department of Mechanical Engineering, Iowa State University, Ames, IA 50011, USA
| | | | - Arian Jafari
- Department of Mechanical Engineering, Iowa State University, Ames, IA 50011, USA
| | - Cheng-Hau Yang
- Department of Mechanical Engineering, Iowa State University, Ames, IA 50011, USA
| | - Michael S. Sacks
- Oden Institute for Computational Engineering and Sciences, The University of Texas at Austin, Austin, TX 78712, USA
- Department of Biomedical Engineering, The University of Texas at Austin, Austin, TX 78712, USA
| | - Adarsh Krishnamurthy
- Department of Mechanical Engineering, Iowa State University, Ames, IA 50011, USA
| | - Ming-Chen Hsu
- Department of Mechanical Engineering, Iowa State University, Ames, IA 50011, USA
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Bermejo J, González-Mansilla A, Mombiela T, Fernández AI, Martínez-Legazpi P, Yotti R, García-Orta R, Sánchez-Fernández PL, Castaño M, Segovia-Cubero J, Escribano-Subias P, Alberto San Román J, Borrás X, Alonso-Gómez A, Botas J, Crespo-Leiro MG, Velasco S, Bayés-Genís A, López A, Muñoz-Aguilera R, Jiménez-Navarro M, González-Juanatey JR, Evangelista A, Elízaga J, Martín-Moreiras J, González-Santos JM, Moreno-Escobar E, Fernández-Avilés F. Persistent Pulmonary Hypertension in Corrected Valvular Heart Disease: Hemodynamic Insights and Long-Term Survival. J Am Heart Assoc 2021; 10:e019949. [PMID: 33399006 PMCID: PMC7955299 DOI: 10.1161/jaha.120.019949] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background The determinants and consequences of pulmonary hypertension after successfully corrected valvular heart disease remain poorly understood. We aim to clarify the hemodynamic bases and risk factors for mortality in patients with this condition. Methods and Results We analyzed long-term follow-up data of 222 patients with pulmonary hypertension and valvular heart disease successfully corrected at least 1 year before enrollment who had undergone comprehensive hemodynamic and imaging characterization as per the SIOVAC (Sildenafil for Improving Outcomes After Valvular Correction) clinical trial. Median (interquartile range) mean pulmonary pressure was 37 mm Hg (32-44 mm Hg) and pulmonary artery wedge pressure was 23 mm Hg (18-26 mm Hg). Most patients were classified either as having combined precapillary and postcapillary or isolated postcapillary pulmonary hypertension. After a median follow-up of 4.5 years, 91 deaths accounted for 4.21 higher-than-expected mortality in the age-matched population. Risk factors for mortality were male sex, older age, diabetes mellitus, World Health Organization functional class III and higher pulmonary vascular resistance-either measured by catheterization or approximated from ultrasound data. Higher pulmonary vascular resistance was related to diabetes mellitus and smaller residual aortic and mitral valve areas. In turn, the latter correlated with prosthetic nominal size. Six-month changes in the composite clinical score and in the 6-minute walk test distance were related to survival. Conclusions Persistent valvular heart disease-pulmonary hypertension is an ominous disease that is almost universally associated with elevated pulmonary artery wedge pressure. Pulmonary vascular resistance is a major determinant of mortality in this condition and is related to diabetes mellitus and the residual effective area of the corrected valve. These findings have important implications for individualizing valve correction procedures. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT00862043.
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Affiliation(s)
- Javier Bermejo
- Hospital General Universitario Gregorio MarañónInstituto de Investigación Sanitaria Gregorio MarañónFacultad de Medicina, Universidad Complutense de Madrid, and CIBERCV Madrid Spain
| | - Ana González-Mansilla
- Hospital General Universitario Gregorio MarañónInstituto de Investigación Sanitaria Gregorio MarañónFacultad de Medicina, Universidad Complutense de Madrid, and CIBERCV Madrid Spain
| | - Teresa Mombiela
- Hospital General Universitario Gregorio MarañónInstituto de Investigación Sanitaria Gregorio MarañónFacultad de Medicina, Universidad Complutense de Madrid, and CIBERCV Madrid Spain
| | - Ana I Fernández
- Hospital General Universitario Gregorio MarañónInstituto de Investigación Sanitaria Gregorio MarañónFacultad de Medicina, Universidad Complutense de Madrid, and CIBERCV Madrid Spain
| | - Pablo Martínez-Legazpi
- Hospital General Universitario Gregorio MarañónInstituto de Investigación Sanitaria Gregorio MarañónFacultad de Medicina, Universidad Complutense de Madrid, and CIBERCV Madrid Spain
| | | | | | | | | | | | | | | | - Xavier Borrás
- Hospital Santa Creu i San Pau and CIBERCV Barcelona Spain
| | | | - Javier Botas
- Hospital Universitario Fundación Alcorcón Alcorcón Spain
| | | | | | | | - Amador López
- Hospital Universitario Reina Sofía Córdoba Spain
| | | | | | | | | | - Jaime Elízaga
- Hospital General Universitario Gregorio MarañónInstituto de Investigación Sanitaria Gregorio MarañónFacultad de Medicina, Universidad Complutense de Madrid, and CIBERCV Madrid Spain
| | | | | | | | - Francisco Fernández-Avilés
- Hospital General Universitario Gregorio MarañónInstituto de Investigación Sanitaria Gregorio MarañónFacultad de Medicina, Universidad Complutense de Madrid, and CIBERCV Madrid Spain
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Ghaffar FA, Redzuan AM, Makmor-Bakry M. Effectiveness of Sildenafil in Pulmonary Hypertension Secondary to Valvular Heart Disease: A Systematic Review and Meta-Analysis. ARCHIVES OF PHARMACY PRACTICE 2021. [DOI: 10.51847/tcievrcfgf] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Pulmonary Hypertension in Heart Failure. INTERNATIONAL JOURNAL OF HEART FAILURE 2021; 3:147-159. [PMID: 36262642 PMCID: PMC9536651 DOI: 10.36628/ijhf.2020.0053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 03/19/2021] [Accepted: 03/26/2021] [Indexed: 11/18/2022]
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Tomšič A, Arabkhani B, Schoones JW, Etnel JRG, Marsan NA, Klautz RJM, Palmen M. Prosthesis-patient mismatch after mitral valve replacement: A pooled meta-analysis of Kaplan-Meier-derived individual patient data. J Card Surg 2020; 35:3477-3485. [PMID: 33085138 PMCID: PMC7756724 DOI: 10.1111/jocs.15108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 07/26/2020] [Accepted: 08/20/2020] [Indexed: 11/30/2022]
Abstract
Objective The hemodynamic effect and early and late survival impact of prosthesis–patient mismatch (PPM) after mitral valve replacement remains insufficiently explored. Methods Pubmed, Embase, Web of Science, and Cochrane Library databases were searched for English language original publications. The search yielded 791 potentially relevant studies. The final review and analysis included 19 studies compromising 11,675 patients. Results Prosthetic effective orifice area was calculated with the continuity equation method in 7 (37%), pressure half‐time method in 2 (10%), and partially or fully obtained from referenced values in 10 (53%) studies. Risk factors for PPM included gender (male), diabetes mellitus, chronic renal disease, and the use of bioprostheses. When pooling unadjusted data, PPM was associated with higher perioperative (odds ratio [OR]: 1.66; 95% confidence interval [CI]: 1.32–2.10; p < .001) and late mortality (hazard ratio [HR]: 1.46; 95% CI: 1.21–1.77; p < .001). Moreover, PPM was associated with higher late mortality when Cox proportional‐hazards regression (HR: 1.97; 95% CI: 1.57–2.47; p < .001) and propensity score (HR: 1.99; 95% CI: 1.34–2.95; p < .001) adjusted data were pooled. Contrarily, moderate (HR: 1.01; 95% CI: 0.84–1.22; p = .88) or severe (HR: 1.19; 95% CI: 0.89–1.58; p = .24) PPM were not related to higher late mortality when adjusted data were pooled individually. PPM was associated with higher systolic pulmonary pressures (mean difference: 7.88 mmHg; 95% CI: 4.72–11.05; p < .001) and less pulmonary hypertension regression (OR: 5.78; 95% CI: 3.33–10.05; p < .001) late after surgery. Conclusions Mitral valve PPM is associated with higher postoperative pulmonary artery pressure and might impair perioperative and overall survival. The relation should be further assessed in properly designed studies.
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Affiliation(s)
- Anton Tomšič
- Department of Cardiothoracic Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Bardia Arabkhani
- Department of Cardiothoracic Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Jan W Schoones
- Walaeus Library, Leiden University Medical Centre, Leiden, The Netherlands
| | - Jonathan R G Etnel
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Nina A Marsan
- Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Robert J M Klautz
- Department of Cardiothoracic Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Meindert Palmen
- Department of Cardiothoracic Surgery, Leiden University Medical Centre, Leiden, The Netherlands
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Palanisamy V, Raman K, Rajakumar AP, Mohanraj A, Jamesraj J, Sheriff EA, Kurian VM, Sethuratnam R. Weight gain potential-a neglected entity during valve replacement. Indian J Thorac Cardiovasc Surg 2020; 36:21-27. [PMID: 33061090 DOI: 10.1007/s12055-019-00838-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 04/09/2019] [Accepted: 05/06/2019] [Indexed: 11/25/2022] Open
Abstract
Introduction During valve replacement, appropriate valve size will be chosen based on many factors, neglecting the potential of the patient for gaining weight. We aimed at evaluating the weight gain potential and its effect on hemodynamics in post mitral valve replacement (MVR) patients. Material and methods In 118 post-MVR patients, demographic and echocardiographic data at the time of discharge and follow-up were obtained and analyzed. Primary aim of study is to analyze the hemodynamics of patients based on weight gain/loss. Secondary aim is to evaluate the same in patient-prosthesis mismatch (PPM) subgroup and to evaluate the study population for the potential to gain/loss weight. Results Among 118 patients, 87 patients (73.7%) gained weight. In 87 weight gained patients, left atrial (LA) size (p = 0.011) and pulmonary artery systolic (PA) pressure (p = 0.028) at follow-up were significantly elevated than the discharge values. Among 53 PPM patients (incidence, 44.9%), 34 patients gained weight and their PA pressure was found to be elevated at follow-up (p = 0.021) whereas weight lost group does not show any significant difference (p = 0.972). Frequency of weight gain was more among patients who weighed < 50 kg preoperatively (28 out of 30) (p = 0.013) and 20 to 30 years age group patients (p = 0.043). No sex predilection was noted (p = 0.149). Conclusion In post-MVR patients, weight gain has definitive influence over hemodynamics. In PPM subgroup, weight gained patients had significantly increased PA systolic pressure at follow-up. Young, < 50 kg weighed, and PPM patients should be advised to maintain their weight post MVR for better hemodynamics.
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Affiliation(s)
- Vijayanand Palanisamy
- Department of Cardiac Surgery-Institute of Cardiovascular Diseases, The Madras Medical Mission, 4A, Dr. J.J. Nagar, Mogappair, Chennai, Tamil Nadu 600037 India
| | - Karthik Raman
- Department of Cardiac Surgery-Institute of Cardiovascular Diseases, The Madras Medical Mission, 4A, Dr. J.J. Nagar, Mogappair, Chennai, Tamil Nadu 600037 India
| | - Anjith Prakash Rajakumar
- Department of Cardiac Surgery-Institute of Cardiovascular Diseases, The Madras Medical Mission, 4A, Dr. J.J. Nagar, Mogappair, Chennai, Tamil Nadu 600037 India
| | - Anbarasu Mohanraj
- Department of Cardiac Surgery-Institute of Cardiovascular Diseases, The Madras Medical Mission, 4A, Dr. J.J. Nagar, Mogappair, Chennai, Tamil Nadu 600037 India
| | - Jacob Jamesraj
- Department of Cardiac Surgery-Institute of Cardiovascular Diseases, The Madras Medical Mission, 4A, Dr. J.J. Nagar, Mogappair, Chennai, Tamil Nadu 600037 India
| | - Ejaz Ahmed Sheriff
- Department of Cardiac Surgery-Institute of Cardiovascular Diseases, The Madras Medical Mission, 4A, Dr. J.J. Nagar, Mogappair, Chennai, Tamil Nadu 600037 India
| | - Valikapthalil Mathew Kurian
- Department of Cardiac Surgery-Institute of Cardiovascular Diseases, The Madras Medical Mission, 4A, Dr. J.J. Nagar, Mogappair, Chennai, Tamil Nadu 600037 India
| | - Rajan Sethuratnam
- Department of Cardiac Surgery-Institute of Cardiovascular Diseases, The Madras Medical Mission, 4A, Dr. J.J. Nagar, Mogappair, Chennai, Tamil Nadu 600037 India
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Impact of prosthesis-patient mismatch on early and late outcomes after mitral valve replacement: a meta-analysis. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2020; 17:455-475. [PMID: 32952521 PMCID: PMC7475218 DOI: 10.11909/j.issn.1671-5411.2020.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background Prognostic significance of prosthesis-patient mismatch (PPM) after mitral valve replacement (MVR) remains uncertain because of the limited studies reporting inconsistent or even contrary results. This meta-analysis pooled results of all available studies comparing early and late prognoses between patients with significant mitral PPM and those without. Methods Studies were identified by searching Pubmed, Excerpta Medica Database, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. Impact of PPM on postoperative hemodynamic results, thirty-day mortality, overall mortality, mortality of thirty-day survivors, and primary morbidity after MVR was evaluated via meta-analysis. Robustness of pooled estimates, source of heterogeneity, and publication bias were assessed via sensitivity analyses, meta-regression as well as subgroup analysis stratified according to methodological or clinical heterogeneity, or sequential omission method, and funnel plot or Begg's and Egger's tests, respectively. Results Nineteen cohort studies involving 9302 individuals (PPM group: n = 5109, Control group: n = 4193) were included for meta-analysis. Total PPM and severe PPM prevalence were 3.8%-85.9% and 1%-27%, with a mean value of 54.9% and 14.1%, respectively. As compared with control group, mitral PPM group demonstrated a poorer postoperative hemodynamic status of higher mean and peak residual transprosthetic pressure gradients (TPG), higher postoperative systolic pulmonary artery pressure (SPAP) and less reduction, higher postoperative pulmonary hypertension (PH) prevalence and less PH regression, smaller net atrioventricular compliance, less NYHA class decrease, higher postoperative functional tricuspid regurgitation prevalence and less regression. The PPM group also revealed a higher thirty-day mortality, long-term overall mortality, mortality of thirty-day survivors, and postoperative congestive heart failure prevalence, which were positively correlated with the severity of PPM if it was classified into tri-level subgroups. Left ventricular end-diastolic diameter, postoperative atrial fibrillation (AF) prevalence, and the AF regression were analogous between groups. Most pooled estimates were robust according to sensitivity analyses. Male patients and bioprosthesis implantation proportion were prominent source of between-study heterogeneity on thirty-day mortality. Publication bias was not significant in tests for all the outcomes, except for SPAP and TPG. Conclusions Mitral PPM would result in poorer postoperative hemodynamics and worse early and late prognosis. Severe PPM must be avoided since deleterious impact of mitral PPM was severity dependent.
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Bermejo J, Yotti R, García-Orta R, Sánchez-Fernández PL, Castaño M, Segovia-Cubero J, Escribano-Subías P, San Román JA, Borrás X, Alonso-Gómez A, Botas J, Crespo-Leiro MG, Velasco S, Bayés-Genís A, López A, Muñoz-Aguilera R, de Teresa E, González-Juanatey JR, Evangelista A, Mombiela T, González-Mansilla A, Elízaga J, Martín-Moreiras J, González-Santos JM, Moreno-Escobar E, Fernández-Avilés F. Sildenafil for improving outcomes in patients with corrected valvular heart disease and persistent pulmonary hypertension: a multicenter, double-blind, randomized clinical trial. Eur Heart J 2019; 39:1255-1264. [PMID: 29281101 PMCID: PMC5905634 DOI: 10.1093/eurheartj/ehx700] [Citation(s) in RCA: 141] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 11/14/2017] [Indexed: 11/16/2022] Open
Abstract
Aims We aimed to determine whether treatment with sildenafil improves outcomes of patients with persistent pulmonary hypertension (PH) after correction of valvular heart disease (VHD). Methods and results The sildenafil for improving outcomes after valvular correction (SIOVAC) study was a multricentric, randomized, parallel, and placebo-controlled trial that enrolled stable adults with mean pulmonary artery pressure ≥ 30 mmHg who had undergone a successful valve replacement or repair procedure at least 1 year before inclusion. We assigned 200 patients to receive sildenafil (40 mg three times daily, n = 104) or placebo (n = 96) for 6 months. The primary endpoint was the composite clinical score combining death, hospital admission for heart failure (HF), change in functional class, and patient global self-assessment. Only 27 patients receiving sildenafil improved their composite clinical score, as compared with 44 patients receiving placebo; in contrast 33 patients in the sildenafil group worsened their composite score, as compared with 14 in the placebo group [odds ratio 0.39; 95% confidence interval (CI) 0.22–0.67; P < 0.001]. The Kaplan–Meier estimates for survival without admission due to HF were 0.76 and 0.86 in the sildenafil and placebo groups, respectively (hazard ratio 2.0, 95% CI = 1.0–4.0; log-rank P = 0.044). Changes in 6-min walk test distance, natriuretic peptides, and Doppler-derived systolic pulmonary pressure were similar in both groups. Conclusion Treatment with sildenafil in patients with persistent PH after successfully corrected VHD is associated to worse clinical outcomes than placebo. Off-label usage of sildenafil for treating this source of left heart disease PH should be avoided. The trial is registered with ClinicalTrials.gov, number NCT00862043.
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Affiliation(s)
- Javier Bermejo
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, and CIBERCV. Dr Esquerdo 46. 28007 Madrid, Spain
| | - Raquel Yotti
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, and CIBERCV. Dr Esquerdo 46. 28007 Madrid, Spain
| | | | | | | | | | | | | | - Xavier Borrás
- Hospital Santa Creu i San Pau and CIBERCV, Barcelona
| | | | - Javier Botas
- Hospital Universitario Fundación Alcorcón, Alcorcón
| | | | | | | | | | | | | | | | | | - Teresa Mombiela
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, and CIBERCV. Dr Esquerdo 46. 28007 Madrid, Spain
| | - Ana González-Mansilla
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, and CIBERCV. Dr Esquerdo 46. 28007 Madrid, Spain
| | - Jaime Elízaga
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, and CIBERCV. Dr Esquerdo 46. 28007 Madrid, Spain
| | | | | | | | - Francisco Fernández-Avilés
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, and CIBERCV. Dr Esquerdo 46. 28007 Madrid, Spain
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12
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El Midany AA, Mostafa EA, Hikal T, Elbarbary MG, Doghish A, Khorshid R, Abdelgawad BM, Sharaa M, El-Sokkary IN, Hossiny ME, Abdelmoaty H, Elkhonezy BA. Incidence and predictors of mismatch after mechanical mitral valve replacement. Asian Cardiovasc Thorac Ann 2019; 27:535-541. [PMID: 31390876 DOI: 10.1177/0218492319869560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Patient-prosthesis mismatch after mitral valve replacement has an unfavorable postoperative hemodynamic outcome, which underlines the importance of identifying and preventing prosthesis- and patient-related risk factors. This study was conducted to determine the incidence and identify possible predictors of patient-prosthesis mismatch. Methods A prospective study was conducted on 715 patients with a mean age of 42 ± 11 years who underwent mechanical mitral valve replacement between 2013 and 2017. The effective orifice area of the prostheses was estimated by the continuity equation, and a mismatch was defined as an effective orifice area index ≤1.2 cm2·m−2. The mean clinical and echocardiographic follow-up was 26.74 ± 11.58 months. Multivariate regression analysis was performed to identify predictors of patient-prosthesis mismatch. Results Patient-prosthesis mismatch was detected in 382 (53.4%) patients. A small mechanical prosthesis (<27 mm) was inserted in 54.3%. Mortality during follow-up was 9% (65 patients). Patient-prosthesis mismatch was identified in patients with preoperative rheumatic mitral valve pathology, associated tricuspid regurgitation, higher New York Heart Association class, preoperative atrial fibrillation, mitral stenosis, and small preoperative left ventricular dimensions. Multivariate analysis identified mitral stenosis, preoperative atrial fibrillation, and small postoperative left ventricular end-diastolic dimension as risk factors for patient-prosthesis mismatch. Conclusion Patient-prosthesis mismatch is a common sequela after mechanical mitral valve replacement. Identification of predictors of patient-prosthesis mismatch can help so that a preoperative strategy can be implemented to avoid its occurrence.
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Affiliation(s)
- Ashraf Ah El Midany
- 1 Department of Cardiovascular & Thoracic Surgery, Ain-Shams University Hospital, Faculty of Medicine, Cairo, Egypt
| | - Ezzeldin A Mostafa
- 1 Department of Cardiovascular & Thoracic Surgery, Ain-Shams University Hospital, Faculty of Medicine, Cairo, Egypt
| | - Tamer Hikal
- 1 Department of Cardiovascular & Thoracic Surgery, Ain-Shams University Hospital, Faculty of Medicine, Cairo, Egypt
| | - Mostafa G Elbarbary
- 1 Department of Cardiovascular & Thoracic Surgery, Ain-Shams University Hospital, Faculty of Medicine, Cairo, Egypt
| | - Ayman Doghish
- 1 Department of Cardiovascular & Thoracic Surgery, Ain-Shams University Hospital, Faculty of Medicine, Cairo, Egypt
| | - Ramy Khorshid
- 1 Department of Cardiovascular & Thoracic Surgery, Ain-Shams University Hospital, Faculty of Medicine, Cairo, Egypt
| | - Basem M Abdelgawad
- 2 Department of Cardiovascular & Thoracic Surgery, Faculty of Medicine, Banha University, Banha, Egypt
| | - Mohamed Sharaa
- 3 Department of Cardiovascular & Thoracic Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Ismail N El-Sokkary
- 3 Department of Cardiovascular & Thoracic Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Mohamed El Hossiny
- 3 Department of Cardiovascular & Thoracic Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Haytham Abdelmoaty
- 3 Department of Cardiovascular & Thoracic Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Bahaa A Elkhonezy
- 3 Department of Cardiovascular & Thoracic Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
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13
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Lombard FW, Liang Y. Risk Factors for Mitral Valve Surgery: Atrial Fibrillation and Pulmonary Hypertension. Semin Cardiothorac Vasc Anesth 2019; 23:57-69. [PMID: 30608218 DOI: 10.1177/1089253218821694] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | - Yafen Liang
- 1 Vanderbilt University Medical Center, Nashville, TN, USA
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14
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Mehra P, Mehta V, Sukhija R, Sinha AK, Gupta M, Girish M, Aronow WS. Pulmonary hypertension in left heart disease. Arch Med Sci 2019; 15:262-273. [PMID: 30697278 PMCID: PMC6348356 DOI: 10.5114/aoms.2017.68938] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 09/14/2016] [Indexed: 12/20/2022] Open
Affiliation(s)
- Pratishtha Mehra
- Department of Cardiology, Maulana Azad Medical College and G.B. Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Vimal Mehta
- Department of Cardiology, Maulana Azad Medical College and G.B. Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Rishi Sukhija
- Division of Cardiology, Indiana University La Porte Hospital, La Porte, Indiana, USA
| | - Anjan K. Sinha
- Division of Cardiology, Indiana University Health, Indianapolis, Indiana, USA
| | - Mohit Gupta
- Department of Cardiology, Maulana Azad Medical College and G.B. Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - M.P. Girish
- Department of Cardiology, Maulana Azad Medical College and G.B. Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
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15
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Malhotra A. Prosthesis patient mismatch: myth or reality? Indian J Thorac Cardiovasc Surg 2019; 35:3-5. [PMID: 33060962 PMCID: PMC7525692 DOI: 10.1007/s12055-018-0708-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 07/13/2018] [Indexed: 10/28/2022] Open
Affiliation(s)
- Amber Malhotra
- Department of Cardio vascular and Thoracic Surgery, U. N. Mehta Institute of Cardiology and Research Center, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat 380016 India
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16
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Ram E, Sternik L, Klempfner R, Eldar M, Goldenberg I, Peled Y, Raanani E, Kogan A. Sildenafil for Pulmonary Hypertension in the Early Postoperative Period After Mitral Valve Surgery. J Cardiothorac Vasc Anesth 2018; 33:1648-1656. [PMID: 30685151 DOI: 10.1053/j.jvca.2018.12.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The phosphodiesterase-5 inhibitor sildenafil was developed for the treatment of pulmonary hypertension. The authors investigated the efficacy and safety of sildenafil in the early postoperative period after mitral valve surgery in patients with pulmonary hypertension. DESIGN A double-blind, placebo-controlled randomized trial was performed. SETTING The trial was performed in a single tertiary referral center. PARTICIPANTS Fifty consecutive patients who experienced pulmonary hypertension and underwent mitral valve surgery. INTERVENTIONS Patients were randomly assigned to the following 2 groups: 25 patients received 20 mg sildenafil every 8 hours, and the remaining 25 patients received placebo during the same period. Hemodynamic parameters were studied by using a pulmonary artery catheter at baseline and every 6 hours up to 36 hours. RESULTS Patients who received sildenafil showed a decrease in mean pulmonary pressure, from 32 ± 7 mmHg at baseline to 26 ± 3 mmHg after 36 hours, whereas no change was seen in patients who received placebo (mean pulmonary pressure 34 ± 6 mmHg at baseline and 35 ± 5 mmHg after 36 h) (p < 0.001). No significant changes in systemic hemodynamic and oxygenation were observed. Patients who received sildenafil compared with those who received placebo had a median mechanical lung ventilation time of 16 (10-31) hours versus 19 (13-41) hours (p = 0.431), intensive care unit stay of 74 (44-106) hours versus 91 (66-141) hours (p = 0.410), and a total hospitalization stay of 7 (5-10) days versus 11 (7-15) days (p = 0.009). CONCLUSIONS The immediate postoperative administration of sildenafil after mitral valve surgery is safe. Sildenafil demonstrates a favorable decreasing effect on pulmonary vascular pressure without systemic hypotension and ventilation-perfusion mismatch.
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Affiliation(s)
- Eilon Ram
- Department of Cardiac Surgery, Sheba Medical Center at Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Leonid Sternik
- Department of Cardiac Surgery, Sheba Medical Center at Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Robert Klempfner
- Heart Institute, Sheba Medical Center at Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michael Eldar
- Heart Institute, Sheba Medical Center at Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ilan Goldenberg
- Heart Institute, Sheba Medical Center at Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Peled
- Heart Institute, Sheba Medical Center at Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ehud Raanani
- Department of Cardiac Surgery, Sheba Medical Center at Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alexander Kogan
- Department of Cardiac Surgery, Sheba Medical Center at Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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17
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Akuffu AM, Zhao H, Zheng J, Ni Y. Prosthesis-patient mismatch after mitral valve replacement: a single-centered retrospective analysis in East China. J Cardiothorac Surg 2018; 13:100. [PMID: 30285794 PMCID: PMC6169081 DOI: 10.1186/s13019-018-0788-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 09/25/2018] [Indexed: 11/30/2022] Open
Abstract
Background Prosthesis–patient mismatch (PPM) may affect the clinical outcomes of patients undergoing mitral valve replacement (MVR) surgery. We aimed to investigate the incidence of PPM of the mitral position in our center and analyze the possible predictors of PPM as well as its effect on short-term outcomes. Methods We retrospectively examined all consecutive patients with isolated or concomitant MVR at our center from 2013 to 2015. PPM was defined as an indexed effective orifice area (iEOA) of ≤1.2 cm2/m2. After inclusion and exclusion, a total of 1067 patients were analyzed. The baseline information were collected and compared between the two groups. Multivariate logistic regression analysis was conducted to determine the preoperative predictors of PPM as well as the effect of PPM on early mortality. Results A total of 1067 patients were included in the study. PPM was detected in 15.9% of the patients while 12 patients (1.12%) met the criteria for severe PPM. Patients with PPM compared to the non-PPM patients had higher age, larger body surface area and were more likely to be male and obese. Logistic regression analysis showed that higher age, larger BSA, bioprosthesis and smaller left ventricle end-diastolic diameter were predictors of PPM. There were no significant differences between the PPM and non-PPM groups regarding post-operative complications. Logistic regression analysis showed that PPM was not a risk factor of short-term mortality (P = 0.654). Also, there were no significant differences regarding short−/mid-term heart function between the PPM and non PPM groups (P = 0.902). Conclusions Our results demonstrated that higher age, bioprosthesis, larger BSA and smaller left ventricle size were associated with mitral PPM. However, PPM was not associated with poorer early outcomes after MVR surgery. In eastern of China, the prevalence of mitral valve stenosis is high; therefore, whether the standard PPM criteria are suitable for patients of this district needs to be further verified.
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Affiliation(s)
- Armah M Akuffu
- Department of Cardiothoracic Surgery, the First Affiliated Hospital of Zhejiang University, No.79 Qingchun Road, Hangzhou, 310003, China
| | - Haige Zhao
- Department of Cardiothoracic Surgery, the First Affiliated Hospital of Zhejiang University, No.79 Qingchun Road, Hangzhou, 310003, China
| | - Junnan Zheng
- Department of Cardiothoracic Surgery, the First Affiliated Hospital of Zhejiang University, No.79 Qingchun Road, Hangzhou, 310003, China.
| | - Yiming Ni
- Department of Cardiothoracic Surgery, the First Affiliated Hospital of Zhejiang University, No.79 Qingchun Road, Hangzhou, 310003, China
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18
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Totaro P, Pelenghi S. Patient-prosthesis mismatch after mitral valve replacement: complex enigma with more than one solution. Eur J Cardiothorac Surg 2018; 54:609. [PMID: 29684117 DOI: 10.1093/ejcts/ezy163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 03/26/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Pasquale Totaro
- Division of Cardiac Surgery, IRCCS Foundation Hospital San Matteo, Pavia, Italy
| | - Stefano Pelenghi
- Division of Cardiac Surgery, IRCCS Foundation Hospital San Matteo, Pavia, Italy
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19
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Ammannaya GKK, Mishra P, Khandekar JV, Mohapatra CKR, Seth HS, Raut C, Shah V, Saini JS. Effect of prosthesis patient mismatch in mitral position on pulmonary hypertension. Eur J Cardiothorac Surg 2018; 52:1168-1174. [PMID: 28591821 DOI: 10.1093/ejcts/ezx167] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Accepted: 04/27/2017] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Pulmonary arterial hypertension (PAH) is associated with poor outcome after mitral valve replacement (MVR). We proposed to evaluate the effect of valve prosthesis patient mismatch (PPM) on pulmonary arterial (PA) pressure following MVR. METHODS Five hundred patients who have undergone MVR were studied retrospectively. Postoperative PA systolic pressure (PASP) measured 6 months postoperatively by Doppler echocardiography was compared with preoperative values. PASP ≥ 40 mmHg was defined as PAH. Mitral valve effective orifice area was calculated by the continuity equation and indexed for body surface area. PPM was defined as indexed effective orifice area ≤ 1.2 cm2/m2. A multivariate model was constructed to ascertain the independent determinants of systolic PA pressure. Also, a propensity score model was constructed to overcome the baseline differences between the PPM and no PPM groups. RESULTS The incidence of PPM in this study was 37.2%. The average postoperative PASPs were 30.49 and 42.35 mmHg in the no PPM and PPM groups, respectively; (P < 0.001). Regression of PAH in the PPM and no PPM groups was 76.26% and 20.64%, respectively; (P < 0.001). The indexed effective orifice area correlated well with postoperative PASP (r = 0.71). The overall survival and freedom from cardiac death at 10 years were 79.8% and 85.3%; and at 20 years were 66.5% and 74.3%, respectively. Both, overall survival and the freedom from cardiac death were higher in the no PPM group than in the PPM group; (P < 0.001). Propensity score matching analysis yielded 112 pairs of the PPM and no PPM cohorts, which revealed higher overall survival and freedom from cardiac death in the no PPM group; (P = 0.028 and 0.012, respectively). CONCLUSIONS Mitral PPM is an independent predictor of persistent PAH after MVR along with associated morbidity and reduced survival.
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Affiliation(s)
- Ganesh Kumar K Ammannaya
- Department of Cardiovascular & Thoracic Surgery, Lokmanya Tilak Municipal Medical College & General Hospital, Mumbai, India
| | - Prashant Mishra
- Department of Cardiovascular & Thoracic Surgery, Lokmanya Tilak Municipal Medical College & General Hospital, Mumbai, India
| | - Jayant V Khandekar
- Department of Cardiovascular & Thoracic Surgery, Lokmanya Tilak Municipal Medical College & General Hospital, Mumbai, India
| | - Chandan Kumar Ray Mohapatra
- Department of Cardiovascular & Thoracic Surgery, Lokmanya Tilak Municipal Medical College & General Hospital, Mumbai, India
| | - Harsh S Seth
- Department of Cardiovascular & Thoracic Surgery, Lokmanya Tilak Municipal Medical College & General Hospital, Mumbai, India
| | - Chaitanya Raut
- Department of Cardiovascular & Thoracic Surgery, Lokmanya Tilak Municipal Medical College & General Hospital, Mumbai, India
| | - Vaibhav Shah
- Department of Cardiovascular & Thoracic Surgery, Lokmanya Tilak Municipal Medical College & General Hospital, Mumbai, India
| | - Jaskaran S Saini
- Department of Cardiovascular & Thoracic Surgery, Lokmanya Tilak Municipal Medical College & General Hospital, Mumbai, India
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20
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Iyer R, Chalekian A, Lane R, Evans M, Yi S, Morris J. Transcatheter Mitral Valve Replacement: Functional Requirements for Device Design, Bench-Top, and Pre-Clinical Evaluation. Cardiovasc Eng Technol 2018; 9:301-338. [PMID: 29951830 DOI: 10.1007/s13239-018-0364-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 05/17/2018] [Indexed: 10/28/2022]
Abstract
Transcatheter Mitral Valve Replacement (TMVR) is currently under clinical investigation as a viable treatment option for mitral regurgitation (MR). Therefore, it is important to outline the key functional requirements of a TMVR prosthesis in order to provide an overall approach to assessing mitral valve replacement devices utilizing a combination of in vitro and preclinical methods. This article provides a review of the mitral valve disease as well as general considerations and guidance for developing a TMVR device based on International Industry Standards. Specific details pertaining to the mitral valve apparatus, morphology of mitral valve disease, assessment of specific patient population as well as hazard analysis to evaluate and develop a TMVR device to treat a specific patient population have been included. The details contained within this report are not all inclusive or explicate for every technology being developed but rather thought of as a general guide on how a TMVR technology could be developed in alignment with International Industry Standards. Key learnings from the Transcatheter Aortic Valve Replacement (TAVR) experience has also been considered and taken into account when outlining this general guidance for TMVR. Key learning points from the TAVR development experience included the following: quantification of acceptable levels of paravalvular leak, valve migration potential using various anchoring methods and overall implant frame failure modes when treating the native aortic valve. It should be noted that TAVR is over a decade further along in development and clinical experience compared to TMVR. These key learnings from the early experience with TAVR should be considered with all transcatheter development projects.
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Affiliation(s)
| | | | | | | | - Seung Yi
- Edwards Life Sciences, Irvine, CA, USA
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21
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Stock S, Sievers HH, Richardt D, Scharfschwerdt M. Mitral valve replacement with the novel TRIBIO and an established stented bioprosthesis in a sheep model. Interact Cardiovasc Thorac Surg 2018; 26:438-442. [PMID: 29149268 DOI: 10.1093/icvts/ivx361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 10/06/2017] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Heart valve replacement with a bioprosthesis is one of the most frequently performed procedures in cardiac surgery and represents a highly effective therapy to relieve diseased heart valves. Nevertheless, as postoperatively elevated transvalvular gradients and prosthesis-patient mismatch are reported as shortcomings of the procedure or of the currently used devices, there is a need for novel bioprostheses with improved haemodynamics. This study presents preclinical haemodynamic results after mitral valve replacement with the novel TRIBIO bioprosthesis (TRIBIO) compared with an established bioprosthesis in a sheep model. METHODS Six female sheep had their mitral valves replaced with the TRIBIO and 3 with the Carpentier-Edwards Perimount, both sized 19 mm. The TRIBIO consists of a flexible valve-bearing crown, a force-decoupled interface and an intra-annular base ring. Mean and peak transvalvular gradients as well as an effective orifice area were monitored in both groups using transthoracic echocardiography over the course of the 90-day study. RESULTS In both groups, haemodynamic performance diminished over time. The TRIBIO demonstrated overall superior haemodynamics, i.e. lower transvalvular gradients and a larger effective orifice area, although the results were not statistically significant. On Day 90, the mean values for the mean and peak transvalvular gradients and the effective orifice area were 6 mmHg, 10.2 mmHg and 1.2 cm2 for the TRIBIO and 10 mmHg, 15.8 mmHg and 0.8 cm2 for the Carpentier-Edwards Perimount, respectively. CONCLUSIONS This study demonstrates a trend towards improved preclinical haemodynamic performance following mitral valve replacement with the TRIBIO compared to that with an established bioprosthesis in a sheep model.
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Affiliation(s)
- Sina Stock
- Department of Cardiac and Thoracic Vascular Surgery, University of Luebeck, Luebeck, Germany
| | - Hans-Hinrich Sievers
- Department of Cardiac and Thoracic Vascular Surgery, University of Luebeck, Luebeck, Germany
| | - Doreen Richardt
- Department of Cardiac and Thoracic Vascular Surgery, University of Luebeck, Luebeck, Germany
| | - Michael Scharfschwerdt
- Department of Cardiac and Thoracic Vascular Surgery, University of Luebeck, Luebeck, Germany
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22
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Jansen R, Urgel K, Cramer MJ, van Aarnhem EEHL, Zwetsloot PPM, Doevendans PA, Kluin J, Chamuleau SAJ. Reference Values for Physical Stress Echocardiography in Asymptomatic Patients after Mitral Valve Repair. Front Surg 2018. [PMID: 29516004 PMCID: PMC5826059 DOI: 10.3389/fsurg.2018.00006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Background Clinical decision-making in symptomatic patients after mitral valve (MV) repair remains challenging as echocardiographic reference values are lacking. In native MV disease intervention is recommended for mean transmitral pressure gradient (TPG) >15 mmHg or systolic pulmonary artery pressure (SPAP) >60 mmHg at peak exercise. Insight into standard stress echo parameters after MV repair may therefore aid to clinical decision-making during follow-up. Hypothesis Stress echocardiography derived parameters in asymptomatic patients after successful MV repair differ from current guidelines for native valves. Material and methods In 25 patients (NYHA I) after MV repair stress echocardiography was performed on a semi-supine bicycle. Doppler flow records and MV related hemodynamics at rest and peak were obtained. Linear regression analysis was performed for mean TPG and SPAP at peak, using predetermined variables and confounders. Results Mean TPG at rest (3.2 ± 1.4 mmHg) significantly increased at peak (15.0 ± 3.4 mmHg) but was always <25 mmHg. Mean SPAP at rest (21.4 ± 3.8 mmHg) significantly increased at peak (41.8 ± 8.9 mmHg) but was never >57 mmHg. Only the indexed MV ring diameter was inversely correlated to mean TPG at peak in a multivariable model. Conclusion In contrast to current recommendations in native MV disease, our data indicate that the standard value for mean TPG during stress echocardiography in asymptomatic patients after successful MV repair was above the guideline threshold of 15 mmHg in >50%, but always <25 mmHg. For SPAP, patients never reached the guideline cutoff (60 mmHg). Long-term follow-up data are needed to provide insight in clinical consequences. Baseline stress echocardiography may indicate individual reference values to compare with during follow-up. Clinical trial registration https://clinicaltrials.gov/ct2/show/NCT02371863?term=chamuleau+AND+Mitral&rank=1.
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Affiliation(s)
- Rosemarijn Jansen
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Kim Urgel
- Department of Cardiology, St Antonius Hospital Woerden, Woerden, Netherlands
| | - Maarten J Cramer
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | | | - Peter P M Zwetsloot
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Pieter A Doevendans
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Jolanda Kluin
- Department of Cardiothoracic Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | - Steven A J Chamuleau
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
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23
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Aboul-Hassan SS, Stankowski T, Marczak J, Cichon R. Does patient–prosthesis mismatch have a negative impact on outcomes following mitral valve replacement? Interact Cardiovasc Thorac Surg 2018; 26:1027-1034. [DOI: 10.1093/icvts/ivx426] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 12/17/2017] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Tomasz Stankowski
- Department of Cardiac Surgery, Sana-Heart Center Cottbus, Cottbus, Germany
| | - Jakub Marczak
- Department of Cardiac Surgery, MEDINET Heart Center Ltd, Nowa Sol, Poland
- Department of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Romuald Cichon
- Department of Cardiac Surgery, Warsaw Medical University, Warsaw, Poland
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24
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Fino C, Iacovoni A, Pibarot P, Pepper JR, Ferrero P, Merlo M, Galletti L, Caputo M, Ferrazzi P, Anagnostopoulos C, Cugola D, Senni M, Bellavia D, Magne J. Exercise Hemodynamic and Functional Capacity After Mitral Valve Replacement in Patients With Ischemic Mitral Regurgitation. Circ Heart Fail 2018; 11:e004056. [DOI: 10.1161/circheartfailure.117.004056] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 11/30/2017] [Indexed: 01/06/2023]
Abstract
Background
In patients with ischemic mitral regurgitation requiring mitral valve replacement (MVR), the choice of the prosthesis type is crucial. The exercise hemodynamic and functional capacity performance in patients with contemporary prostheses have never been investigated. To compare exercise hemodynamic and functional capacity between biological (MVRb) and mechanical (MVRm) prostheses.
Methods and Results
We analyzed 86 consecutive patients with ischemic mitral regurgitation who underwent MVRb (n=41) or MVRm (n=45) and coronary artery bypass grafting. All patients underwent preoperative resting echocardiography and 6-minute walking test. At follow-up, exercise stress echocardiography was performed, and the 6-minute walking test was repeated. Resting and exercise indexed effective orifice areas of MVRm were larger when compared with MVRb (resting: 1.30±0.2 versus 1.19±0.3 cm
2
/m
2
;
P
=0.03; exercise: 1.57±0.2 versus 1.18±0.3 cm
2
/m
2
;
P
=0.0001). The MVRm had lower exercise systolic pulmonary arterial pressure at follow-up compared with MVRb (41±5 versus 59±7 mm Hg;
P
=0.0001). Six-minute walking test distance was improved in the MVRm (pre-operative: 242±43, post-operative: 290±50 m;
P
=0.001), whereas it remained similar in the MVRb (pre-operative: 250±40, post-operative: 220±44 m;
P
=0.13). In multivariable analysis, type of prosthesis, exercise indexed effective orifice area, and systolic pulmonary arterial pressure were joint predictors of change in 6-minute walking test (ie, difference between baseline and follow-up).
Conclusions
In patients with ischemic mitral regurgitation, bioprostheses are associated with worse hemodynamic performance and reduced functional capacity, when compared with MVRm. Randomized studies with longer follow-up including quality of life and survival data are required to confirm these results.
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Affiliation(s)
- Carlo Fino
- >From the Cardiovascular Department, Ospedale Papa Giovanni XXIII, Bergamo, Italy (C.F., A.I., P.F., M.M., L.G., P.F., D.C., M.S.); Hypertrofic Cardiomyopathy Centre, Policlinico di Monza, Monza, Italy (P.F.); Québec Heart & Lung Institute, Department of Medicine, Laval University, Quebec City, QC, Canada (P.P.); Department of Cardiothoracic Surgery, Royal Brompton and Harefield Hospital, London, United Kingdom (J.R.P.); Bristol Royal Infirmary, University of Bristol, United Kingdom (M.C.)
| | - Attilio Iacovoni
- >From the Cardiovascular Department, Ospedale Papa Giovanni XXIII, Bergamo, Italy (C.F., A.I., P.F., M.M., L.G., P.F., D.C., M.S.); Hypertrofic Cardiomyopathy Centre, Policlinico di Monza, Monza, Italy (P.F.); Québec Heart & Lung Institute, Department of Medicine, Laval University, Quebec City, QC, Canada (P.P.); Department of Cardiothoracic Surgery, Royal Brompton and Harefield Hospital, London, United Kingdom (J.R.P.); Bristol Royal Infirmary, University of Bristol, United Kingdom (M.C.)
| | - Philippe Pibarot
- >From the Cardiovascular Department, Ospedale Papa Giovanni XXIII, Bergamo, Italy (C.F., A.I., P.F., M.M., L.G., P.F., D.C., M.S.); Hypertrofic Cardiomyopathy Centre, Policlinico di Monza, Monza, Italy (P.F.); Québec Heart & Lung Institute, Department of Medicine, Laval University, Quebec City, QC, Canada (P.P.); Department of Cardiothoracic Surgery, Royal Brompton and Harefield Hospital, London, United Kingdom (J.R.P.); Bristol Royal Infirmary, University of Bristol, United Kingdom (M.C.)
| | - John R. Pepper
- >From the Cardiovascular Department, Ospedale Papa Giovanni XXIII, Bergamo, Italy (C.F., A.I., P.F., M.M., L.G., P.F., D.C., M.S.); Hypertrofic Cardiomyopathy Centre, Policlinico di Monza, Monza, Italy (P.F.); Québec Heart & Lung Institute, Department of Medicine, Laval University, Quebec City, QC, Canada (P.P.); Department of Cardiothoracic Surgery, Royal Brompton and Harefield Hospital, London, United Kingdom (J.R.P.); Bristol Royal Infirmary, University of Bristol, United Kingdom (M.C.)
| | - Paolo Ferrero
- >From the Cardiovascular Department, Ospedale Papa Giovanni XXIII, Bergamo, Italy (C.F., A.I., P.F., M.M., L.G., P.F., D.C., M.S.); Hypertrofic Cardiomyopathy Centre, Policlinico di Monza, Monza, Italy (P.F.); Québec Heart & Lung Institute, Department of Medicine, Laval University, Quebec City, QC, Canada (P.P.); Department of Cardiothoracic Surgery, Royal Brompton and Harefield Hospital, London, United Kingdom (J.R.P.); Bristol Royal Infirmary, University of Bristol, United Kingdom (M.C.)
| | - Maurizio Merlo
- >From the Cardiovascular Department, Ospedale Papa Giovanni XXIII, Bergamo, Italy (C.F., A.I., P.F., M.M., L.G., P.F., D.C., M.S.); Hypertrofic Cardiomyopathy Centre, Policlinico di Monza, Monza, Italy (P.F.); Québec Heart & Lung Institute, Department of Medicine, Laval University, Quebec City, QC, Canada (P.P.); Department of Cardiothoracic Surgery, Royal Brompton and Harefield Hospital, London, United Kingdom (J.R.P.); Bristol Royal Infirmary, University of Bristol, United Kingdom (M.C.)
| | - Lorenzo Galletti
- >From the Cardiovascular Department, Ospedale Papa Giovanni XXIII, Bergamo, Italy (C.F., A.I., P.F., M.M., L.G., P.F., D.C., M.S.); Hypertrofic Cardiomyopathy Centre, Policlinico di Monza, Monza, Italy (P.F.); Québec Heart & Lung Institute, Department of Medicine, Laval University, Quebec City, QC, Canada (P.P.); Department of Cardiothoracic Surgery, Royal Brompton and Harefield Hospital, London, United Kingdom (J.R.P.); Bristol Royal Infirmary, University of Bristol, United Kingdom (M.C.)
| | - Massimo Caputo
- >From the Cardiovascular Department, Ospedale Papa Giovanni XXIII, Bergamo, Italy (C.F., A.I., P.F., M.M., L.G., P.F., D.C., M.S.); Hypertrofic Cardiomyopathy Centre, Policlinico di Monza, Monza, Italy (P.F.); Québec Heart & Lung Institute, Department of Medicine, Laval University, Quebec City, QC, Canada (P.P.); Department of Cardiothoracic Surgery, Royal Brompton and Harefield Hospital, London, United Kingdom (J.R.P.); Bristol Royal Infirmary, University of Bristol, United Kingdom (M.C.)
| | - Paolo Ferrazzi
- >From the Cardiovascular Department, Ospedale Papa Giovanni XXIII, Bergamo, Italy (C.F., A.I., P.F., M.M., L.G., P.F., D.C., M.S.); Hypertrofic Cardiomyopathy Centre, Policlinico di Monza, Monza, Italy (P.F.); Québec Heart & Lung Institute, Department of Medicine, Laval University, Quebec City, QC, Canada (P.P.); Department of Cardiothoracic Surgery, Royal Brompton and Harefield Hospital, London, United Kingdom (J.R.P.); Bristol Royal Infirmary, University of Bristol, United Kingdom (M.C.)
| | - Constantinos Anagnostopoulos
- >From the Cardiovascular Department, Ospedale Papa Giovanni XXIII, Bergamo, Italy (C.F., A.I., P.F., M.M., L.G., P.F., D.C., M.S.); Hypertrofic Cardiomyopathy Centre, Policlinico di Monza, Monza, Italy (P.F.); Québec Heart & Lung Institute, Department of Medicine, Laval University, Quebec City, QC, Canada (P.P.); Department of Cardiothoracic Surgery, Royal Brompton and Harefield Hospital, London, United Kingdom (J.R.P.); Bristol Royal Infirmary, University of Bristol, United Kingdom (M.C.)
| | - Diego Cugola
- >From the Cardiovascular Department, Ospedale Papa Giovanni XXIII, Bergamo, Italy (C.F., A.I., P.F., M.M., L.G., P.F., D.C., M.S.); Hypertrofic Cardiomyopathy Centre, Policlinico di Monza, Monza, Italy (P.F.); Québec Heart & Lung Institute, Department of Medicine, Laval University, Quebec City, QC, Canada (P.P.); Department of Cardiothoracic Surgery, Royal Brompton and Harefield Hospital, London, United Kingdom (J.R.P.); Bristol Royal Infirmary, University of Bristol, United Kingdom (M.C.)
| | - Michele Senni
- >From the Cardiovascular Department, Ospedale Papa Giovanni XXIII, Bergamo, Italy (C.F., A.I., P.F., M.M., L.G., P.F., D.C., M.S.); Hypertrofic Cardiomyopathy Centre, Policlinico di Monza, Monza, Italy (P.F.); Québec Heart & Lung Institute, Department of Medicine, Laval University, Quebec City, QC, Canada (P.P.); Department of Cardiothoracic Surgery, Royal Brompton and Harefield Hospital, London, United Kingdom (J.R.P.); Bristol Royal Infirmary, University of Bristol, United Kingdom (M.C.)
| | - Diego Bellavia
- >From the Cardiovascular Department, Ospedale Papa Giovanni XXIII, Bergamo, Italy (C.F., A.I., P.F., M.M., L.G., P.F., D.C., M.S.); Hypertrofic Cardiomyopathy Centre, Policlinico di Monza, Monza, Italy (P.F.); Québec Heart & Lung Institute, Department of Medicine, Laval University, Quebec City, QC, Canada (P.P.); Department of Cardiothoracic Surgery, Royal Brompton and Harefield Hospital, London, United Kingdom (J.R.P.); Bristol Royal Infirmary, University of Bristol, United Kingdom (M.C.)
| | - Julien Magne
- >From the Cardiovascular Department, Ospedale Papa Giovanni XXIII, Bergamo, Italy (C.F., A.I., P.F., M.M., L.G., P.F., D.C., M.S.); Hypertrofic Cardiomyopathy Centre, Policlinico di Monza, Monza, Italy (P.F.); Québec Heart & Lung Institute, Department of Medicine, Laval University, Quebec City, QC, Canada (P.P.); Department of Cardiothoracic Surgery, Royal Brompton and Harefield Hospital, London, United Kingdom (J.R.P.); Bristol Royal Infirmary, University of Bristol, United Kingdom (M.C.)
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Mechanical Surface Area of Prosthetic Heart Valve: Adverse Clinical Impact of Large Mechanical Valve in Mitral Position. ASAIO J 2017; 64:779-784. [PMID: 29135480 DOI: 10.1097/mat.0000000000000718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Although thromboembolic accidents are serious adverse events associated with mechanical mitral valves, there have been no studies on the clinical impact of the large mechanical surface areas (MSAs) of mechanical mitral prostheses. Between 1995 and 2010, 488 consecutive adult patients underwent isolated mechanical mitral valve replacement. We measured the MSA via three-dimensional computed tomography for each prosthesis. Mean patient age was 50.6 ± 11.1 years. The mean body surface area (BSA) and MSA index (MSAI, MSA/BSA) were 1.6 ± 0.17 m and 12.9 ± 1.7 cm/m, respectively. The patients were divided into two groups according to the median MSAI. Patients in the high MSAI group had higher indexed left ventricular end-diastolic dimensions and smaller BSAs. The multivariate analysis demonstrated that old age, New York Heart Association class III or IV, and high MSAI were independent predictors of death. With respect to thromboembolic complications, New York Heart Association class III or IV and high MSAI were identified as independent risk factors. There were 11 patients (3%) with mean pressure gradients across the mitral valve greater than 6 mm Hg 1 year after operation. A large MSA relative to patient size was identified as a predictor of poor clinical outcome after mechanical mitral valve replacement.
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Luis SA, Blauwet LA, Samardhi H, West C, Mehta RA, Luis CR, Scalia GM, Miller FA, Burstow DJ. Usefulness of Mitral Valve Prosthetic or Bioprosthetic Time Velocity Index Ratio to Detect Prosthetic or Bioprosthetic Mitral Valve Dysfunction. Am J Cardiol 2017; 120:1373-1380. [PMID: 28826894 DOI: 10.1016/j.amjcard.2017.07.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 07/05/2017] [Accepted: 07/12/2017] [Indexed: 11/16/2022]
Abstract
This study aimed to investigate the utility of transthoracic echocardiographic (TTE) Doppler-derived parameters in detection of mitral prosthetic dysfunction and to define optimal cut-off values for identification of such dysfunction by valve type. In total, 971 TTE studies (647 mechanical prostheses; 324 bioprostheses) were compared with transesophageal echocardiography for evaluation of mitral prosthesis function. Among all prostheses, mitral valve prosthesis (MVP) ratio (ratio of time velocity integral of MVP to that of left ventricular outflow tract; odds ratio [OR] 10.34, 95% confidence interval [95% CI] 6.43 to 16.61, p<0.001), E velocity (OR 3.23, 95% CI 1.61 to 6.47, p<0.001), and mean gradient (OR 1.13, 95% CI 1.02 to 1.25, p=0.02) provided good discrimination of clinically normal and clinically abnormal prostheses. Optimal cut-off values by receiver operating characteristic analysis for differentiating clinically normal and abnormal prostheses varied by prosthesis type. Combining MVP ratio and E velocity improved specificity (92%) and positive predictive value (65%) compared with either parameter alone, with minimal decline in negative predictive value (92%). Pressure halftime (OR 0.99, 95% CI 0.98 to 1.00, p=0.04) did not differentiate between clinically normal and clinically abnormal prostheses but was useful in discriminating obstructed from normal and regurgitant prostheses. In conclusion, cut-off values for TTE-derived Doppler parameters of MVP function were specific to prosthesis type and carried high sensitivity and specificity for identifying prosthetic valve dysfunction. MVP ratio was the best predictor of prosthetic dysfunction and, combined with E velocity, provided a useful parameter for determining likelihood of dysfunction and need for further assessment.
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Affiliation(s)
- Sushil Allen Luis
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota; School of Medicine, The University of Queensland, Brisbane, Queensland, Australia.
| | - Lori A Blauwet
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Himabindu Samardhi
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Cathy West
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Ramila A Mehta
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Chris R Luis
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Department of Cardiology, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Gregory M Scalia
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Department of Cardiology, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Fletcher A Miller
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Darryl J Burstow
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Department of Cardiology, The Prince Charles Hospital, Brisbane, Queensland, Australia
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Lee SH, Chang BC, Youn YN, Joo HC, Yoo KJ, Lee S. Impact of prosthesis-patient mismatch after mitral valve replacement in rheumatic population: Does mitral position prosthesis-patient mismatch really exist? J Cardiothorac Surg 2017; 12:88. [PMID: 29017586 PMCID: PMC5635500 DOI: 10.1186/s13019-017-0653-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 10/05/2017] [Indexed: 01/20/2023] Open
Abstract
Background Prosthesis-patient mismatch (PPM) is characterised by the effects of inadequate prosthesis size relative to body surface area (BSA).The purpose of this study was to determine the impact of PPM on late clinical outcomes after mitral valve replacement (MVR) in rheumatic population. Methods From 2000 to 2013, a total of 445 patients (mean age 54.2 ± 11.7 years) underwent isolated MVR (±tricuspid annuloplasty) for rheumatic disease were investigated. Effective orifice area (EOA) was determined by the continuity equation and PPM was defined as indexed EOA (EOA/BSA) ≤ 1.2 cm2/m2. Clinical and echocardiographic follow-up (mean follow up 8.7 ± 4.0 years) results were compared. Results 37% of patients (n = 165) had PPM. There were no significant differences in baseline and operative characteristics between patients with and without PPM except age and IEOA. A significant decrease in mean trans-valvular pressure gradient (MPG) over time following MVR, however the change of MPG showed no differences between groups (No PPM vs. PPM: 8.9 ± 4.7 mmHg → 3.6 ± 1.2 mmHg vs. 8.7 ± 4.5 mmHg → 3.8 ± 1.4 mmHg, p-value = 0.28). In all patients, there was a reduction of left atrium dimension (58.6 ± 12.0 mm → 53.2 ± 12.0 mm vs. 57.9 ± 8.9 mm → 52.2 ± 8.9 mm, p-value = 0.68) and left ventricular end diastolic diameter (49.9 ± 5.7 mm → 48.9 ± 5.7 mm vs. 49.7 ± 6.0 mm → 48.3 ± 5.0 mm, p = 0.24) without statistical significance. Freedom from TR progression rates at 3 and 5 years (99% vs.98%, 99% vs. 98%, p-value = 0.1), and overall survival rates at 3 and 5 years (97% vs. 96%, 94% vs. 94%, p-value = 0.7) were similar. Conclusion This study shows that mitral PPM is not associated with atrial /ventricular remodeling and might not influence late clinical outcome including late TR progression, survival in rheumatic population.
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Affiliation(s)
- Seung Hyun Lee
- Division of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei Cardiovascular Research Institute, Yonsei University, College of Medicine, 250 Seongsanno, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Byung Chul Chang
- Division of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei Cardiovascular Research Institute, Yonsei University, College of Medicine, 250 Seongsanno, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Young-Nam Youn
- Division of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei Cardiovascular Research Institute, Yonsei University, College of Medicine, 250 Seongsanno, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Hyun Chel Joo
- Division of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei Cardiovascular Research Institute, Yonsei University, College of Medicine, 250 Seongsanno, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Kyung-Jong Yoo
- Division of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei Cardiovascular Research Institute, Yonsei University, College of Medicine, 250 Seongsanno, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Sak Lee
- Division of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei Cardiovascular Research Institute, Yonsei University, College of Medicine, 250 Seongsanno, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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van der Merwe J, Casselman F. Mitral Valve Replacement-Current and Future Perspectives. Open J Cardiovasc Surg 2017; 9:1179065217719023. [PMID: 28757798 PMCID: PMC5513524 DOI: 10.1177/1179065217719023] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 06/13/2017] [Indexed: 11/20/2022] Open
Abstract
The favorable outcomes achieved with modern mitral valve repair techniques redefined the role of mitral valve replacement. Various international databases report a significant decrease in replacement procedures performed compared with repairs, and contemporary guidelines limit the application of surgical mitral valve replacement to pathology in which durable repair is unlikely to be achieved. The progressive paradigm shift toward endoscopic and robotic mitral valve surgery is also paralleled by rapid developments in transcatheter devices, which is progressively expanding from experimental approaches to becoming clinical reality. This article outlines the current role and future perspectives of contemporary surgical mitral valve replacement within the context of mitral valve repair and the dynamic evolution of exciting transcatheter alternatives.
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Affiliation(s)
- Johan van der Merwe
- The Department of Cardiovascular and Thoracic Surgery, OLV-Clinic, Aalst, Belgium
| | - Filip Casselman
- The Department of Cardiovascular and Thoracic Surgery, OLV-Clinic, Aalst, Belgium
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Bertrand PB, Schwammenthal E, Levine RA, Vandervoort PM. Exercise Dynamics in Secondary Mitral Regurgitation: Pathophysiology and Therapeutic Implications. Circulation 2017; 135:297-314. [PMID: 28093494 DOI: 10.1161/circulationaha.116.025260] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Secondary mitral valve regurgitation (MR) remains a challenging problem in the diagnostic workup and treatment of patients with heart failure. Although secondary MR is characteristically dynamic in nature and sensitive to changes in ventricular geometry and loading, current therapy is mainly focused on resting conditions. An exercise-induced increase in secondary MR, however, is associated with impaired exercise capacity and increased mortality. In an era where a multitude of percutaneous solutions are emerging for the treatment of patients with heart failure, it becomes important to address the dynamic component of secondary MR during exercise as well. A critical reappraisal of the underlying disease mechanisms, in particular the dynamic component during exercise, is of timely importance. This review summarizes the pathophysiological mechanisms involved in the dynamic deterioration of secondary MR during exercise, its functional and prognostic impact, and the way current treatment options affect the dynamic lesion and exercise hemodynamics in general.
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Affiliation(s)
- Philippe B Bertrand
- From Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium (P.B.B., P.M.V.); Faculty of Medicine and Life Sciences, Hasselt University, Belgium (P.B.B., P.M.V.); Heart Center, Sheba Medical Center, Tel Hashomer, Israel (E.S.); and Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston (R.A.L.).
| | - Ehud Schwammenthal
- From Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium (P.B.B., P.M.V.); Faculty of Medicine and Life Sciences, Hasselt University, Belgium (P.B.B., P.M.V.); Heart Center, Sheba Medical Center, Tel Hashomer, Israel (E.S.); and Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston (R.A.L.)
| | - Robert A Levine
- From Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium (P.B.B., P.M.V.); Faculty of Medicine and Life Sciences, Hasselt University, Belgium (P.B.B., P.M.V.); Heart Center, Sheba Medical Center, Tel Hashomer, Israel (E.S.); and Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston (R.A.L.)
| | - Pieter M Vandervoort
- From Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium (P.B.B., P.M.V.); Faculty of Medicine and Life Sciences, Hasselt University, Belgium (P.B.B., P.M.V.); Heart Center, Sheba Medical Center, Tel Hashomer, Israel (E.S.); and Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston (R.A.L.)
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Bertrand PB, Pettinari M, De Cannière H, Gutermann H, Smeets CJ, Verhaert D, Dion RA, Verdonck P, Vandervoort PM. Effective Orifice Area during Exercise in Bileaflet Mechanical Valve Prostheses. J Am Soc Echocardiogr 2017; 30:404-413. [DOI: 10.1016/j.echo.2016.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Indexed: 10/20/2022]
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Prosthesis–patient mismatch due to small ring annuloplasty in patients with degenerative mitral insufficiency. J Cardiol 2016; 68:141-7. [DOI: 10.1016/j.jjcc.2015.09.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 08/27/2015] [Accepted: 09/12/2015] [Indexed: 11/17/2022]
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Toyama M, Usui A, Abe T, Oshima H, Akita T, Ueda Y. Mitral Valve Surgery for Dilated Cardiomyopathy with Mitral Regurgitation. Asian Cardiovasc Thorac Ann 2016; 14:371-6. [PMID: 17005882 DOI: 10.1177/021849230601400505] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Outcomes of surgery for non-ischemic non-valvular dilated cardiomyopathy with associated mitral regurgitation were assessed in 8 consecutive patients who underwent 9 mitral valve operations between 2001 and 2004. Mitral valve replacement was performed when the coaptation depth exceeded 10 mm. Two patients initially underwent mitral valvuloplasty, and 6 underwent valve replacement. One patient had valve replacement soon after valvuloplasty. Transthoracic echocardiography was performed immediately before surgery, before discharge, and during follow-up. Transesophageal echocardiography was carried out intraoperatively to assess valvular and ventricular function. Postoperative mean functional class was significantly better than the preoperative value (2.4 ± 0.7 vs. 3.3 ± 0.7), and the improvement was sustained during follow-up (2.0 ± 0.7). The ejection fraction and left ventricular end-diastolic dimension did not improve. One patient died without leaving hospital and two died during follow-up. The 2- and 4-year survival rates were 75.0% and 37.5%. Mitral valve surgery improved functional class without obvious changes in ejection fraction or left ventricular end-diastolic dimension.
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Affiliation(s)
- Masashi Toyama
- Department of Cardiothoracic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan.
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Predictors of Very Late Events After Percutaneous Mitral Valvuloplasty in Patients With Mitral Stenosis. Am J Cardiol 2016; 117:1978-84. [PMID: 27131615 DOI: 10.1016/j.amjcard.2016.03.051] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Revised: 03/16/2016] [Accepted: 03/16/2016] [Indexed: 11/21/2022]
Abstract
Data on long-term outcomes of percutaneous mitral valvuloplasty (PMV) are still scarce. In addition, the persistence of pulmonary hypertension (PH) after PMV is a complication for which mechanisms and prognostic implications are unclear. Our aims were (1) to report the long-term outcomes of patients with rheumatic mitral stenosis treated with PMV; (2) to determine the risk factors for long-term poor outcomes; and (3) to analyze the prevalence and predictors of persistent PH. We prospectively enrolled 532 patients who underwent PMV from 1987 to 2011 at 2 hospitals. The following end points were assessed after PMV: all-cause mortality, mitral reintervention, a composite end point of all-cause mortality and mitral reintervention, and PH persistence. Survival status was available for 97% patients; the median follow-up was 10 years (interquartile range 4 to 18 years). Procedural success was achieved in 85% patients. During the follow-up, 21% patients died and 27% required mitral reintervention. Before PMV, 74% patients had PH that persisted after PMV in 45% of patients (p <0.001). Unfavorable valve anatomy (Wilkins score >8) and post-PMV mean pulmonary arterial pressure (PAP) were independent predictors of all-cause mortality, mitral reintervention, and the composite end point. Post-PMV mean PAP was significantly correlated with a mitral valve area (MVA) <2.5 cm(2) (p <0.001); in addition, on the echocardiographic follow-up, MVA was an independent predictor of systolic PAP (p <0.001). In conclusion, PMV represents an advantageous therapeutic option for patients with mitral stenosis in terms of long-term outcomes. Unfavorable valve anatomy and persistent PH were the most important predictors of long-term outcomes. The persistence of PH is associated with the MVA obtained after PMV.
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Patient-Prosthesis Mismatch After Mitral Valve Replacement: A Propensity Score Analysis. Ann Thorac Surg 2016; 101:1796-802. [DOI: 10.1016/j.athoracsur.2015.10.032] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 10/04/2015] [Accepted: 10/12/2015] [Indexed: 11/21/2022]
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Cho IJ, Hong GR, Lee SH, Lee S, Chang BC, Shim CY, Chang HJ, Ha JW, Chung N. Prosthesis-Patient Mismatch after Mitral Valve Replacement: Comparison of Different Methods of Effective Orifice Area Calculation. Yonsei Med J 2016; 57:328-36. [PMID: 26847283 PMCID: PMC4740523 DOI: 10.3349/ymj.2016.57.2.328] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 05/13/2015] [Accepted: 06/19/2015] [Indexed: 01/20/2023] Open
Abstract
PURPOSE The incidence of prosthesis-patient mismatch (PPM) after mitral valve replacement (MVR) has been reported to vary. The purpose of the current study was to investigate incidence of PPM according to the different methods of calculating effective orifice area (EOA), including the continuity equation (CE), pressure half time (PHT) method and use of reference EOA, and to compare these with various echocardiographic variables. MATERIALS AND METHODS We retrospectively reviewed 166 individuals who received isolated MVR due to rheumatic mitral stenosis and had postoperative echocardiography performed between 12 and 60 months after MVR. EOA was determined by CE (EOA(CE)) and PHT using Doppler echocardiography. Reference EOA was determined from the literature or values offered by the manufacturer. Indexed EOA was used to define PPM as present if ≤1.2 cm²/m². RESULTS Prevalence of PPM was different depending on the methods used to calculate EOA, ranging from 7% in PHT method to 49% in referred EOA method to 62% in CE methods. The intraclass correlation coefficient was low between the methods. PPM was associated with raised trans-prosthetic pressure, only when calculated by CE (p=0.021). Indexed EOA(CE) was the only predictor of postoperative systolic pulmonary artery (PA) pressure, even after adjusting for age, preoperative systolic PA pressure and postoperative left atrial volume index (p<0.001). CONCLUSION Prevalence of mitral PPM varied according to the methods used to calculate EOA in patients with mitral stenosis after MVR. Among the various methods used to define PPM, EOA(CE) was the only predictor of postoperative hemodynamic parameters.
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Affiliation(s)
- In Jeong Cho
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Geu Ru Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.
| | - Seung Hyun Lee
- Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sak Lee
- Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Chul Chang
- Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Chi Young Shim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyuk Jae Chang
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Won Ha
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Namsik Chung
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
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Cao H, Qiu Z, Chen L, Chen D, Chen Q. Star GK Bileaflet Mechanical Valve Prosthesis-Patient Mismatch after Mitral Valve Replacement: A Chinese Multicenter Clinical Study. Med Sci Monit 2015; 21:2542-6. [PMID: 26313311 PMCID: PMC4556164 DOI: 10.12659/msm.894044] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The aim of this study was to investigate the incidence and immediate and mid-term effects of heart valve prosthesis-patient mismatch (PPM) after mitral valve replacement using the GK bileaflet mechanical valve. MATERIAL AND METHODS A total of 493 cases of mechanical mitral valve replacement were performed in the departments of cardiac surgery in 7 hospitals from January 2000 to January 2008. The patients included 142 men and 351 women ages 21 to 67 (average age, 48.75). The patients were followed for 3 years after surgery. The effective orifice area index (EOAI), ≤1.2 cm2/m2, was detected during the follow-up period and was defined as PPM. The patients were assigned to either the PPM group or the non-PPM group. Finally, the preoperative, perioperative and postoperative indexes of the 2 groups of patients were compared. RESULTS A total of 157 patients had PPM 3 years after surgery. The incidence of PPM was 31.84%. Sixty-three patients in the PPM group received a 25-mm GK bileaflet valve (40.13%), 82 received a 27-mm valve (52.23%), and 12 (7.64%) received a 29-mm valve. There were significant differences in length of intensive care unit stay, duration of ventilator use, length of hospitalization, body surface area, EOAI, mean transmitral pressure gradient, and pulmonary artery pressure between the PPM and non-PPM group (P<0.05). There was a significant difference between preoperative and postoperative pulmonary artery pressures among non-PPM patients (P<0.05); however, there was no statistical difference in preoperative and postoperative pulmonary artery pressures among patients with PPM (P>0.05). CONCLUSIONS PPM after mitral valve replacement influences postoperative hemodynamics. Thus, larger-sized GK bileaflet mechanical valves are often used to reduce the risk of PPM.
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Affiliation(s)
- Hua Cao
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China (mainland)
| | - Zhihuang Qiu
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China (mainland)
| | - Liangwan Chen
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China (mainland)
| | - Daozhong Chen
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China (mainland)
| | - Qiang Chen
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China (mainland)
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Briongos Figuero S, Moya Mur JL, García-Lledó A, Centella T, Salido L, Aceña Navarro Á, García Martín A, García-Andrade I, Oliva E, Zamorano JL. Predictors of persistent pulmonary hypertension after mitral valve replacement. Heart Vessels 2015; 31:1091-9. [PMID: 26056027 DOI: 10.1007/s00380-015-0700-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 06/03/2015] [Indexed: 12/21/2022]
Abstract
Persistent pulmonary hypertension (P-PH) after mitral valve replacement (MVR) leads to an increased risk of morbidity and mortality. We sought to determine which factors were involved in its occurrence. Patients undergoing MVR for a 3-year period were collected in a retrospective way. We excluded those with an available follow-up shorter than 3 months. Sample size was 111 patients. PH was diagnosed if systolic pulmonary artery pressure (sPAP) estimated by Doppler echocardiography was >40 mmHg. Clinical, echocardiographic, and surgical factors were analyzed. P-PH was present in 42.3 % of patients after 12.6 months of mean follow-up. P-PH was more frequently observed in elderly and female patients, in those with severe degrees of PH before surgery, and significant tricuspid regurgitation (TR). On multivariable analysis, significant TR (OR 1.739; p = 0.01) and more severe degrees of PH before surgery (OR 1.761; p = 0.03) were significantly associated with the presence of P-PH after MVR. Surgical factors related to P-PH were prosthesis size and tricuspid annuloplasty: no need for the performing of tricuspid annuloplasty (OR 0.345; p = 0.025) and the implantation of a smaller prosthesis (OR 0.656; p = 0.004) were related to higher rates of P-PH after MVR. MVR was associated with high prevalence of P-PH after mid-term follow-up. Both PH and significant TR before surgery were associated with P-PH. Our data point out that MVR should be planned before the development of PH and greater TR. Smaller prosthetic size is also a risk factor for P-PH and bigger prostheses are desirable when possible.
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Affiliation(s)
- Sem Briongos Figuero
- Cardiology Department, Infanta Leonor, María de Guzmán 38, 3ºE, 28003, Madrid, Spain.
| | | | - Alberto García-Lledó
- Cardiology Department, Hospital Príncipe de Asturias, Alcalá De Henares (Madrid), Spain
| | - Tomasa Centella
- Cardiac Surgery Department, Hospital Ramón y Cajal, Madrid, Spain
| | - Luisa Salido
- Cardiology Department, Hospital Ramón y Cajal, Madrid, Spain
| | | | | | | | - Enrique Oliva
- Cardiac Surgery Department, Hospital Ramón y Cajal, Madrid, Spain
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Management of severe pulmonary hypertension in patients undergoing mitral valve surgery. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2015; 17:382. [PMID: 25912147 DOI: 10.1007/s11936-015-0382-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OPINION STATEMENT Pulmonary hypertension (PH) is simply defined as a mean pulmonary artery pressure greater than 25 mmHg at rest; however, may result from varying combinations of abnormal pulmonary artery (PA) blood flow, pulmonary vascular resistance (PVR), PA compliance, and pulmonary venous pressure. Mitral regurgitation (MR) allows for partial transmission of systemic arterial pressure into the pulmonary venous system. Mitral stenosis (MS) prevents pulmonary venous drainage into the left ventricle. In either case, the direct result is marked pressurization of the pulmonary venous system, with the primary cause of PH in significant mitral valve disease (PHMVD) being pulmonary venous hypertension (PVH). Chronic and severe PVH may then lead to muscularization of the pulmonary arterial bed, with a rise in PVR and loss of pulmonary arterial compliance that follows ("reactive" pulmonary vascular disease). Right heart dysfunction ensues once the PVR rises and the compliance falls to a point in which the right ventricle (RV) cannot overcome the increased afterload. However, it is worth emphasizing that in the setting of PHMVD, no matter the degree of mismatch between RV afterload and RV function, the root condition in the patient and cause of the PH remains severe MV disease. Without correction of the primary condition, the patient's heart failure (HF), PH, PVR, and RV dysfunction will remain or progress. Moreover, direct PH medical therapies are ineffective and may actually worsen left heart congestion in the setting of unremediated MVD. Therefore, although surgery may be a higher risk in some patients with PHMVD, the potential benefits justify the risks in the majority of cases. If needed, direct medical management of PH is far simpler and more effective once the MVD is corrected, given the degree of left heart congestion often improves dramatically. Therefore, corrective mitral valve intervention should be considered as the main and definitive treatment for these patients.
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Bertrand PB, Verbrugge FH, Verhaert D, Smeets CJP, Grieten L, Mullens W, Gutermann H, Dion RA, Levine RA, Vandervoort PM. Mitral valve area during exercise after restrictive mitral valve annuloplasty: importance of diastolic anterior leaflet tethering. J Am Coll Cardiol 2015; 65:452-61. [PMID: 25660923 DOI: 10.1016/j.jacc.2014.11.037] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Revised: 10/27/2014] [Accepted: 11/04/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND Restrictive mitral valve annuloplasty (RMA) for secondary mitral regurgitation might cause functional mitral stenosis, yet its clinical impact and underlying pathophysiological mechanisms remain debated. OBJECTIVES The purpose of our study was to assess the hemodynamic and clinical impact of effective orifice area (EOA) after RMA and its relationship with diastolic anterior leaflet (AL) tethering at rest and during exercise. METHODS Consecutive RMA patients (n = 39) underwent a symptom-limited supine bicycle exercise test with Doppler echocardiography and respiratory gas analysis. EOA, transmitral flow rate, mean transmitral gradient, and systolic pulmonary arterial pressure were assessed at different stages of exercise. AL opening angles were measured at rest and peak exercise. Mortality and heart failure readmission data were collected for at least 20 months after surgery. RESULTS EOA and AL opening angle were 1.5 ± 0.4 cm(2) and 68 ± 10°, respectively, at rest (r = 0.4; p = 0.014). EOA increased significantly to 2.0 ± 0.5 cm(2) at peak exercise (p < 0.001), showing an improved correlation with AL opening angle (r = 0.6; p < 0.001). Indexed EOA (EOAi) at peak exercise was an independent predictor of exercise capacity (maximal oxygen uptake, p = 0.004) and was independently associated with freedom from all-cause mortality or hospital admission for heart failure (p = 0.034). Patients with exercise EOAi <0.9 cm(2)/m(2) (n = 14) compared with ≥0.9 cm(2)/m(2) (n = 25) had a significantly worse outcome (p = 0.048). In multivariate analysis, AL opening angle at peak exercise (p = 0.037) was the strongest predictor of exercise EOAi. CONCLUSIONS In RMA patients, EOA increases during exercise despite fixed annular size. Diastolic AL tethering plays a key role in this dynamic process, with increasing AL opening during exercise being associated with higher exercise EOA. EOAi at peak exercise is a strong and independent predictor of exercise capacity and is associated with clinical outcome. Our findings stress the importance of maximizing AL opening by targeting the subvalvular apparatus in future repair algorithms for secondary mitral regurgitation.
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Affiliation(s)
- Philippe B Bertrand
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Frederik H Verbrugge
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - David Verhaert
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | | | - Lars Grieten
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Herbert Gutermann
- Department of Cardiac Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Robert A Dion
- Department of Cardiac Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Robert A Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Pieter M Vandervoort
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium.
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Gurzun MM, Popescu AC, Ginghina C, Popescu BA. Management of organic mitral regurgitation: guideline recommendations and controversies. Korean Circ J 2015; 45:96-105. [PMID: 25810729 PMCID: PMC4372987 DOI: 10.4070/kcj.2015.45.2.96] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 12/18/2014] [Accepted: 12/23/2014] [Indexed: 11/25/2022] Open
Abstract
Mitral regurgitation (MR) represents the second most frequent valvular heart disease. The appropriate management of organic MR remains unclear in many aspects, especially in several specific clinical scenarios. This review aims to discuss the current guideline recommendations regarding the management of organic MR, while highlighting the controversial aspects encountered in daily clinical practice. The role of imaging is essential in establishing the most appropriate type of surgical treatment (repair or replace), which is based on morphological mitral valve (MV) characteristics (reparability of the valve) and local surgical expertise in valve repair. The potential advantages of 3-dimensional echocardiography in assessing the MV are discussed. Other modern imaging techniques (tissue Doppler and speckle tracking) may provide additional useful information in borderline cases. Exercise echocardiography (evaluating MR severity, pulmonary pressure, or right ventricular function) may have an important role in the management of difficult cases. Finally, the moment when surgery is no longer an option and alternative solutions should be sought is also discussed. Although in everyday clinical practice the timing of surgery is not always straightforward, some newer clinical and echocardiographic indicators can guide this decision and help improve the outcome of these patients.
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Affiliation(s)
- Maria-Magdalena Gurzun
- Cardiology Department, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania. ; Cardiology Department, Emergency Institute for Cardiovascular Diseases "Prof. Dr. C. C. Iliescu", Bucharest, Romania
| | - Andreea C Popescu
- Cardiology Department, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania. ; Cardiology Department, Emergency University Hospital Elias, Bucharest, Romania
| | - Carmen Ginghina
- Cardiology Department, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania. ; Cardiology Department, Emergency Institute for Cardiovascular Diseases "Prof. Dr. C. C. Iliescu", Bucharest, Romania
| | - Bogdan A Popescu
- Cardiology Department, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania. ; Cardiology Department, Emergency Institute for Cardiovascular Diseases "Prof. Dr. C. C. Iliescu", Bucharest, Romania
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Magne J, Pibarot P, Sengupta PP, Donal E, Rosenhek R, Lancellotti P. Pulmonary Hypertension in Valvular Disease. JACC Cardiovasc Imaging 2015; 8:83-99. [DOI: 10.1016/j.jcmg.2014.12.003] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 12/04/2014] [Accepted: 12/05/2014] [Indexed: 10/24/2022]
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Fino C, Iacovoni A, Ferrero P, Senni M, Merlo M, Cugola D, Ferrazzi P, Caputo M, Miceli A, Magne J. Restrictive mitral valve annuloplasty versus mitral valve replacement for functional ischemic mitral regurgitation: An exercise echocardiographic study. J Thorac Cardiovasc Surg 2014; 148:447-53.e2. [DOI: 10.1016/j.jtcvs.2013.05.053] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Revised: 05/16/2013] [Accepted: 05/31/2013] [Indexed: 11/29/2022]
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Abstract
Resting echocardiography is the most important tool for diagnosing valvular heart disease. However, treatment planning in valvular heart diseases may require additional information in some patients, particularly asymptomatic patients with severe valve disease or symptomatic patients with moderate disease. Stress echocardiography provides invaluable information in these situations and aids decision making. Stress echocardiography is performed using either physical stress or dobutamine stress and various valve parameters are monitored during the stress. Further, the ventricular performance, which is an important determinant of outcome in valve disease is also closely monitored during stress which helps immensely in planning the intervention. Lastly, possibility of associated coronary artery disease can also be evaluated, especially in the elderly. This article discusses the role of stress evaluation in assessment of valve disease in the commonly encountered clinical situations.
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Affiliation(s)
- S T Yavagal
- Professor and HOD Cardiology, Kempegowda Institute of Medical Sciences, Bangalore, India.
| | - Niteen Deshpande
- Director, Cardiac Cath Lab, Spandan Heart Institute and Research Center, Dhantoli, Nagpur, India
| | - Parag Admane
- Senior Registrar Cardiology, Spandan Heart Institute and Research Center, Dhantoli, Nagpur, India
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Maslow A, Mahmood F, Poppas A, Singh A. Three-Dimensional Echocardiographic Assessment of the Repaired Mitral Valve. J Cardiothorac Vasc Anesth 2014; 28:11-17. [DOI: 10.1053/j.jvca.2013.05.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Indexed: 12/16/2022]
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Sato S, Fujita T, Shimahara Y, Hata H, Kobayashi J. Impact of Prosthesis-Patient Mismatch on Late Recurrence of Atrial Fibrillation After Cryomaze Procedure With Mitral Valve Replacement. Circ J 2014; 78:1908-14. [DOI: 10.1253/circj.cj-14-0431] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Shunsuke Sato
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Tomoyuki Fujita
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Yusuke Shimahara
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Hiroki Hata
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Junjiro Kobayashi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
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Ulus AT, Poyraz NY, Arat N, Babaroğlu S, Parlar Aİ, Yavaş S, Unlü M. Right ventricular and septal function in patients with pulmonary hypertension. Heart Lung Circ 2013; 22:1003-10. [PMID: 23906876 DOI: 10.1016/j.hlc.2013.04.116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Revised: 04/19/2013] [Accepted: 04/23/2013] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Pulmonary hypertension (PHT) exacerbates the functions of both ventricles. This prospective, randomised study was planned to investigate the effects of PHT on kinetics of both ventricles and the septum. METHODS Twenty-five patients were randomly selected among the patients who had been planned to undergo mitral valve replacement (MVR) because of isolated mitral stenosis and divided into two groups according to their preoperative pulmonary artery pressure (PAP) values. Blood pool gated single photon emission tomography (BPGS) and transthoracic echocardiography were performed. Ventricles' regional, global and functional parameters were also assessed by using pulsed wave Doppler tissue imaging (DTI). RESULTS Preoperative and postoperative PAP of the group 1 (PAP < 50 mmHg) were 40.0 ± 2.8 and 30.0 ± 2.6 mmHg (p = 0.03), group 2 (PAP ≥ 50 mmHg) were 71.9 ± 4.7 and 50.6 ± 3.5 mmHg (p < 0.05). The global right and left ventricle scores were decreased after the operation. The decrement was only significant in group 2. Considering the septal kinetics, right ventricle septal score was decreased from 7.6 to 3.3 (p < 0.05) in group 1, from 3.8 to 1.6 (p < 0.05) in group 2 postoperatively. CONCLUSION Following MVR, a decrement in PAP values, and an improvement in ventricular function, especially in the right ventricular and septal kinetics were achieved. Furthermore, it was found that both DTI and BPGS techniques are beneficial to investigate the functional changes postoperatively and in the follow-up period of the patients who undergo mitral valve surgery.
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Affiliation(s)
- A Tulga Ulus
- Department of Cardiovascular Surgery, Türkiye Yüksek Ihtisas Hospital, Ankara, Turkey.
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Nozohoor S, Hyllén S, Meurling C, Wierup P, Sjögren J. Prognostic value of pulmonary hypertension in patients undergoing surgery for degenerative mitral valve disease with leaflet prolapse. J Card Surg 2013; 27:668-75. [PMID: 23173853 DOI: 10.1111/jocs.12026] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND AIM OF THE STUDY The aim of this study was to evaluate the impact of pulmonary hypertension (PH) on early and late outcomes following surgery in patients with degenerative mitral regurgitation. METHODS The study included 270 patients who had undergone isolated mitral valve surgery (MVS) for leaflet prolapse during 1998 to 2010. Pulmonary artery systolic pressure (PASP) was measured with Doppler echocardiography pre- and postoperatively. The impact of PH (PASP > 50 mmHg) on mortality and the potential for postoperative resolution of preoperatively elevated PASP was retrospectively analyzed. RESULTS The incidence of PH was 27% (n = 74/270). Postoperative normalization, or reduction of preoperative PASP, was demonstrated in 87% of the patients with PH at a median of two months (interquartile range 1 to 19). Absent improvement or a postoperative increase in PASP was independently predicted by age (OR 1.08, 95% CI 1.02-1.14, p = 0.010). Preoperative PH resulted in a fourfold higher risk of postoperative mortality (HR 4.3, 95% CI 1.1-17.4, p = 0.039) during the first three years of follow-up. CONCLUSIONS PH is an independent predictor of mortality during the initial three years following MVS. The majority of patients with PH demonstrated a reduction of preoperatively elevated PASP following surgery and the increased risk of mortality gradually decreased after three years. Our findings support early admission for mitral valve surgery before the occurrence of PH.
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Affiliation(s)
- Shahab Nozohoor
- Department of Cardiothoracic Surgery, Anesthesia and Intensive Care, Skane University Hospital, Lund University, Lund, Sweden.
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Bottio T, Dal Lin C, Lika A, Rizzoli G, Tarzia V, Buratto E, Gerosa G. In vitro comparison of different mechanical prostheses suitable for replacement of the systemic atrioventricular valve in children. J Thorac Cardiovasc Surg 2012; 143:558-68. [DOI: 10.1016/j.jtcvs.2011.05.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2010] [Revised: 04/28/2011] [Accepted: 05/18/2011] [Indexed: 11/24/2022]
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Grimaldi A, Olivotto I, Figini F, Pappalardo F, Capritti E, Ammirati E, Maisano F, Benussi S, Fumero A, Castiglioni A, De Bonis M, Vermi AC, Colombo A, Zangrillo A, Alfieri O. Dynamic assessment of 'valvular reserve capacity' in patients with rheumatic mitral stenosis. Eur Heart J Cardiovasc Imaging 2011; 13:476-82. [DOI: 10.1093/ejechocard/jer269] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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