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Gulati A, Gulati V, Hu R, Rajiah PS, Stojanovska J, Febbo J, Litt HI, Pavri B, Sundaram B. Mitral Annular Disjunction: Review of an Increasingly Recognized Mitral Valve Entity. Radiol Cardiothorac Imaging 2023; 5:e230131. [PMID: 38166341 PMCID: PMC11163248 DOI: 10.1148/ryct.230131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 08/22/2023] [Accepted: 10/30/2023] [Indexed: 01/04/2024]
Abstract
Mitral annular disjunction (MAD) refers to atrial displacement of the hinge point of the mitral valve annulus from the ventricular myocardium. MAD leads to paradoxical expansion of the annulus in systole and may often be associated with mitral valve prolapse (MVP), leaflet degeneration, myocardial and papillary muscle fibrosis, and, potentially, malignant cardiac arrhythmias. Patients with MAD and MVP may present similarly, and MAD is potentially the missing link in explaining why some patients with MVP experience adverse outcomes. Patients with a 5 mm or longer MAD distance have an elevated risk of malignant cardiac arrhythmia compared with those with a shorter MAD distance. Evaluation for MAD is an important component of cardiac imaging, especially in patients with MVP and unexplained cardiac arrhythmias. Cardiac MRI is an important diagnostic tool that aids in recognizing and quantifying MAD, MVP, and fibrosis in the papillary muscle and myocardium, which may predict and help improve outcomes following electrophysiology procedures and mitral valve surgery. This article reviews the history, pathophysiology, controversy, prevalence, clinical implications, and imaging considerations of MAD, focusing on cardiac MRI. Keywords: MR-Dynamic Contrast Enhanced, Cardiac, Mitral Valve, Mitral Annular Disjunction, Mitral Valve Prolapse, Floppy Mitral Valve, Cardiac MRI, Arrhythmia, Sudden Cardiac Death, Barlow Valve © RSNA, 2023.
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Affiliation(s)
- Aishwarya Gulati
- From the Department of Radiology (A.G., B.S.) and Department of
Internal Medicine, Division of Cardiology (B.P.), Thomas Jefferson University
Hospital, 132 S 10th St, Philadelphia, PA 19107; Department of Radiology, Mercy
Fitzgerald Hospital, Darby, Pa (V.G.); Division of Cardiovascular Medicine
(R.H., H.I.L.) and Department of Radiology (H.I.L.), University of Pennsylvania
Perelman School of Medicine, Philadelphia, Pa; Department of Radiology, Mayo
Clinic, Rochester, Minn (P.S.R.); Department of Radiology, New York University
Hospital, New York, NY (J.S.); and Department of Radiology, University of New
Mexico, Albuquerque, NM (J.F.)
| | - Vaibhav Gulati
- From the Department of Radiology (A.G., B.S.) and Department of
Internal Medicine, Division of Cardiology (B.P.), Thomas Jefferson University
Hospital, 132 S 10th St, Philadelphia, PA 19107; Department of Radiology, Mercy
Fitzgerald Hospital, Darby, Pa (V.G.); Division of Cardiovascular Medicine
(R.H., H.I.L.) and Department of Radiology (H.I.L.), University of Pennsylvania
Perelman School of Medicine, Philadelphia, Pa; Department of Radiology, Mayo
Clinic, Rochester, Minn (P.S.R.); Department of Radiology, New York University
Hospital, New York, NY (J.S.); and Department of Radiology, University of New
Mexico, Albuquerque, NM (J.F.)
| | - Ray Hu
- From the Department of Radiology (A.G., B.S.) and Department of
Internal Medicine, Division of Cardiology (B.P.), Thomas Jefferson University
Hospital, 132 S 10th St, Philadelphia, PA 19107; Department of Radiology, Mercy
Fitzgerald Hospital, Darby, Pa (V.G.); Division of Cardiovascular Medicine
(R.H., H.I.L.) and Department of Radiology (H.I.L.), University of Pennsylvania
Perelman School of Medicine, Philadelphia, Pa; Department of Radiology, Mayo
Clinic, Rochester, Minn (P.S.R.); Department of Radiology, New York University
Hospital, New York, NY (J.S.); and Department of Radiology, University of New
Mexico, Albuquerque, NM (J.F.)
| | - Prabhakar Shantha Rajiah
- From the Department of Radiology (A.G., B.S.) and Department of
Internal Medicine, Division of Cardiology (B.P.), Thomas Jefferson University
Hospital, 132 S 10th St, Philadelphia, PA 19107; Department of Radiology, Mercy
Fitzgerald Hospital, Darby, Pa (V.G.); Division of Cardiovascular Medicine
(R.H., H.I.L.) and Department of Radiology (H.I.L.), University of Pennsylvania
Perelman School of Medicine, Philadelphia, Pa; Department of Radiology, Mayo
Clinic, Rochester, Minn (P.S.R.); Department of Radiology, New York University
Hospital, New York, NY (J.S.); and Department of Radiology, University of New
Mexico, Albuquerque, NM (J.F.)
| | - Jadranka Stojanovska
- From the Department of Radiology (A.G., B.S.) and Department of
Internal Medicine, Division of Cardiology (B.P.), Thomas Jefferson University
Hospital, 132 S 10th St, Philadelphia, PA 19107; Department of Radiology, Mercy
Fitzgerald Hospital, Darby, Pa (V.G.); Division of Cardiovascular Medicine
(R.H., H.I.L.) and Department of Radiology (H.I.L.), University of Pennsylvania
Perelman School of Medicine, Philadelphia, Pa; Department of Radiology, Mayo
Clinic, Rochester, Minn (P.S.R.); Department of Radiology, New York University
Hospital, New York, NY (J.S.); and Department of Radiology, University of New
Mexico, Albuquerque, NM (J.F.)
| | - Jennifer Febbo
- From the Department of Radiology (A.G., B.S.) and Department of
Internal Medicine, Division of Cardiology (B.P.), Thomas Jefferson University
Hospital, 132 S 10th St, Philadelphia, PA 19107; Department of Radiology, Mercy
Fitzgerald Hospital, Darby, Pa (V.G.); Division of Cardiovascular Medicine
(R.H., H.I.L.) and Department of Radiology (H.I.L.), University of Pennsylvania
Perelman School of Medicine, Philadelphia, Pa; Department of Radiology, Mayo
Clinic, Rochester, Minn (P.S.R.); Department of Radiology, New York University
Hospital, New York, NY (J.S.); and Department of Radiology, University of New
Mexico, Albuquerque, NM (J.F.)
| | - Harold I. Litt
- From the Department of Radiology (A.G., B.S.) and Department of
Internal Medicine, Division of Cardiology (B.P.), Thomas Jefferson University
Hospital, 132 S 10th St, Philadelphia, PA 19107; Department of Radiology, Mercy
Fitzgerald Hospital, Darby, Pa (V.G.); Division of Cardiovascular Medicine
(R.H., H.I.L.) and Department of Radiology (H.I.L.), University of Pennsylvania
Perelman School of Medicine, Philadelphia, Pa; Department of Radiology, Mayo
Clinic, Rochester, Minn (P.S.R.); Department of Radiology, New York University
Hospital, New York, NY (J.S.); and Department of Radiology, University of New
Mexico, Albuquerque, NM (J.F.)
| | - Behzad Pavri
- From the Department of Radiology (A.G., B.S.) and Department of
Internal Medicine, Division of Cardiology (B.P.), Thomas Jefferson University
Hospital, 132 S 10th St, Philadelphia, PA 19107; Department of Radiology, Mercy
Fitzgerald Hospital, Darby, Pa (V.G.); Division of Cardiovascular Medicine
(R.H., H.I.L.) and Department of Radiology (H.I.L.), University of Pennsylvania
Perelman School of Medicine, Philadelphia, Pa; Department of Radiology, Mayo
Clinic, Rochester, Minn (P.S.R.); Department of Radiology, New York University
Hospital, New York, NY (J.S.); and Department of Radiology, University of New
Mexico, Albuquerque, NM (J.F.)
| | - Baskaran Sundaram
- From the Department of Radiology (A.G., B.S.) and Department of
Internal Medicine, Division of Cardiology (B.P.), Thomas Jefferson University
Hospital, 132 S 10th St, Philadelphia, PA 19107; Department of Radiology, Mercy
Fitzgerald Hospital, Darby, Pa (V.G.); Division of Cardiovascular Medicine
(R.H., H.I.L.) and Department of Radiology (H.I.L.), University of Pennsylvania
Perelman School of Medicine, Philadelphia, Pa; Department of Radiology, Mayo
Clinic, Rochester, Minn (P.S.R.); Department of Radiology, New York University
Hospital, New York, NY (J.S.); and Department of Radiology, University of New
Mexico, Albuquerque, NM (J.F.)
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Battaglia V, Santangelo G, Bursi F, Simeoli P, Guazzi M. Arrhythmogenic Mitral Valve Prolapse and Sudden Cardiac Death: An Update and Current Perspectives. Curr Probl Cardiol 2023; 48:101724. [PMID: 36967070 DOI: 10.1016/j.cpcardiol.2023.101724] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 03/22/2023] [Indexed: 04/22/2023]
Abstract
Mitral valve prolapse (MVP) affects about 2% to 3% of the general population, mostly women, and is the most common cause of primary chronic mitral regurgitation (MR) in western countries. The natural history is heterogeneous and widely determined by the severity of MR. Although most patients remain asymptomatic with a near-normal life expectancy, approximately 5% to 10 % progress to severe MR. As largely recognized, left ventricular (LV) dysfunction due to chronic volume overload per se identifies a subgroup at risk of cardiac death. However, there is rising evidence of a link between MVP and life threating ventricular arrhythmias (VAs)/sudden cardiac death (SCD) in a small subset of middle-aged patients without significant MR, heart failure and remodeled hearts. The present review focuses on the underlying mechanism of electric instability and unexpected cardiac death in this subset of young patients, from the myocardial scarring of the LV infero-lateral wall due to mechanical stretch exerted by the prolapsing leaflets and mitral annular disjunction, to the inflammation's impact on fibrosis pathways along with a constitutional hyperadrenergic state. The heterogeneity of clinical course reveals a necessity of risk stratification, preferably through noninvasive multimodality imaging, that will help to identify and prevent adverse scenarios in young MVP patients.
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Affiliation(s)
- Valeria Battaglia
- Division of Cardiology, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan, Italy.
| | - Gloria Santangelo
- Division of Cardiology, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan, Italy
| | - Francesca Bursi
- Division of Cardiology, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan, Italy
| | - Pasquale Simeoli
- Division of Cardiology, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan, Italy
| | - Marco Guazzi
- Division of Cardiology, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan, Italy
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Mineralocorticoid Receptor Antagonists Mitigate Mitral Regurgitation-Induced Myocardial Dysfunction. Cells 2022; 11:cells11172750. [PMID: 36078158 PMCID: PMC9455158 DOI: 10.3390/cells11172750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 08/25/2022] [Accepted: 08/29/2022] [Indexed: 12/02/2022] Open
Abstract
Mitral regurgitation (MR), the disruption of the mitral valve, contributes to heart failure (HF). Under conditions of volume overload, excess mineralocorticoids promote cardiac fibrosis. The mineralocorticoid receptor antagonist spironolactone is a potassium-sparing diuretic and a guideline-recommended therapy for HF, but whether it can ameliorate degenerative MR remains unknown. Herein, we investigate the efficacy of spironolactone in improving cardiac remodeling in MR-induced HF compared with that of a loop diuretic, furosemide. Using a novel and mini-invasive technique, we established a rat model of MR. We treated the rats with spironolactone or furosemide for twelve weeks. The levels of cardiac fibrosis, apoptosis, and stress-associated proteins were then measured. In parallel, we compared the cardiac remodeling of 165 patients with degenerative MR receiving either spironolactone or furosemide. Echocardiography was performed at baseline and at six months. In MR rats treated with spironolactone, left ventricular function—especially when strained—and the pressure volume relationship significantly improved compared to those of rats treated with furosemide. Spironolactone treatment demonstrated significant attenuation of cardiac fibrosis and apoptosis in left ventricular tissue compared to furosemide. Further, spironolactone suppressed the expression of apoptosis-, NADPH oxidase 4 (NOX4)- and inducible nitric oxide synthase (iNOS)-associated proteins. Similarly, compared with MR patients receiving furosemide those prescribed spironolactone demonstrated a trend toward reduction in MR severity and showed improvement in left ventricular function. Collectively, MR-induced cardiovascular dysfunction, including fibrosis and apoptosis, was effectively attenuated by spironolactone treatment. Our findings suggest a potential therapeutic option for degenerative MR-induced HF.
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Malignant Mitral Valve Prolapse: Risk and Prevention of Sudden Cardiac Death. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2022; 24:61-86. [PMID: 35784809 PMCID: PMC9241643 DOI: 10.1007/s11936-022-00956-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Purpose of review The purpose of this review is to explore the prevalence and risk factors for a malignant phenotype in mitral valve prolapse (MVP) characterized by life-threatening ventricular arrhythmias and sudden cardiac arrest and death (SCD), including mechanistic and pathophysiologic findings and mechanism-based potential therapies. Recent findings A malignant phenotype in MVP characterized by life-threatening arrhythmias has long been recognized, although MVP is often benign. Efforts to identify this malignant phenotype have revealed potential risk factors for SCD that include elongated, myxomatous leaflets, ECG changes and complex ventricular ectopy. More recently, malignant MVP has been associated with myocardial fibrosis in the papillary muscles and inferobasal left ventricular wall. This localization suggests a central role of prolapse-induced mechanical forces on the myocardium in creating an arrhythmogenic substrate and triggering life-threatening arrhythmias. This mechanism for fibrosis is also consistent with imaging evidence of prolapse-induced mechanical changes in the papillary muscles and inferobasal left ventricular wall. Currently, no therapy to prevent SCD in malignant MVP has been established and limited clinical data are available. Mechanistic information and prospective study have the potential to identify patients at risk of SCD and preventive strategies. Summary Malignant MVP relates to unique properties and mechanical abnormalities in the mitral valve apparatus and adjacent myocardium. Increased understanding of disease mechanisms and determinants of arrhythmias is needed to establish effective therapies.
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Primary Cilia and Their Role in Acquired Heart Disease. Cells 2022; 11:cells11060960. [PMID: 35326411 PMCID: PMC8946116 DOI: 10.3390/cells11060960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 12/10/2022] Open
Abstract
Primary cilia are non-motile plasma membrane extrusions that display a variety of receptors and mechanosensors. Loss of function results in ciliopathies, which have been strongly linked with congenital heart disease, as well as abnormal development and function of most organ systems. Adults with congenital heart disease have high rates of acquired heart failure, and usually die from a cardiac cause. Here we explore primary cilia’s role in acquired heart disease. Intraflagellar Transport 88 knockout results in reduced primary cilia, and knockout from cardiac endothelium produces myxomatous degeneration similar to mitral valve prolapse seen in adult humans. Induced primary cilia inactivation by other mechanisms also produces excess myocardial hypertrophy and altered scar architecture after ischemic injury, as well as hypertension due to a lack of vascular endothelial nitric oxide synthase activation and the resultant left ventricular dysfunction. Finally, primary cilia have cell-to-cell transmission capacity which, when blocked, leads to progressive left ventricular hypertrophy and heart failure, though this mechanism has not been fully established. Further research is still needed to understand primary cilia’s role in adult cardiac pathology, especially heart failure.
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Morningstar JE, Nieman A, Wang C, Beck T, Harvey A, Norris RA. Mitral Valve Prolapse and Its Motley Crew-Syndromic Prevalence, Pathophysiology, and Progression of a Common Heart Condition. J Am Heart Assoc 2021; 10:e020919. [PMID: 34155898 PMCID: PMC8403286 DOI: 10.1161/jaha.121.020919] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 04/21/2021] [Indexed: 01/01/2023]
Abstract
Mitral valve prolapse (MVP) is a commonly occurring heart condition defined by enlargement and superior displacement of the mitral valve leaflet(s) during systole. Although commonly seen as a standalone disorder, MVP has also been described in case reports and small studies of patients with various genetic syndromes. In this review, we analyzed the prevalence of MVP within syndromes where an association to MVP has previously been reported. We further discussed the shared biological pathways that cause MVP in these syndromes, as well as how MVP in turn causes a diverse array of cardiac and noncardiac complications. We found 105 studies that identified patients with mitral valve anomalies within 18 different genetic, developmental, and connective tissue diseases. We show that some disorders previously believed to have an increased prevalence of MVP, including osteogenesis imperfecta, fragile X syndrome, Down syndrome, and Pseudoxanthoma elasticum, have few to no studies that use up-to-date diagnostic criteria for the disease and therefore may be overestimating the prevalence of MVP within the syndrome. Additionally, we highlight that in contrast to early studies describing MVP as a benign entity, the clinical course experienced by patients can be heterogeneous and may cause significant cardiovascular morbidity and mortality. Currently only surgical correction of MVP is curative, but it is reserved for severe cases in which irreversible complications of MVP may already be established; therefore, a review of clinical guidelines to allow for earlier surgical intervention may be warranted to lower cardiovascular risk in patients with MVP.
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Affiliation(s)
- Jordan E. Morningstar
- Department of Regenerative Medicine and Cell BiologyMedical University of South CarolinaCharlestonSC
| | - Annah Nieman
- Department of Regenerative Medicine and Cell BiologyMedical University of South CarolinaCharlestonSC
| | - Christina Wang
- Department of Regenerative Medicine and Cell BiologyMedical University of South CarolinaCharlestonSC
| | - Tyler Beck
- Department of Regenerative Medicine and Cell BiologyMedical University of South CarolinaCharlestonSC
| | - Andrew Harvey
- Department of Regenerative Medicine and Cell BiologyMedical University of South CarolinaCharlestonSC
| | - Russell A. Norris
- Department of Regenerative Medicine and Cell BiologyMedical University of South CarolinaCharlestonSC
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7
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Toomer KA, Yu M, Fulmer D, Guo L, Moore KS, Moore R, Drayton KD, Glover J, Peterson N, Ramos-Ortiz S, Drohan A, Catching BJ, Stairley R, Wessels A, Lipschutz JH, Delling FN, Jeunemaitre X, Dina C, Collins RL, Brand H, Talkowski ME, Del Monte F, Mukherjee R, Awgulewitsch A, Body S, Hardiman G, Hazard ES, da Silveira WA, Wang B, Leyne M, Durst R, Markwald RR, Le Scouarnec S, Hagege A, Le Tourneau T, Kohl P, Rog-Zielinska EA, Ellinor PT, Levine RA, Milan DJ, Schott JJ, Bouatia-Naji N, Slaugenhaupt SA, Norris RA. Primary cilia defects causing mitral valve prolapse. Sci Transl Med 2020; 11:11/493/eaax0290. [PMID: 31118289 PMCID: PMC7331025 DOI: 10.1126/scitranslmed.aax0290] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 04/25/2019] [Indexed: 12/15/2022]
Abstract
Mitral valve prolapse (MVP) affects 1 in 40 people and is the most common indication for mitral valve surgery. MVP can cause arrhythmias, heart failure, and sudden cardiac death, and to date, the causes of this disease are poorly understood. We now demonstrate that defects in primary cilia genes and their regulated pathways can cause MVP in familial and sporadic nonsyndromic MVP cases. Our expression studies and genetic ablation experiments confirmed a role for primary cilia in regulating ECM deposition during cardiac development. Loss of primary cilia during development resulted in progressive myxomatous degeneration and profound mitral valve pathology in the adult setting. Analysis of a large family with inherited, autosomal dominant nonsyndromic MVP identified a deleterious missense mutation in a cilia gene, DZIP1 A mouse model harboring this variant confirmed the pathogenicity of this mutation and revealed impaired ciliogenesis during development, which progressed to adult myxomatous valve disease and functional MVP. Relevance of primary cilia in common forms of MVP was tested using pathway enrichment in a large population of patients with MVP and controls from previously generated genome-wide association studies (GWAS), which confirmed the involvement of primary cilia genes in MVP. Together, our studies establish a developmental basis for MVP through altered cilia-dependent regulation of ECM and suggest that defects in primary cilia genes can be causative to disease phenotype in some patients with MVP.
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Affiliation(s)
- Katelynn A Toomer
- Cardiovascular Developmental Biology Center, Department of Regenerative Medicine and Cell Biology, College of Medicine, Children's Research Institute, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425, USA
| | - Mengyao Yu
- INSERM, UMR-970, Paris Cardiovascular Research Center, 75015 Paris, France.,Paris Descartes University, Sorbonne Paris Cité, Faculty of Medicine, 75006 Paris, France
| | - Diana Fulmer
- Cardiovascular Developmental Biology Center, Department of Regenerative Medicine and Cell Biology, College of Medicine, Children's Research Institute, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425, USA
| | - Lilong Guo
- Cardiovascular Developmental Biology Center, Department of Regenerative Medicine and Cell Biology, College of Medicine, Children's Research Institute, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425, USA
| | - Kelsey S Moore
- Cardiovascular Developmental Biology Center, Department of Regenerative Medicine and Cell Biology, College of Medicine, Children's Research Institute, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425, USA
| | - Reece Moore
- Cardiovascular Developmental Biology Center, Department of Regenerative Medicine and Cell Biology, College of Medicine, Children's Research Institute, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425, USA
| | - Ka'la D Drayton
- Cardiovascular Developmental Biology Center, Department of Regenerative Medicine and Cell Biology, College of Medicine, Children's Research Institute, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425, USA
| | - Janiece Glover
- Cardiovascular Developmental Biology Center, Department of Regenerative Medicine and Cell Biology, College of Medicine, Children's Research Institute, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425, USA
| | - Neal Peterson
- Cardiovascular Developmental Biology Center, Department of Regenerative Medicine and Cell Biology, College of Medicine, Children's Research Institute, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425, USA
| | - Sandra Ramos-Ortiz
- Cardiovascular Developmental Biology Center, Department of Regenerative Medicine and Cell Biology, College of Medicine, Children's Research Institute, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425, USA
| | - Alex Drohan
- Cardiovascular Developmental Biology Center, Department of Regenerative Medicine and Cell Biology, College of Medicine, Children's Research Institute, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425, USA
| | - Breiona J Catching
- Cardiovascular Developmental Biology Center, Department of Regenerative Medicine and Cell Biology, College of Medicine, Children's Research Institute, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425, USA
| | - Rebecca Stairley
- Cardiovascular Developmental Biology Center, Department of Regenerative Medicine and Cell Biology, College of Medicine, Children's Research Institute, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425, USA
| | - Andy Wessels
- Cardiovascular Developmental Biology Center, Department of Regenerative Medicine and Cell Biology, College of Medicine, Children's Research Institute, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425, USA
| | - Joshua H Lipschutz
- Department of Medicine, Medical University of South Carolina, Charleston, SC 29425, USA.,Department of Medicine, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC 29401, USA
| | - Francesca N Delling
- Department of Medicine, Division of Cardiology, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Xavier Jeunemaitre
- INSERM, UMR-970, Paris Cardiovascular Research Center, 75015 Paris, France.,Paris Descartes University, Sorbonne Paris Cité, Faculty of Medicine, 75006 Paris, France.,Assistance Publique-Hôpitaux de Paris, Département de Génétique, Hôpital Européen Georges Pompidou, 75015 Paris, France
| | - Christian Dina
- INSERM, CNRS, Univ Nantes, L'Institut du Thorax, Nantes 44093, France.,CHU Nantes, L'Institut du Thorax, Service de Cardiologie, Nantes 44093, France
| | - Ryan L Collins
- Center for Genomic Medicine, Department of Neurology, Massachusetts General Hospital Research Institute, Harvard Medical School, 185 Cambridge St., Boston, MA 02114, USA
| | - Harrison Brand
- Center for Genomic Medicine, Department of Neurology, Massachusetts General Hospital Research Institute, Harvard Medical School, 185 Cambridge St., Boston, MA 02114, USA
| | - Michael E Talkowski
- Center for Genomic Medicine, Department of Neurology, Massachusetts General Hospital Research Institute, Harvard Medical School, 185 Cambridge St., Boston, MA 02114, USA
| | - Federica Del Monte
- Gazes Cardiac Research Institute, Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Rupak Mukherjee
- Gazes Cardiac Research Institute, Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Alexander Awgulewitsch
- Cardiovascular Developmental Biology Center, Department of Regenerative Medicine and Cell Biology, College of Medicine, Children's Research Institute, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425, USA
| | - Simon Body
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Gary Hardiman
- Center for Genomic Medicine, Medical University of South Carolina, 135 Cannon Street, Suite 303 MSC 835, Charleston, SC 29425, USA.,Faculty of Medicine, Health and Life Sciences School of Biological Sciences, Institute for Global Food Security (IGFS), Queen's University Belfast, Belfast, Northern Ireland, BT7 1NN, UK
| | - E Starr Hazard
- Center for Genomic Medicine, Medical University of South Carolina, 135 Cannon Street, Suite 303 MSC 835, Charleston, SC 29425, USA
| | - Willian A da Silveira
- Center for Genomic Medicine, Medical University of South Carolina, 135 Cannon Street, Suite 303 MSC 835, Charleston, SC 29425, USA
| | - Baolin Wang
- Department of Genetic Medicine, Weill Medical College of Cornell University, New York, NY 10065, USA
| | - Maire Leyne
- Center for Genomic Medicine, Department of Neurology, Massachusetts General Hospital Research Institute, Harvard Medical School, 185 Cambridge St., Boston, MA 02114, USA
| | - Ronen Durst
- Cardiology Division, Hadassah Hebrew University Medical Center, POB 12000, Jerusalem, Israel
| | - Roger R Markwald
- Cardiovascular Developmental Biology Center, Department of Regenerative Medicine and Cell Biology, College of Medicine, Children's Research Institute, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425, USA
| | | | - Albert Hagege
- INSERM, UMR-970, Paris Cardiovascular Research Center, 75015 Paris, France.,Paris Descartes University, Sorbonne Paris Cité, Faculty of Medicine, 75006 Paris, France.,Assistance Publique-Hôpitaux de Paris, Department of Cardiology, Hôpital Européen Georges Pompidou, 75015 Paris, France
| | - Thierry Le Tourneau
- INSERM, CNRS, Univ Nantes, L'Institut du Thorax, Nantes 44093, France.,CHU Nantes, L'Institut du Thorax, Service de Cardiologie, Nantes 44093, France
| | - Peter Kohl
- University Heart Center Freiburg, Bad Krozingen and Faculty of Medicine of the Albert-Ludwigs University Freiburg, Institute for Experimental Cardiovascular Medicine, Elsässerstr 2Q, 79110 Freiburg, Germany
| | - Eva A Rog-Zielinska
- University Heart Center Freiburg, Bad Krozingen and Faculty of Medicine of the Albert-Ludwigs University Freiburg, Institute for Experimental Cardiovascular Medicine, Elsässerstr 2Q, 79110 Freiburg, Germany
| | - Patrick T Ellinor
- Cardiovascular Research Center, Cardiology Division, Massachusetts General Hospital Research Institute, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Robert A Levine
- Cardiac Ultrasound Laboratory, Cardiology Division, Massachusetts General Hospital Research Institute, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - David J Milan
- Cardiovascular Research Center, Cardiology Division, Massachusetts General Hospital Research Institute, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA.,Leducq Foundation, 265 Franklin Street, Suite 1902, Boston, MA, 02110, USA
| | - Jean-Jacques Schott
- INSERM, CNRS, Univ Nantes, L'Institut du Thorax, Nantes 44093, France.,CHU Nantes, L'Institut du Thorax, Service de Cardiologie, Nantes 44093, France
| | - Nabila Bouatia-Naji
- INSERM, UMR-970, Paris Cardiovascular Research Center, 75015 Paris, France.,Paris Descartes University, Sorbonne Paris Cité, Faculty of Medicine, 75006 Paris, France
| | - Susan A Slaugenhaupt
- Center for Genomic Medicine, Department of Neurology, Massachusetts General Hospital Research Institute, Harvard Medical School, 185 Cambridge St., Boston, MA 02114, USA
| | - Russell A Norris
- Cardiovascular Developmental Biology Center, Department of Regenerative Medicine and Cell Biology, College of Medicine, Children's Research Institute, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425, USA.
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Fulmer D, Toomer KA, Glover J, Guo L, Moore K, Moore R, Stairley R, Gensemer C, Abrol S, Rumph MK, Emetu F, Lipschutz JH, McDowell C, Bian J, Wang C, Beck T, Wessels A, Renault MA, Norris RA. Desert hedgehog-primary cilia cross talk shapes mitral valve tissue by organizing smooth muscle actin. Dev Biol 2020; 463:26-38. [PMID: 32151560 DOI: 10.1016/j.ydbio.2020.03.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 02/27/2020] [Accepted: 03/02/2020] [Indexed: 01/01/2023]
Abstract
Non-syndromic mitral valve prolapse (MVP) is the most common heart valve disease affecting 2.4% of the population. Recent studies have identified genetic defects in primary cilia as causative to MVP, although the mechanism of their action is currently unknown. Using a series of gene inactivation approaches, we define a paracrine mechanism by which endocardially-expressed Desert Hedgehog (DHH) activates primary cilia signaling on neighboring valve interstitial cells. High-resolution imaging and functional assays show that DHH de-represses smoothened at the primary cilia, resulting in kinase activation of RAC1 through the RAC1-GEF, TIAM1. Activation of this non-canonical hedgehog pathway stimulates α-smooth actin organization and ECM remodeling. Genetic or pharmacological perturbation of this pathway results in enlarged valves that progress to a myxomatous phenotype, similar to valves seen in MVP patients. These data identify a potential molecular origin for MVP as well as establish a paracrine DHH-primary cilium cross-talk mechanism that is likely applicable across developmental tissue types.
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Affiliation(s)
- Diana Fulmer
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC, USA
| | - Katelynn A Toomer
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC, USA; Department of Genetic Medicine, John Hopkins, Baltimore, MD, USA
| | - Janiece Glover
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC, USA
| | - Lilong Guo
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC, USA
| | - Kelsey Moore
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC, USA
| | - Reece Moore
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC, USA
| | - Rebecca Stairley
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC, USA
| | - Cortney Gensemer
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC, USA
| | - Sameer Abrol
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC, USA
| | - Mary Kate Rumph
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC, USA
| | - Faith Emetu
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC, USA
| | - Joshua H Lipschutz
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Colin McDowell
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC, USA
| | - Justin Bian
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC, USA
| | - Christina Wang
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC, USA
| | - Tyler Beck
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC, USA
| | - Andy Wessels
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC, USA
| | | | - Russell A Norris
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC, USA; Department of Medicine, Medical University of South Carolina, Charleston, SC, USA.
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Abdouni AA, Brandão CM, Rochitte CE, Pomerantzeff PM, Veronese ET, Pacheco AB, Santis AS, Tarasoutchi F, Jatene FB. Cardiac Magnetic Resonance Analysis of Mitral Annular Dynamics after Mitral Valve Repair. Clinics (Sao Paulo) 2020; 75:e2428. [PMID: 33263628 PMCID: PMC7654962 DOI: 10.6061/clinics/2020/e2428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 09/24/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES The aim of this study was to analyze mitral annulus (MA) dynamics using cardiac magnetic resonance (CMR) in patients with degenerative mitral insufficiency who underwent mitral valve repair (MVR). METHODS Mitral valve imaging was performed by CMR in twenty-nine patients with degenerative mitral insufficiency who underwent MVR between July 2014 and August 2016, with quadrangular resection of the posterior leaflet without ring annuloplasty. They were prospectively followed up from the preoperative period up to 2 years postoperatively. RESULTS We observed a significant reduction in all measurements of the MA after surgery. The mean systolic circumference of the MA was reduced from 13.28±1.95 cm to 11.50±1.59 cm, and the diastolic circumference was reduced from 12.51±2.01 cm to 10.66±2.09 cm in the immediate postoperative period, measures that remained stable 2 years after MVR (p<0.001). The mean maximum area of the MA was significantly reduced from 14.34±4.03 to 10.45±3.17 cm2 when comparing the immediate postoperative period and the 2 year follow-up (p<0.001). The same occurred with the mean minimum area of the MA, which was reduced from 12.53±3.68 cm2 to 9.23±2.84 cm2 in the same period, and this reduction was greater in the antero-posterior diameter than in the mid-lateral diameter. The mobility of the MA was preserved after surgery, ranging between 19.6% and 25.7% at 2-year follow-up. CONCLUSION We observed a significant reduction in the MA size after MVR, with preservation of the MA mobility at the 2-year follow-up.
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Affiliation(s)
- Ahmad A. Abdouni
- Instituto do Coracao (InCor), Hospital das Cinicas (HCFMUSP), Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding Author. E-mail:
| | - Carlos M.A. Brandão
- Instituto do Coracao (InCor), Hospital das Cinicas (HCFMUSP), Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Carlos E. Rochitte
- Instituto do Coracao (InCor), Hospital das Cinicas (HCFMUSP), Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Pablo M.A. Pomerantzeff
- Instituto do Coracao (InCor), Hospital das Cinicas (HCFMUSP), Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Elinthon T. Veronese
- Instituto do Coracao (InCor), Hospital das Cinicas (HCFMUSP), Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Ariane B. Pacheco
- Instituto do Coracao (InCor), Hospital das Cinicas (HCFMUSP), Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Antonio S. Santis
- Instituto do Coracao (InCor), Hospital das Cinicas (HCFMUSP), Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Flávio Tarasoutchi
- Instituto do Coracao (InCor), Hospital das Cinicas (HCFMUSP), Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Fábio B. Jatene
- Instituto do Coracao (InCor), Hospital das Cinicas (HCFMUSP), Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
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Borger MA, Mansour MC, Levine RA. Atrial Fibrillation and Mitral Valve Prolapse: Time to Intervene? J Am Coll Cardiol 2019; 73:275-277. [PMID: 30678756 DOI: 10.1016/j.jacc.2018.11.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 11/09/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Michael A Borger
- University Clinic for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.
| | - Moussa C Mansour
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Robert A Levine
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
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11
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Canpolat U. Mechanoelectric abnormality of “myocardial‐valvular syndrome”: More than a leaflet prolapse. Pacing Clin Electrophysiol 2019; 42:566. [PMID: 30758062 DOI: 10.1111/pace.13631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 01/27/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Ugur Canpolat
- Department of Cardiology, Arrhythmia and Electrophysiology UnitHacettepe University Ankara Turkey
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