1
|
Sunaga A, Matsuoka Y, Nakatani D, Okada K, Kida H, Sakamoto D, Kitamura T, Tanaka N, Masuda M, Watanabe T, Minamiguchi H, Egami Y, Oka T, Miyoshi M, Okada M, Matsuda Y, Kawasaki M, Inoue K, Hikoso S, Sotomi Y, Sakata Y. Extensive ablation for persistent atrial fibrillation patients with mitral regurgitation: Insights from the EARNEST-PVI prospective randomized trial. Int J Cardiol 2024; 410:132231. [PMID: 38838745 DOI: 10.1016/j.ijcard.2024.132231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 05/09/2024] [Accepted: 06/03/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND Extensive ablation in addition to pulmonary vein isolation (PVI) in patients with persistent atrial fibrillation (AF) has not yielded consistent results, indicating diversity in their efficacy. Mitral regurgitation (MR) associated with AF may indicate a higher prevalence of arrhythmogenic substrate, suggesting potential benefits of extensive ablation for these patients. METHODS This post-hoc analysis of the EARNEST-PVI trial compared PVI alone versus an extensive ablation strategy (PVI-plus) in persistent AF patients, stratified by MR presence. The primary endpoint of the study was the recurrence of AF. The secondary endpoints included death, cerebral infarction, and procedure-related complications. RESULTS The trial included 495 eligible patients divided into MR and non-MR groups. The MR group consisted of 192 patients (89 in the PVI-alone arm and 103 in the PVI-plus arm), while the non-MR group had 303 patients (158 in the PVI-alone arm and 145 in the PVI-plus arm). In the non-MR group, recurrence rates were similar between PVI-alone and PVI-plus arms (Log-rank P = 0.47, Hazard ratio = 0.85 [95%CI: 0.54-1.33], P = 0.472). However, in the MR group, PVI-plus was significantly more effective in preventing AF recurrence (Log-rank P = 0.0014, Hazard ratio = 0.40 [95%CI: 0.22-0.72], P = 0.0021). No significant differences were observed in secondary endpoints between the two arms. CONCLUSIONS For persistent AF patients with mild or greater MR, receiving PVI-plus was superior to PVI-alone in preventing AF recurrence. Conversely, for patients without MR, the effectiveness of extensive ablation was not demonstrated. These findings suggest tailoring ablation strategies based on MR presence can lead to better outcomes in AF management.
Collapse
Affiliation(s)
- Akihiro Sunaga
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yuki Matsuoka
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Daisaku Nakatani
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Katsuki Okada
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan; Department of Transformative System for Medical Information, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hirota Kida
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Daisuke Sakamoto
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tetsuhisa Kitamura
- Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Nobuaki Tanaka
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Masaharu Masuda
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | - Tetsuya Watanabe
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | | | - Yasuyuki Egami
- Division of Cardiology, Osaka Rosai Hospital, Sakai, Japan
| | - Takafumi Oka
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Miwa Miyoshi
- Department of Cardiology, Osaka Hospital, Japan Community Healthcare Organization, Osaka, Japan
| | - Masato Okada
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
| | | | - Masato Kawasaki
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Koichi Inoue
- Cardiovascular Division, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Shungo Hikoso
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan; Department of Cardiovascular Medicine, Nara Medical University
| | - Yohei Sotomi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan.
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| |
Collapse
|
2
|
Tomšič A, Meucci MC, de Jong AR, Braun J, Marsan NA, Klautz RJM, Palmen M. Mitral regurgitation in atrial fibrillation: Is a simple repair enough to tackle a complex problem? J Cardiol 2024; 84:86-92. [PMID: 38103635 DOI: 10.1016/j.jjcc.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 11/24/2023] [Accepted: 12/04/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Clinical and echocardiographic results of valve repair for mitral regurgitation in the setting of atrial fibrillation are poorly studied. METHODS Between January 2008 and December 2020, 89 patients underwent valve repair for mitral regurgitation in the setting of atrial fibrillation. Clinical and echocardiographic follow-up data were collected and studied. The primary composite endpoint consisted of all-cause mortality or hospitalization for heart failure. RESULTS Valve repair with true-sized annuloplasty was performed in 83 (93 %) and restrictive annuloplasty in 6 (7 %) patients. Early mortality occurred in 3 (3 %) and residual mitral regurgitation in 1 (1 %) patient. During a median follow-up of 5.4 years (interquartile range 3.4-9.5), 25 patients died, 6 due to end-stage heart failure. Ten patients were hospitalized for heart failure. The estimated event-free survival rate at 10 years was 48.2 % (95 % CI 33.5 %-62.9 %). Recurrent mitral regurgitation was observed in 14 patients and most often caused by leaflet tethering. When analyzed as a time-dependent variable, recurrent regurgitation was related to the occurrence of the primary endpoint (hazard ratio 3.192, 95 % CI 1.219-8.359, p = 0.018). On exploratory sub-analyses, no recurrent regurgitation was observed after restrictive annuloplasty or in patients with paroxysmal atrial fibrillation. Moreover, recurrent regurgitation was observed more often when signs of left ventricular impairment were present preoperatively. CONCLUSIONS Despite good initial results, recurrent regurgitation was a frequent observation after valve repair for mitral regurgitation in atrial fibrillation and had an effect on heart failure related morbidity and mortality. Refinements in the timing of surgery and surgical technique might help improve outcomes.
Collapse
Affiliation(s)
- Anton Tomšič
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands.
| | - Maria Chiara Meucci
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands; Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Anne R de Jong
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Jerry Braun
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Robert J M Klautz
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Meindert Palmen
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| |
Collapse
|
3
|
Nabeta T, Galloo X, Tops L, Stassen J, Marsan NA, van der Bijl P, Bax JJ. Significant Mitral Regurgitation After Permanent Right Ventricular Pacemaker Implantation: Prognostic Implications. Am J Cardiol 2024; 222:78-86. [PMID: 38723856 DOI: 10.1016/j.amjcard.2024.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 04/25/2024] [Accepted: 05/05/2024] [Indexed: 05/23/2024]
Abstract
The underlying mechanisms leading to the development of mitral regurgitation (MR) after right ventricular (RV) pacemaker (PM) implantation and its prognostic value have yet to be fully understood. The purpose of this study was to evaluate the prevalence and clinical variables associated with the development of MR after RV pacing and its association with outcomes. A total of 451 patients (mean age 69 ± 15 years, 61% male) who underwent de novo RV PM implantation were included. The development of significant MR, defined as ≥moderate from mild or none/trace at baseline, occurred in 131 (29%) patients at a median of 2.4 years (interquartile range: 1.0 to 3.8 years) after PM implantation. Multivariate logistic regression analysis demonstrated that implantation of a single-chamber PM, left ventricular end-systolic volume index, and the presence of mild MR (vs no MR) at baseline were independently associated with the development of significant MR post-implant. Cardiac events, defined as the composite of all-cause mortality or heart failure hospitalization, occurred in 143 patients (31.7%) during a median follow-up of 5.4 years (interquartile range: 3.0 to 8.1 years). Multivariate Cox regression analysis demonstrated that the development of significant MR was independently related to the occurrence of cardiac events. In conclusion, the development of significant MR after PM implantation is seen in about one-third of recipients and is independently associated with adverse cardiac events.
Collapse
Affiliation(s)
- Takeru Nabeta
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.
| | - Xavier Galloo
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Laurens Tops
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jan Stassen
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands; Department of Cardiology, Jessa Hospital, Hasselt, Belgium
| | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Pieter van der Bijl
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands; Heart Centre, University of Turku and Turku University Hospital, Turku, Finland
| |
Collapse
|
4
|
Abdelgawad H, Mowafy B, Khidr K, Elsharkawy E. Distinct leaflet-annular remodeling pattern in severe atrial functional mitral regurgitation: a three-dimensional echocardiography study. Egypt Heart J 2024; 76:77. [PMID: 38913258 PMCID: PMC11196451 DOI: 10.1186/s43044-024-00509-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 06/14/2024] [Indexed: 06/25/2024] Open
Abstract
BACKGROUND Atrial functional mitral regurgitation (AFMR) is best described with normal left ventricular size and function, structurally normal mitral leaflets and dilated left atrium. Unlike the ventricular functional phenotype, changes in the annular geometry more than the tethering forces are the main culprit for mitral regurgitation. The aim of this study is to illuminate the leaflet-annular remodeling in patients with mitral regurgitation and atrial fibrillation (AF) using three-dimensional transesophageal echocardiography (3D TOE). RESULTS Consecutive fifty patients with AFMR underwent transthoracic echocardiography and 3D TOE: 25 patients with AF and non-mild MR and 25 patients with AF and mild MR were studied. A special mitral valve analysis software was used to accurately assess the three unique pillars for MR: annular size, leaflets' geometry and tenting parameters. Compared to the mild MR group, non-mild MR group had long-standing AF of more than 1 year and larger left atrial volumes (51.83 ± 12.07 ml/m2 vs 33.68 ± 10.97 ml/m2, p < 0.001). No significant differences were noted in respect of tenting height, area and volume (13.06 ± 2.57 mm vs 11.43 ± 2.89 mm, p = 0.064, 3.58 ± 1.26 cm2 vs 2.80 ± 0.95 cm2, 0.081 and 6.70 ± 2.96 cm3 vs 5.04 ± 2.32 cm3, p = 0.081). Conversely, the non-mild MR group had larger annular area and perimeter (16.20 ± 3.90 cm2 vs 13.51 ± 3.85 cm2, p = 0.023 and 14.73 ± 1.72 cm vs 13.46 ± 1.79 cm, p = 0.033). Similarly, the non-mild MR group had larger anterior and posterior leaflets' areas (10.18 ± 4.02 cm2 vs 8.71 ± 3.08 cm2, p = 0.04 and 8.96 ± 2.60 cm2 vs 7.30 ± 2.17 cm2, p = 0.029). Correspondingly, more disproportionate leaflet-annular remodeling, as assessed by the ratio of total leaflets' area to the annular area, was noted in the non-mild MR as opposed to the mild MR group (1.22 ± 0.04 vs 1.26 ± 0.04, p = 0.008). CONCLUSIONS Recently, AFMR has been recognized as a remarkable entity of secondary MR with unique mechanisms. Annular dilatation with disproportionate leaflet remodeling can validate the central regurgitation. However, the call for more parameters is being emphasized to characterize the suitable candidates for percutaneous interventions.
Collapse
Affiliation(s)
- Hoda Abdelgawad
- Cardiology Department, Faculty of Medicine, Alexandria University Hospital, Champollion Street, Khartoom Square, Qism Bab Sharqi, Alexandria, Egypt.
- King's College Hospital NHS Foundation, Denmark Hill, London, SE5 9RS, UK.
| | - Bassant Mowafy
- Cardiology Department, Faculty of Medicine, Alexandria University Hospital, Champollion Street, Khartoom Square, Qism Bab Sharqi, Alexandria, Egypt
| | - Kawkab Khidr
- Cardiology Department, Faculty of Medicine, Alexandria University Hospital, Champollion Street, Khartoom Square, Qism Bab Sharqi, Alexandria, Egypt
| | - Eman Elsharkawy
- Cardiology Department, Faculty of Medicine, Alexandria University Hospital, Champollion Street, Khartoom Square, Qism Bab Sharqi, Alexandria, Egypt
| |
Collapse
|
5
|
Li S, Wang Z, Fu W, Li F, Gu H, Cui N, Lin Y, Xie M, Yang Y. Left Ventricular Papillary Muscle: Anatomy, Pathophysiology, and Multimodal Evaluation. Diagnostics (Basel) 2024; 14:1270. [PMID: 38928685 PMCID: PMC11202998 DOI: 10.3390/diagnostics14121270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Revised: 06/04/2024] [Accepted: 06/13/2024] [Indexed: 06/28/2024] Open
Abstract
As an integral part of the mitral valve apparatus, the left ventricle papillary muscle (PM) controls mitral valve closure during systole and participates in the ejection process during left ventricular systole. Mitral regurgitation (MR) is the most immediate and predominant result when the PM is structurally or functionally abnormal. However, dysfunction of the PM is easily underestimated or overlooked in clinical interventions for MR-related diseases. Therefore, adequate recognition of PM dysfunction and PM-derived MR is critical. In this review, we systematically describe the normal anatomical variations in the PM and the pathophysiology of PM dysfunction-related diseases and summarize the commonly used parameters and the advantages and disadvantages of various noninvasive imaging modalities for the structural and functional assessment of the PM.
Collapse
Affiliation(s)
- Shiying Li
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; (S.L.); (Z.W.); (W.F.); (F.L.); (H.G.); (N.C.); (Y.L.); (M.X.)
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Zhen Wang
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; (S.L.); (Z.W.); (W.F.); (F.L.); (H.G.); (N.C.); (Y.L.); (M.X.)
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Wenpei Fu
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; (S.L.); (Z.W.); (W.F.); (F.L.); (H.G.); (N.C.); (Y.L.); (M.X.)
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Fangya Li
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; (S.L.); (Z.W.); (W.F.); (F.L.); (H.G.); (N.C.); (Y.L.); (M.X.)
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Hui Gu
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; (S.L.); (Z.W.); (W.F.); (F.L.); (H.G.); (N.C.); (Y.L.); (M.X.)
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Nan Cui
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; (S.L.); (Z.W.); (W.F.); (F.L.); (H.G.); (N.C.); (Y.L.); (M.X.)
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Yixia Lin
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; (S.L.); (Z.W.); (W.F.); (F.L.); (H.G.); (N.C.); (Y.L.); (M.X.)
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Mingxing Xie
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; (S.L.); (Z.W.); (W.F.); (F.L.); (H.G.); (N.C.); (Y.L.); (M.X.)
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Yali Yang
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; (S.L.); (Z.W.); (W.F.); (F.L.); (H.G.); (N.C.); (Y.L.); (M.X.)
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| |
Collapse
|
6
|
Drake DH, Zhang P, Zimmerman KG, Morrow CD, Sidebotham DA. Anatomic, stage-based repair of secondary mitral valve disease. J Thorac Cardiovasc Surg 2024; 167:1733-1744. [PMID: 36775783 DOI: 10.1016/j.jtcvs.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 12/20/2022] [Accepted: 01/05/2023] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Intervention for repair of secondary mitral valve disease is frequently associated with recurrent regurgitation. We sought to determine if there was sufficient evidence to support inclusion of anatomic indices of leaflet dysfunction in the management of secondary mitral valve disease. METHODS We performed a systematic review and meta-analysis of published reports comparing anatomic indices of leaflet dysfunction with the complexity of valve repair and the outcome from intervention. Patients were stratified by the severity of leaflet dysfunction. A secondary analysis was performed comparing outcomes when procedural complexity was optimally matched to severity of leaflet dysfunction and when intervention was not matched to dysfunction. RESULTS We identified 6864 publications, of which 65 met inclusion criteria. An association between the severity of leaflet dysfunction and the procedural complexity was highly predictive of satisfactory freedom from recurrent regurgitation. Patients were categorized into 4 groups based on stratification of leaflet dysfunction. Satisfactory results were achieved in 93.7% of patients in whom repair complexity was appropriately matched to severity of leaflet dysfunction and in 68.8% in whom repair was not matched to dysfunction (odds ratio, 0.148; 95% confidence interval, 0.119-0.184; P < .0001). CONCLUSIONS For patients with secondary mitral valve disease, satisfactory outcome from valve repair improves when procedural complexity is matched to anatomic indices of leaflet dysfunction. Anatomic indices of leaflet dysfunction should be considered when planning interventions for secondary mitral regurgitation. Routine inclusion of anatomic indices in trial design and reporting should facilitate comparison of results and strengthen guidelines. There are sufficient data to support anatomic staging of secondary mitral valve disease.
Collapse
Affiliation(s)
- Daniel H Drake
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Mich; Department of Surgery, Munson Medical Center, Traverse City, Mich.
| | - Peng Zhang
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Mich
| | | | - Cynthia D Morrow
- Health Systems, Management & Policy, Colorado School of Public Health, Aurora, Colo
| | - David A Sidebotham
- Department of Cardiothoracic Anaesthesia and Cardiothoracic Intensive Care, Auckland City Hospital, Auckland, New Zealand
| |
Collapse
|
7
|
Spieker M, Sidabras J, Lagarden H, Christian L, Angendohr S, Zweck E, Bejinariu A, Veulemanns V, Schulze C, Polzin A, Rana O, Westenfeld R, Kelm M, Horn P. Prevalence and prognostic impact of dynamic atrial functional mitral regurgitation assessed by isometric handgrip exercise. Eur Heart J Cardiovasc Imaging 2024; 25:589-598. [PMID: 38066677 DOI: 10.1093/ehjci/jead336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 11/17/2023] [Accepted: 12/02/2023] [Indexed: 01/10/2024] Open
Abstract
AIMS In atrial functional mitral regurgitation (aFMR), a considerable proportion of patients displays a discrepancy between symptoms and echocardiographic findings at rest. Exercise testing plays a substantial role in assessing the haemodynamic relevance of mitral regurgitation (MR) and is recommended by current guidelines. Here, we aimed to assess the prevalence, extent, and prognostic impact of exercise-induced changes in patients with aFMR. METHODS AND RESULTS Patients with at least mild MR who underwent handgrip exercise echocardiography at the University Hospital Duesseldorf between January 2019 and September 2021 were enrolled. Patients were followed up for 1 year to assess clinical outcomes. Eighty patients with aFMR were included [median age: 80 (77-83) years; 53.8% female]. The median N-terminal pro-brain natriuretic peptide level was 1756 (1034-3340) ng/L. At rest, half of the patients (53.8%) had mild MR, 20 patients (25.0%) had moderate MR, and 17 patients (21.2%) had severe MR. In approximately every fifth patient (17.5%) with non-severe MR at rest, the MR became severe during exercise. Handgrip exercise led to a reclassification of MR severity in 28 patients (35.0%). At 1-year follow-up, adverse events occurred more often in patients with severe MR at rest (76.5%) and exercise-induced dynamic severe MR (66.7%) than in those with non-severe MR (28.6%; P < 0.001). CONCLUSION Handgrip exercise during echocardiography revealed exercise-induced changes in aFMR in every third patient. These data may have implications for therapeutic decision-making in symptomatic patients with non-severe aFMR at rest.
Collapse
Affiliation(s)
- Maximilian Spieker
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Jonas Sidabras
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Hannah Lagarden
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Lucas Christian
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Stephan Angendohr
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Elric Zweck
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Alexandru Bejinariu
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Verena Veulemanns
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Christian Schulze
- Division of Cardiology, Intensive Care Medicine and Vascular Medicine, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Amin Polzin
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Obaida Rana
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Ralf Westenfeld
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
- Cardiovascular Research Institute Duesseldorf, Medical Faculty, Heinrich-Heine University, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Patrick Horn
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
| |
Collapse
|
8
|
Digrande K, Xu J, Shavelle D, Mendoza F. Atrial Tachycardia Facilitating Transcatheter Edge-to-Edge Repair for Severe Functional Mitral Regurgitation. JACC Case Rep 2024; 29:102272. [PMID: 38645287 PMCID: PMC11031670 DOI: 10.1016/j.jaccas.2024.102272] [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: 11/07/2023] [Revised: 01/23/2024] [Accepted: 01/30/2024] [Indexed: 04/23/2024]
Abstract
An 89-year-old woman with paroxysmal atrial tachycardia (AT) was diagnosed with severe atrial functional mitral regurgitation. On transesophageal echocardiography, the mitral regurgitation jet appeared larger during sinus rhythm and smaller during AT. During transcatheter repair of the valve, chronotropic agents were given to induce AT, assisting with leaflet capture.
Collapse
Affiliation(s)
- Kyle Digrande
- Department of Medicine, Irvine Medical Center, University of California, Orange, California, USA
| | - Jennifer Xu
- Division of Cardiology, Department of Medicine, Irvine Medical Center, University of California, Orange, California, USA
| | - David Shavelle
- MemorialCare Heart and Vascular Institute, Long Beach Medical Center, Long Beach, California, USA
| | - Fernando Mendoza
- MemorialCare Heart and Vascular Institute, Long Beach Medical Center, Long Beach, California, USA
| |
Collapse
|
9
|
Dhont S, van den Acker G, van Loon T, Verbrugge FH, Verwerft J, Deferm S, Churchill TW, Mullens W, Lumens J, Bertrand PB. Mitral regurgitation in heart failure with preserved ejection fraction: The interplay of valve, ventricle, and atrium. Eur J Heart Fail 2024; 26:974-983. [PMID: 38629747 PMCID: PMC11184410 DOI: 10.1002/ejhf.3231] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/22/2024] [Accepted: 03/26/2024] [Indexed: 05/31/2024] Open
Abstract
Mitral regurgitation (MR) is highly prevalent among patients with heart failure and preserved ejection fraction (HFpEF). Despite this combination being closely associated with unfavourable outcomes, it remains relatively understudied. This is partly due to the inherent heterogeneity of patients with HFpEF. To address this gap, dissecting HFpEF into mechanism-based phenotypes may offer a promising avenue for advancing our comprehension of these complex intertwined conditions. This review employs the validated CircAdapt model to explore the haemodynamic implications of moderate to severe MR across a well-defined spectrum of myocardial disease, characterized by impaired relaxation and reduced myocardial compliance. Both heart failure and mitral valve disease share overlapping symptomatology, primarily attributed to elevated pulmonary pressures. The intricate mechanisms contributing to these elevated pressures are multifaceted, potentially influenced by diastolic dysfunction, left atrial myopathy, and MR. Accurate evaluation of the haemodynamic and clinical impact of MR necessitates a comprehensive approach, taking into account the characteristics of both the left atrium and left ventricle, as well as their intricate interactions, which may currently be underemphasized in diagnostic practice. This holistic assessment is imperative for enhancing our understanding and refining therapeutic strategies within this patient cohort.
Collapse
Affiliation(s)
- Sebastiaan Dhont
- Faculty of Medicine and Life Sciences, LCRC, Hasselt University, Diepenbeek, Belgium
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Department of Future Health, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Gitte van den Acker
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Tim van Loon
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Frederik H. Verbrugge
- Center for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Jan Verwerft
- Faculty of Medicine and Life Sciences, LCRC, Hasselt University, Diepenbeek, Belgium
- Department of Cardiology, Jessa Hospital, Hasselt, Belgium
| | - Sébastien Deferm
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Department of Cardiology, Inselspital Bern, Bern, Switzerland
| | | | - Wilfried Mullens
- Faculty of Medicine and Life Sciences, LCRC, Hasselt University, Diepenbeek, Belgium
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Department of Future Health, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Joost Lumens
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Philippe B. Bertrand
- Faculty of Medicine and Life Sciences, LCRC, Hasselt University, Diepenbeek, Belgium
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Department of Future Health, Ziekenhuis Oost-Limburg, Genk, Belgium
| |
Collapse
|
10
|
Tanaka T, Sugiura A, Vogelhuber J, Öztürk C, Böhm L, Wilde N, Zimmer S, Nickenig G, Weber M. Outcomes of transcatheter edge-to-edge repair for atrial functional mitral regurgitation. EUROINTERVENTION 2024; 20:e250-e260. [PMID: 38389471 PMCID: PMC10870009 DOI: 10.4244/eij-d-23-00819] [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: 09/29/2023] [Accepted: 11/08/2023] [Indexed: 02/24/2024]
Abstract
BACKGROUND The prognostic benefits of transcatheter edge-to-edge repair (TEER) remain unclear in patients with atrial functional mitral regurgitation (AFMR). AIMS We aimed to investigate the clinical outcomes of TEER for patients with AFMR. METHODS We retrospectively classified functional mitral regurgitation (FMR) patients undergoing TEER into those with AFMR or ventricular FMR (VFMR). A residual MR ≤1+ at discharge was considered optimal mitral regurgitation (MR) reduction, and an elevated mean mitral valve pressure gradient (MPG) was defined as an MPG ≥5 mmHg at discharge. The primary outcome was a composite of all-cause mortality and hospitalisation due to heart failure within one year. RESULTS Of 441 FMR patients, 125 patients were considered as having AFMR. Residual MR ≤1+ was associated with a lower risk of the composite outcome in both AFMR and VFMR patients, while an MPG ≥5 mmHg was associated with a higher risk of the composite outcome in patients with AFMR but not with VFMR. AFMR patients with residual MR ≤1+ and an MPG ≥5 mmHg, as well as those with residual MR >1+, had a higher incidence of the composite outcome than those with residual MR ≤1+ and an MPG <5 mmHg (50.7%, 41.8%, and 14.3%, respectively; p<0.001). This association was consistent after adjustment for clinical and echocardiographic characteristics. CONCLUSIONS An MR reduction to ≤1+ following TEER was associated with a lower risk of clinical outcomes in patients with AFMR, while an MPG ≥5 mmHg was related to a higher risk of clinical outcomes. Optimal MR reduction by TEER may have potential benefits on the prognosis of patients with AFMR, although the prognostic benefit may be attenuated by an elevated MPG.
Collapse
Affiliation(s)
- Tetsu Tanaka
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Atsushi Sugiura
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Johanna Vogelhuber
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Can Öztürk
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Lukas Böhm
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Nihal Wilde
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Sebastian Zimmer
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Georg Nickenig
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Marcel Weber
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| |
Collapse
|
11
|
Luis SA, Michelena HI, Nkomo VT. Navigating the Complex Landscape of Atrial Functional Mitral Regurgitation: Insights, Challenges, and Emerging Interventions. Am J Cardiol 2024; 213:170-172. [PMID: 38103768 DOI: 10.1016/j.amjcard.2023.11.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 11/29/2023] [Indexed: 12/19/2023]
Affiliation(s)
- Sushil Allen Luis
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Hector I Michelena
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Vuyisile T Nkomo
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
12
|
Masiero G, Montonati C, Rubbio AP, Adamo M, Grasso C, Denti P, Giordano A, Godino C, Bartorelli AL, De Felice F, Mongiardo A, Monteforte I, Villa E, Giannini C, Tamburino C, Petroni AS, Montorfano M, Giulia L, Dario G, Bedogni F, Giuseppe T. Impact of Transcatheter Edge-to-Edge Mitral Valve Repair on Atrial Functional Mitral Regurgitation from the GIOTTO Registry. Am J Cardiol 2024; 211:219-227. [PMID: 37944779 DOI: 10.1016/j.amjcard.2023.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 10/23/2023] [Accepted: 11/04/2023] [Indexed: 11/12/2023]
Abstract
Atrial functional mitral regurgitation (aFMR) has a peculiar pathophysiology that may have distinctive outcomes. We investigated the impact of transcatheter edge-to-edge repair in aFMR compared with other FMR etiologies. The GIOTTO (GIse registry Of Transcatheter treatment of MR) is a multicenter, prospective study enrolling patients with symptomatic MR treated with MitraClip up to 2020. We categorized patients with FMR as aFMR, ischemic FMR (iFMR), and nonischemic ventricular FMR (niFMR). The clinical end points were defined according to the Mitral Valve Academic Research Consortium. Of 1,153 patients, 6% had aFMR, 47% iFMR, and 47% niFMR. Patients with aFMR were older, mostly women, and had a higher atrial fibrillation rate. They had better left ventricular ejection fraction and smaller left ventricular volumes, with no difference in mitral effective regurgitant orifice area. The acute device and procedural success rates were similar among the groups. At the longest available follow-up (median 478 days, interquartile range 91 to 741 days), the rate of MR ≥2+ was similar among the groups. Patients with aFMR had a lower rate of cardiovascular death and heart failure than patients with iFMR (hazard ratio [HR] 0.43, p = 0.02) and niFMR (HR 0.45, p = 0.03). The aFMR etiology remained independently associated with the composite outcome, together with postprocedural MR ≤1+ (HR 0.63, p <0.01) and peripheral arteriopathy (HR 1.82, p = 0.003). The results of this GIOTTO subanalysis suggested that aFMR is less prevalent and associated with better outcomes compared with other causes of FMR treated by transcatheter edge-to-edge repair. Postprocedural MR >1+, peripheral vasculopathy, non-aFMR were independent predictors of worse outcomes.
Collapse
Affiliation(s)
- Giulia Masiero
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Carolina Montonati
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Antonio Popolo Rubbio
- Department of Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Marianna Adamo
- Cardiology and Cardiac Catheterization Laboratory, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Carmelo Grasso
- Division of Cardiology, Centro Alte Specialità e Trapianti (CAST), Azienda Ospedaliero-universitaria Policlinico-Vittorio Emanuele, University of Catania, Catania, Italy
| | - Paolo Denti
- Cardiac Surgery Department, San Raffaele University Hospital, Milan, Italy
| | - Arturo Giordano
- Invasive Cardiology Unit, Pineta Grande Hospital, Castel Volturno, Caserta, Italy
| | - Cosmo Godino
- Cardio-Thoracic-Vascular Department, San Raffaele University Hospital, Milan, Italy
| | | | - Francesco De Felice
- Division of Interventional Cardiology, Azienda Ospedaliera S. Camillo Forlanini, Rome, Italy
| | | | - Ida Monteforte
- AORN Ospedali dei Colli, Monaldi Hospital, Naples, Italy
| | - Emmanuel Villa
- Cardiac Surgery Unit, Poliambulanza Hospital, Fondazione Poliambulanza, Brescia, Italy
| | - Cristina Giannini
- Cardiac Catheterization Laboratory, Cardiothoracic and Vascular Department, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Corrado Tamburino
- Division of Cardiology, Centro Alte Specialità e Trapianti (CAST), Azienda Ospedaliero-universitaria Policlinico-Vittorio Emanuele, University of Catania, Catania, Italy
| | - Anna Sonia Petroni
- Cardiac Catheterization Laboratory, Cardiothoracic and Vascular Department, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Matteo Montorfano
- Cardio-Thoracic-Vascular Department, San Raffaele University Hospital, Milan, Italy
| | - Lorenzoni Giulia
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Gregori Dario
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Francesco Bedogni
- Department of Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Tarantini Giuseppe
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy.
| |
Collapse
|
13
|
Hasegawa H, Kuwajima K, Kagawa S, Yamane T, Rader F, Siegel RJ, Shiota T. Impact of eccentric jet on outcomes in patients with atrial functional mitral regurgitation: An echocardiographic study. Int J Cardiol 2023; 391:131342. [PMID: 37678430 DOI: 10.1016/j.ijcard.2023.131342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 08/17/2023] [Accepted: 09/03/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Previous studies have reported the mechanisms underlying atrial functional mitral regurgitation (A-FMR). Recently, A-FMR subtypes based on mitral regurgitation (MR) mechanisms were proposed: "central jet" due to insufficient leaflet remodeling and "eccentric jet" due to atriogenic tethering. However, their prognostic value remains unclear. Therefore, this study investigated the impact of A-FMR subtypes on clinical outcomes. METHODS Outpatients with significant A-FMR between January 2013 and December 2016 were retrospectively reviewed. They were classified into two subtypes according to the MR jet's direction. All-cause mortality, heart failure hospitalization, and any mitral valve interventions were the primary composite endpoint. RESULTS Among 101 patients with significant A-FMR, 32% had eccentric jet. The primary endpoint was observed in 56 patients during the follow-up period (median 0.7 years, range 0.1-4.2 years). Kaplan-Meier curves demonstrated that the composite endpoint was higher among patients with eccentric jet than those with central jet (log-rank p < 0.001). Eccentric jet (hazard ratio [HR] 2.46, 95% confidence interval [CI] 1.28-4.73; p = 0.007), age (HR 1.06, 95% CI 1.02-1.11; p = 0.002), symptoms (HR 6.22, 95% CI 2.18-17.8; p < 0.001), severe MR (HR 3.97, 95% CI 1.92-8.18; p < 0.001), and significant tricuspid regurgitation (TR; HR 2.00, 95% CI 1.01-3.97; p = 0.047) were independent predictors of the composite endpoint. CONCLUSIONS Patients with eccentric jet had poorer outcomes than those with central jet. Eccentric jet, age, symptoms, severe MR, and significant TR were independently associated with poor outcomes.
Collapse
Affiliation(s)
- Hiroko Hasegawa
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Ken Kuwajima
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Shunsuke Kagawa
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Takafumi Yamane
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Florian Rader
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Robert J Siegel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Takahiro Shiota
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| |
Collapse
|
14
|
Kumar M, Thompson PD, Chen K. New Perspective on Pathophysiology and Management of Functional Mitral Regurgitation. Trends Cardiovasc Med 2023; 33:386-392. [PMID: 35259483 DOI: 10.1016/j.tcm.2022.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/15/2022] [Accepted: 03/01/2022] [Indexed: 12/31/2022]
Abstract
Functional mitral regurgitation (FMR) occurs as a result of global or segmental left ventricular (LV) dysfunction or left atrial dilatation, leading to mitral annular dilatation, papillary muscle displacement, mitral valve (MV) leaflet tethering, and leaflet remodeling. The prevalence of FMR continues to rise in the United States. Even mild FMR is associated with adverse clinical outcomes. Echocardiography is the primary imaging modality used to assess the type and severity of mitral regurgitation. FMR treatment depends on the etiology. Evidence-based pharmacologic and cardiac resynchronization therapies for underlying LV dysfunction remain the mainstay of treatment. Patients who remain symptomatic despite optimal medical therapy can be considered for surgical or percutaneous MV intervention. This article reviews the pathophysiology, imaging evaluation, and therapeutic options of FMR, highlighting the most recent developments in a rapidly evolving field.
Collapse
Affiliation(s)
- Manish Kumar
- Pat and Jim Calhoun Cardiology Center, Department of Internal Medicine, University of Connecticut Health Center, Farmington, CT, 06030, United States.
| | - Paul D Thompson
- Department of Cardiology, Hartford Hospital, Hartford, 06106, United States
| | - Kai Chen
- Pat and Jim Calhoun Cardiology Center, Department of Internal Medicine, University of Connecticut Health Center, Farmington, CT, 06030, United States.
| |
Collapse
|
15
|
Kim H, Kim IC, Lee S. Implications of the Mitral Leaflet Coaptation Pattern on Clinical Outcomes in Patients With Functional Mitral Regurgitation. Am J Cardiol 2023; 199:25-32. [PMID: 37229968 DOI: 10.1016/j.amjcard.2023.04.040] [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: 01/05/2023] [Revised: 04/13/2023] [Accepted: 04/30/2023] [Indexed: 05/27/2023]
Abstract
The classification of secondary mitral regurgitation (MR) is based on atrial functional MR (AFMR) or ventricular functional MR (VFMR) and volume changes, but the mitral leaflet coaptation angle also contributes to the MR mechanism. The clinical implications of the coaptation angle on cardiovascular (CV) outcomes have not been well evaluated. A total of 469 consecutive patients (265 AFMR vs 204 VFMR) with more than moderate MR were evaluated for the occurrence of heart failure, mitral valve operations, and CV death. The coaptation angle was assessed by measuring the internal angle between both leaflets at mid-systole using the apical 3-chamber view. A coaptation angle ≥130° was classified as leaflet flattening, and an angle <130° was classified as leaflet tethering. AFMR and VFMR were associated with higher frequencies of leaflet flattening and tethering, respectively. AFMR was more likely to be associated with older age, atrial fibrillation, and preserved ejection fraction, all of which were related to leaflet flattening. During a follow-up of 2.3 years, 83 patients had heart failure (17.7%), 21 patients underwent mitral valve operations (4.5%), and 34 patients died (7%). Compared with leaflet tethering, leaflet flattening was more significantly related to CV events, whereas CV event rates were less markedly different in A/VFMR. Irrespective of A/VFMR, leaflet flattening and atrial fibrillation were associated with a higher frequency of CV events. Adjusted analysis showed that leaflet flattening remained an independent predictor of CV events (hazard ratio 3.5, 95% confidence interval 1.11 to 4.88, p = 0.003), whereas A/VFMR did not. In conclusion, the leaflet coaptation angle in patients with functional MR could provide risk stratification superior to that of A/VFMR. Leaflet flattening appears to be associated with unfavorable clinical outcomes.
Collapse
Affiliation(s)
- Hyungseop Kim
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea.
| | - In-Cheol Kim
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Seonhwa Lee
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| |
Collapse
|
16
|
Molnár AÁ, Sánta A, Pásztor DT, Merkely B. Atrial Cardiomyopathy in Valvular Heart Disease: From Molecular Biology to Clinical Perspectives. Cells 2023; 12:1796. [PMID: 37443830 PMCID: PMC10340254 DOI: 10.3390/cells12131796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/01/2023] [Accepted: 07/04/2023] [Indexed: 07/15/2023] Open
Abstract
This review discusses the evolving topic of atrial cardiomyopathy concerning valvular heart disease. The pathogenesis of atrial cardiomyopathy involves multiple factors, such as valvular disease leading to atrial structural and functional remodeling due to pressure and volume overload. Atrial enlargement and dysfunction can trigger atrial tachyarrhythmia. The complex interaction between valvular disease and atrial cardiomyopathy creates a vicious cycle of aggravating atrial enlargement, dysfunction, and valvular disease severity. Furthermore, atrial remodeling and arrhythmia can predispose to atrial thrombus formation and stroke. The underlying pathomechanism of atrial myopathy involves molecular, cellular, and subcellular alterations resulting in chronic inflammation, atrial fibrosis, and electrophysiological changes. Atrial dysfunction has emerged as an essential determinant of outcomes in valvular disease and heart failure. Despite its predictive value, the detection of atrial fibrosis and dysfunction is challenging and is not included in the clinical routine. Transthoracic echocardiography and cardiac magnetic resonance imaging are the main diagnostic tools for atrial cardiomyopathy. Recently published data have revealed that both left atrial volumes and functional parameters are independent predictors of cardiovascular events in valvular disease. The integration of atrial function assessment in clinical practice might help in early cardiovascular risk estimation, promoting early therapeutic intervention in valvular disease.
Collapse
|
17
|
Deferm S, Bertrand PB, Dhont S, von Bardeleben RS, Vandervoort PM. Arrythmia-Mediated Valvular Heart Disease. Heart Fail Clin 2023; 19:357-377. [PMID: 37230650 DOI: 10.1016/j.hfc.2023.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The aging population is rising at record pace worldwide. Along with it, a steep increase in the prevalence of atrial fibrillation and heart failure with preserved ejection fraction is to be expected. Similarly, both atrial functional mitral and tricuspid regurgitation (AFMR and AFTR) are increasingly observed in daily clinical practice. This article summarizes all current evidence regarding the epidemiology, prognosis, pathophysiology, and therapeutic options. Specific attention is addressed to discern AFMR and AFTR from their ventricular counterparts, given their different pathophysiology and therapeutic needs.
Collapse
Affiliation(s)
- Sébastien Deferm
- Hasselt University, Agoralaan Building D, 3590 Diepenbeek, Belgium; Department of Cardiology, Mainz University Hospital, Langenbeckstraße 1, Mainz, Germany. https://twitter.com/S_Deferm
| | - Philippe B Bertrand
- Hasselt University, Agoralaan Building D, 3590 Diepenbeek, Belgium; Department of Cardiology, Hospital Oost-Limburg Genk, Schiepse Bos 6, 3600 Genk, Belgium. https://twitter.com/Ph_Bertrand
| | - Sebastiaan Dhont
- Hasselt University, Agoralaan Building D, 3590 Diepenbeek, Belgium; Department of Cardiology, Hospital Oost-Limburg Genk, Schiepse Bos 6, 3600 Genk, Belgium. https://twitter.com/S_Dhont
| | - Ralph S von Bardeleben
- Department of Cardiology, Mainz University Hospital, Langenbeckstraße 1, Mainz, Germany. https://twitter.com/vonbardelebenRS
| | - Pieter M Vandervoort
- Hasselt University, Agoralaan Building D, 3590 Diepenbeek, Belgium; Department of Cardiology, Hospital Oost-Limburg Genk, Schiepse Bos 6, 3600 Genk, Belgium.
| |
Collapse
|
18
|
Straw S, Gupta A, Johnson K, Cole CA, Kneizeh K, Gierula J, Kearney MT, Malkin CJ, Paton MF, Witte KK, Schlosshan D. Atrial secondary mitral regurgitation: prevalence, characteristics, management, and long-term outcomes. Echo Res Pract 2023; 10:4. [PMID: 36882790 PMCID: PMC9993529 DOI: 10.1186/s44156-023-00015-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 01/06/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND The prevalence, clinical characteristics, management and long-term outcomes of patients with atrial secondary mitral regurgitation (ASMR) are not well described. METHODS We performed a retrospective, observational study of consecutive patients with grade III/IV MR determined by transthoracic echocardiography. The aetiology of MR was grouped as being either primary (due to degenerative mitral valve disease), ventricular SMR (VSMR: due to left ventricular dilatation/dysfunction), ASMR (due to LA dilatation), or other. RESULTS A total of 388 individuals were identified who had grade III/IV MR; of whom 37 (9.5%) had ASMR, 113 (29.1%) had VSMR, 193 had primary MR (49.7%), and 45 (11.6%) were classified as having other causes. Compared to MR of other subtypes, patients with ASMR were on average older (median age 82 [74-87] years, p < 0.001), were more likely to be female (67.6%, p = 0.004) and usually had atrial fibrillation (83.8%, p = 0.001). All-cause mortality was highest in patients with ASMR (p < 0.001), but similar to that in patients with VSMR once adjusted for age and sex (hazard ratio [HR] 0.81, 95% confidence interval [CI] 0.52-1.25). Hospitalisation for worsening heart failure was more commonly observed in those with ASMR or VSMR (p < 0.001) although was similar between these groups when age and sex were accounted for (HR 0.74, 95% CI 0.34-1.58). For patients with ASMR, the only variables associated with outcomes were age and co-morbidities. CONCLUSIONS ASMR is a prevalent and distinct disease process associated with a poor prognosis, with much of this related to older age and co-morbidities.
Collapse
Affiliation(s)
- Sam Straw
- University of Leeds, Leeds, UK.,Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | | | | | | | - John Gierula
- University of Leeds, Leeds, UK.,Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | | | - Maria F Paton
- University of Leeds, Leeds, UK.,Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Klaus K Witte
- University of Leeds, Leeds, UK. .,University Hospital Aachen, RWTH, Aachen, Germany.
| | | |
Collapse
|
19
|
Meucci MC, Stassen J, Tomsic A, Palmen M, Crea F, Bax JJ, Ajmone Marsan N, Delgado V. Prognostic impact of left ventricular global longitudinal strain in atrial mitral regurgitation. Heart 2023; 109:478-484. [PMID: 36270784 DOI: 10.1136/heartjnl-2022-321698] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 10/10/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Left atrial (LA) and left ventricular (LV) mechanics are impaired in patients with atrial functional mitral regurgitation (AFMR), but their prognostic value in this subset of patients remains unknown. The present study aimed to evaluate the association between LA and LV longitudinal strain and clinical outcomes in patients with AFMR. METHODS A total of 197 patients (mean age 73±10 years, 44% men) with at least moderate AFMR were retrospectively identified. LV global longitudinal strain (GLS) and left atrial reservoir strain (LAS) were calculated by two-dimensional speckle tracking echocardiography. All-cause mortality was the primary endpoint of the study. The threshold value of LV GLS (≤16.3%) to identify impaired LV mechanics was defined based on the risk excess of the primary endpoint described with a spline curve analysis. RESULTS Impaired LV GLS (≤16.3%) was found in 89 (45%) patients. During a median follow-up of 69 months, 45 (23%) subjects experienced the primary endpoint. Patients with impaired LV GLS (≤16.3%) had a significantly lower cumulative survival rate at 5 years, as compared with patients with LV GLS (>16.3%) (74% vs 93%, p<0.001). On multivariable Cox regression analysis, LV GLS expressed as continuous variable was independently associated with the occurrence of all-cause mortality (HR 0.856, 95% CI 0.763 to 0.960; p=0.008) after adjustment for age, LAS, pulmonary artery systolic pressure and severe tricuspid regurgitation. Conversely, LAS was not significantly associated with patients' outcome. CONCLUSIONS In patients with significant AFMR, the impairment of LV GLS was independently associated with worse outcomes.
Collapse
Affiliation(s)
- Maria Chiara Meucci
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Jan Stassen
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Cardiology, Jessa Hospital, Hasselt, Belgium
| | - Anton Tomsic
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Meindert Palmen
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.,Heart Center, University of Turku and Turku University Hospital, Turku, Finland
| | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands .,Hospital University Germans Trias i Pujol, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Badalona, Spain
| |
Collapse
|
20
|
Differences in clinical and echocardiographic features and outcomes between atrial functional mitral regurgitation patients with and without posterior mitral leaflet bending. J Cardiol 2023:S0914-5087(23)00023-0. [PMID: 36764515 DOI: 10.1016/j.jjcc.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 12/24/2022] [Accepted: 01/18/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Posterior mitral leaflet (PML) bending is a cause of atrial functional mitral regurgitation (AFMR). We aimed to investigate differences in clinical and echocardiographic features and outcomes between AFMR patients with and without PML bending. METHODS We retrospectively examined 118 AFMR patients with atrial fibrillation (AF), mild or greater MR without degenerative mitral valve changes, and left ventricular ejection fraction ≥50 %. Patients were classified by the presence of PML bending: PML bending (n=24) and no PML bending (n=94). PML bending was defined as PML-to-anterior mitral leaflet angle ratio ≥3.1 calculated using receiver operating characteristics analysis for eccentric MR jet toward left atrial posterior wall. The study endpoint was a composite of cardiac death, admission for heart failure, and mitral valve surgery. RESULTS Overall, a total of 88 patients (75 %) had mild MR. There were no between-group differences in clinical and echocardiographic characteristics including AF duration and cardiac cavities size except for the length of inward bending of the left ventricular posterobasal wall and the mitral annular area. The 36-month event-free survival for the composite endpoint was significantly lower in the PML bending group (63 % vs. 78 %; Log-rank p=0.047). In multivariate analysis, PML bending was also associated with the composite outcome. CONCLUSIONS AFMR patients with PML bending may have worse outcomes than those without PML bending despite similar clinical features.
Collapse
|
21
|
Incidence and causal association of functional atrial mitral regurgitation in HFpEF. Hellenic J Cardiol 2023; 69:51-56. [PMID: 36181999 DOI: 10.1016/j.hjc.2022.09.013] [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: 01/09/2022] [Revised: 09/25/2022] [Accepted: 09/27/2022] [Indexed: 02/07/2023] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is as common as heart failure with reduced ejection fraction. Atrial fibrillation (AF), as well as the presence of mitral regurgitation (MR), is highly prevalent in these patients. Atrial functional MR (AFMR) is a type of functional MR characterized by severe left atrial dilatation and remodeling with normal left ventricular (LV) dimensions and function. Dilatation of the mitral annulus is considered to be the main underlying mechanism, though the leaflets and the rest of the mitral apparatus play significant role in the development of MR, mainly in patients with long standing AF. There are several echocardiographic differences between atrial and ventricular functional MR, better identified with 3D echocardiography. Significant AFMR impairs prognosis, especially of patients with HFpEF, and this is important while they represent a group of under-diagnosed and under-treated patients. Finally, because focused medical evidence-based approach is not available yet, it seems that the prevention of left atrial dilatation and early restoration of sinus rhythm (SR) is the best therapeutic option.
Collapse
|
22
|
Kataoka A, Watanabe Y. MitraClip: a review of its current status and future perspectives. Cardiovasc Interv Ther 2023; 38:28-38. [PMID: 36469300 DOI: 10.1007/s12928-022-00898-4] [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: 06/15/2022] [Accepted: 11/14/2022] [Indexed: 12/12/2022]
Abstract
Mitral regurgitation (MR), among the most common valvular heart diseases, is closely associated with heart failure and worse clinical outcomes. Surgical repair or replacement as an intervention for MR is deemed too high risk in patients who are elderly or have multiple comorbidities; thus, nearly half of all patients with severe symptomatic MR are not referred for surgical therapy. MitraClip, a transcatheter mitral valve repair system for MR that mimics the Alfieri surgical edge-to-edge technique for mitral valve repair, was developed in the late 1990s. After clinical trials demonstrated its safety and efficacy, it received approval for clinical use, particularly for aging and inoperable or high-risk patients for heart surgery in Europe, the US, and Japan. Since the start of its clinical use, randomized clinical trials (RCTs) have optimized patient selection, and the latest generation MitraClip can increase procedural success, even in patients with challenging mitral valve anatomy. Therefore, here, we review evidence from clinical trials and RCTs and discuss optical patient selection and future perspectives for the MitraClip.
Collapse
Affiliation(s)
- Akihisa Kataoka
- Division of Cardiology, Department of Internal Medicine, Teikyo University, 2-11-1 Kaga, Itabashi-Ku, Tokyo, 173-8605, Japan.
| | - Yusuke Watanabe
- Division of Cardiology, Department of Internal Medicine, Teikyo University, 2-11-1 Kaga, Itabashi-Ku, Tokyo, 173-8605, Japan
| |
Collapse
|
23
|
Furuya H, Kuwaki K, Ozawa K, Yamaguchi M. Posterior mitral leaflet augmentation with autologous pericardial patch for the surgical treatment of severe atrial functional mitral regurgitation. J Card Surg 2022; 37:5524-5527. [PMID: 36285539 DOI: 10.1111/jocs.17072] [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: 07/29/2022] [Revised: 09/15/2022] [Accepted: 10/08/2022] [Indexed: 01/06/2023]
Abstract
Atrial functional mitral regurgitation (MR) in patients with chronic atrial fibrillation has not been thoroughly discussed. Although there is insufficient evidence to surgically treat atrial functional MR, it is considered to be reasonable for those patients with severe atrial functional MR who have symptoms of heart failure despite adequate medical therapy. Herein, we report a useful technique for mitral valve repair using posterior mitral leaflet (PML) augmentation with autologous pericardium to obtain good mitral valve coaptation and eliminate atrial functional MR, including tethered PML, in a nonelderly patient.
Collapse
Affiliation(s)
- Hidekazu Furuya
- Department of Cardiovascular Surgery, Tokai University Hachioji Hospital, Hachioji, Japan
| | - Kenji Kuwaki
- Department of Cardiovascular Surgery, Tokai University Hachioji Hospital, Hachioji, Japan
| | - Keisuke Ozawa
- Department of Cardiovascular Surgery, Tokai University Hachioji Hospital, Hachioji, Japan
| | - Masaomi Yamaguchi
- Department of Cardiovascular Surgery, Tokai University Hachioji Hospital, Hachioji, Japan
| |
Collapse
|
24
|
Takahashi Y, Abe Y, Fujii H, Morisaki A, Sakon Y, Shibata T. Aortomitral angle affects cardiovascular events after mitral valve repair for atrial functional mitral regurgitation. J Card Surg 2022; 37:4209-4218. [PMID: 35293028 DOI: 10.1111/jocs.16355] [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: 02/15/2022] [Accepted: 12/06/2021] [Indexed: 01/06/2023]
Abstract
PURPOSE This study aimed to elucidate the geometric parameters of the aortomitral (AM) complex affecting postoperative cardiovascular events (CVEs) in patients with atrial functional mitral regurgitation (MR). METHODS From October 2008 to August 2018, we performed mitral and tricuspid valve repairs in 58 patients with atrial functional MR. We examined the determinants of CVEs using preoperative and postoperative echocardiographic data. Furthermore, we analyzed the effect of left atrial (LA) plication on AM geometries after surgery. The follow-up period ranged from 56 to 3283 days (median, 1073 days). RESULTS All patients underwent mitral and tricuspid annuloplasty. Seventeen patients (29%) underwent additional LA plication. The AM angle was narrowed after surgery in patients with CVEs (115° ± 6.8° to 106° ± 4.2°, p = .00336), whereas it widened in patients without CVEs (115° ± 7.4° to 118° ± 8.4°, p = .0278). The postoperative AM angle was an independent predictor of postoperative CVEs (p = .000829). LA plication was not a predictor of CVEs; however, it was a predictor of the obtuse postoperative AM angle (p = .0071). CONCLUSIONS Our results suggest that a narrow postoperative AM angle is an independent predictor of postoperative CVEs. Additional LA plication reduces the sharpening of the AM angle, which may prevent CVEs after mitral valve repair for atrial functional MR.
Collapse
Affiliation(s)
- Yosuke Takahashi
- Department of Cardiovascular Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yukio Abe
- Department of Cardiology, Osaka City General Hospital, Osaka, Japan
| | - Hiromichi Fujii
- Department of Cardiovascular Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Akimasa Morisaki
- Department of Cardiovascular Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yoshito Sakon
- Department of Cardiovascular Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Toshihiko Shibata
- Department of Cardiovascular Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| |
Collapse
|
25
|
Jainandunsing JS, Massari D, Vos JJ, Wijdh-den Hamer IJ, van den Heuvel AF, Mariani MA, Mahmood F, Bouma W, Scheeren TWL. Mitral Valve Coaptation Reserve Index: A Model to Localize Individual Resistance to Mitral Regurgitation Caused by Annular Dilation. J Cardiothorac Vasc Anesth 2022; 37:690-697. [PMID: 36509635 DOI: 10.1053/j.jvca.2022.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 11/02/2022] [Accepted: 11/07/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The objective of this study was to develop a mathematical model for mitral annular dilatation simulation and determine its effects on the individualized mitral valve (MV) coaptation reserve index (CRI). DESIGN A retrospective analysis of intraoperative transesophageal 3-dimensionalechocardiographic MV datasets was performed. A mathematical model was created to assess the mitral CRI for each leaflet segment (A1-P1, A2-P2, A3-P3). Mitral CRI was defined as the ratio between the coaptation reserve (measured coaptation length along the closure line) and an individualized correction factor. Indexing was chosen to correct for MV sphericity and area of largest valve opening. Mathematical models were created to simulate progressive mitral annular dilatation and to predict the effect on the individual mitral CRI. SETTING At a single-center academic hospital. PARTICIPANTS Twenty-five patients with normally functioning MVs undergoing cardiac surgery. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Direct measurement of leaflet coaptation along the closure line showed the lowest amount of coaptation (reserve) near the commissures (A1-P1 0.21 ± 0.05 cm and A3-P3 0.22 ± 0.06 cm), and the highest amount of coaptation (reserve) at region A2 to P2 0.25 ± 0.06 cm. After indexing, the A2-to-P2 region was the area with the lowest CRI in the majority of patients, and also the area with the least resistance to mitral regurgitation (MR) occurrence after simulation of progressive annular dilation. CONCLUSIONS Quantification and indexing of mitral coaptation reserve along the closure line are feasible. Indexing and mathematical simulation of progressive annular dilatation consistently showed that indexed coaptation reserve was lowest in the A2-to-P2 region. These results may explain why this area is prone to lose coaptation and is often affected in MR.
Collapse
Affiliation(s)
- Jayant S Jainandunsing
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
| | - Dario Massari
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Jaap Jan Vos
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Inez J Wijdh-den Hamer
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Ad Fm van den Heuvel
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Massimo A Mariani
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Feroze Mahmood
- Department of Anesthesiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Wobbe Bouma
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Thomas W L Scheeren
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| |
Collapse
|
26
|
Zoghbi WA, Levine RA, Flachskampf F, Grayburn P, Gillam L, Leipsic J, Thomas JD, Kwong RY, Vandervoort P, Chandrashekhar Y. Atrial Functional Mitral Regurgitation: A JACC: Cardiovascular Imaging Expert Panel Viewpoint. JACC Cardiovasc Imaging 2022; 15:1870-1882. [PMID: 36357130 DOI: 10.1016/j.jcmg.2022.08.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 08/03/2022] [Accepted: 08/11/2022] [Indexed: 11/09/2022]
Abstract
Functional or secondary mitral regurgitation (MR) is associated with increased cardiovascular morbidity and mortality. Mechanistically, secondary MR is attributable to an imbalance between mitral leaflet tethering and closure forces, leading to poor coaptation. The pathophysiology of functional MR is most often the result of abnormalities in left ventricular function and remodeling, seen in ischemic or nonischemic conditions. Less commonly and more recently recognized is the scenario in which left ventricular geometry and function are preserved, the culprit being mitral annular enlargement associated with left atrial dilatation, termed atrial functional mitral regurgitation (AFMR). This most commonly occurs in the setting of chronic atrial fibrillation or heart failure with preserved ejection fraction. There is variability in the published reports and in current investigations as to the definition of AFMR. This paper reviews the pathophysiology of AFMR and focus on the need for a collective definition of AFMR to facilitate consistency in reported data and enhance much-needed research into outcomes and treatment strategies in AFMR.
Collapse
Affiliation(s)
| | | | | | | | - Linda Gillam
- Morristown Medical Center, Morristown, New Jersey, USA
| | - Jonathon Leipsic
- Providence Health Care, Vancouver Coastal Health, Vancouver, Canada
| | - James D Thomas
- Northwestern Medicine, Feinberg School of Medicine, Chicago, Illinois, USA
| | | | | | | |
Collapse
|
27
|
Morisaki A, Takahashi Y, Fujii H, Sakon Y, Murakami T, Shibata T. Patch augmentation vs. valve replacement for patients with atrial functional mitral regurgitation and long-standing atrial fibrillation. J Thorac Dis 2022; 14:3831-3841. [PMID: 36389294 PMCID: PMC9641335 DOI: 10.21037/jtd-22-828] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 09/09/2022] [Indexed: 12/28/2023]
Abstract
BACKGROUND Long-standing atrial fibrillation is associated with atrial functional mitral regurgitation (AFMR) with atriogenic tethering. We compared the outcomes of patch augmentation (PA) and valve replacement (VR) for AFMR. METHODS We retrospectively compared the data of 16 patients who underwent PA for AFMR with the data of 15 patients who underwent VR between 2008 and 2021. Patients with a left ventricular ejection fraction (LVEF) of <50% were excluded. We also performed atrial plication and left appendage closure if the patients had no weak atrial wall that led to severe bleeding. RESULTS The median age was 72.5 and 76.0 years in the PA and VR groups, respectively. The PA group had a longer cardiopulmonary bypass time (206 vs. 172 min, P=0.012). Although there were no differences in hospital morbidity and mortality between the PA and VR groups, one patient underwent reoperation for patch perforation in the PA group. The overall 3-year survival rate was 93.8% and 100% in the PA and VR groups, respectively (P=0.878). The 3-year rate of freedom from major adverse cardiac events was 75.0% and 53.6% in the PA and VR groups, respectively (P=0.181). Three and six patients were readmitted for congestive heart failure in the PA and VR groups, respectively. Two patients in the PA group developed severe recurrent regurgitation, including one patient who required reoperation. No patients in the VR group required reoperation. The postoperative left atrial volume index (LAVI) was associated with thromboembolic events (P=0.016). CONCLUSIONS PA may achieve comparable outcomes to those of VR for AFMR. Operative procedures should be chosen based on each patient's background. Atrial reduction could be considered to prevent thromboembolic events.
Collapse
Affiliation(s)
- Akimasa Morisaki
- Department of Cardiovascular Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Yosuke Takahashi
- Department of Cardiovascular Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Hiromichi Fujii
- Department of Cardiovascular Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Yoshito Sakon
- Department of Cardiovascular Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Takashi Murakami
- Department of Cardiovascular Surgery, Osaka City General Hospital, Osaka, Japan
| | - Toshihiko Shibata
- Department of Cardiovascular Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| |
Collapse
|
28
|
Transcatheter Edge-to-Edge Repair for Atrial Functional Mitral Regurgitation: Effective Therapy or Elusive Target? JACC Cardiovasc Interv 2022; 15:1741-1747. [PMID: 36075645 DOI: 10.1016/j.jcin.2022.06.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 06/28/2022] [Indexed: 11/24/2022]
|
29
|
Milwidsky A, Mathai SV, Topilsky Y, Jorde UP. Medical Therapy for Functional Mitral Regurgitation. Circ Heart Fail 2022; 15:e009689. [PMID: 35862021 DOI: 10.1161/circheartfailure.122.009689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Functional mitral regurgitation (FMR) can be broadly categorized into 2 main groups: ventricular and atrial, which often coexist. The former is secondary to left ventricular remodeling usually in the setting of heart failure with reduced ejection fraction or less frequently due to ischemic papillary muscle remodeling. Atrial FMR develops due to atrial and annular dilatation related to atrial fibrillation/flutter or from increased atrial pressures in the setting of heart failure with preserved ejection fraction. Guideline-directed medical therapy is the first step and prevails as the mainstay in the treatment of FMR. In this review, we address the medical therapeutic options for FMR management and highlight a targeted approach for each FMR category. We further address important clinical and echocardiographic characteristics to aid in determining when medical therapy is expected to have a low yield and an appropriate window for effective interventional approaches exists.
Collapse
Affiliation(s)
- Assi Milwidsky
- Department of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (A.M., U.P.J.).,Department of Cardiology, Tel-Aviv Sourasky Medical Center (affiliated with the Sackler School of Medicine), Tel-Aviv University, Israel (A.M., Y.T.)
| | - Sheetal Vasundara Mathai
- Department of Medicine, Jacobi Medical Center and Albert Einstein College of Medicine, Bronx, NY (S.V.M.)
| | - Yan Topilsky
- Department of Cardiology, Tel-Aviv Sourasky Medical Center (affiliated with the Sackler School of Medicine), Tel-Aviv University, Israel (A.M., Y.T.)
| | - Ulrich P Jorde
- Department of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (A.M., U.P.J.)
| |
Collapse
|
30
|
Tanaka T, Sugiura A, Öztürk C, Vogelhuber J, Tabata N, Wilde N, Zimmer S, Nickenig G, Weber M. Transcatheter Edge-to-Edge Repair for Atrial Secondary Mitral Regurgitation. JACC Cardiovasc Interv 2022; 15:1731-1740. [DOI: 10.1016/j.jcin.2022.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/18/2022] [Accepted: 06/07/2022] [Indexed: 12/12/2022]
|
31
|
Treatment of secondary mitral regurgitation by transcatheter edge-to-edge repair using MitraClip. J Med Ultrason (2001) 2022; 49:389-403. [PMID: 35708872 DOI: 10.1007/s10396-022-01227-1] [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: 02/24/2022] [Accepted: 05/06/2022] [Indexed: 10/18/2022]
Abstract
Transcatheter edge-to-edge repair (TEER) is becoming the standard invasive treatment for ventricular functional mitral regurgitation (MR). It is necessary to determine the severity of MR before treatment with MitraClip; however, the severity of secondary MR is usually underestimated compared with that of primary MR and varies temporally. Therefore, to accurately determine the severity of MR, it is important to correctly use the algorithm of the guidelines for valvular heart disease and aggressively perform stress echocardiography. Before performing TEER, the difficulty of the procedure should be evaluated. First, morphological features that make TEER unsuitable, such as cleft of the mitral leaflet, mitral stenosis (MS), or perforation of the mitral leaflet, should be checked. The mitral valve orifice area, transmitral valve pressure gradient, coaptation depth, coaptation length, and posterior leaflet length should be measured to determine the difficulty of the procedure based on the inclusion criteria of Endovascular Valve Edge-to-Edge Repair Study II and the German consensus. After MitraClip implantation, in addition to assessing the severity of MS and residual MR, the pulmonary venous flow pattern and stroke volume should be evaluated to comprehensively assess whether TEER improves the hemodynamics. MitraClip has also been used to treat atrial functional MR, another type of secondary MR. Several reports suggest that MitraClip is effective for atrial functional MR; however, evidence is still being accumulated.
Collapse
|
32
|
Abstract
In order to achieve the classification of mitral regurgitation, a deep learning network VDS-UNET was designed to automatically segment the critical regions of echocardiography with three sections of apical two-chamber, apical three-chamber, and apical four-chamber. First, an expert-labeled dataset of 153 echocardiographic videos and 2183 images from 49 subjects was constructed. Then, the convolution layer in the VGG16 network was used to replace the contraction path in the original UNet network to extract image features, and depth supervision was added to the expansion path to achieve the segmentation of LA, LV, and MV. The results showed that the Dice coefficients of LA, LV, and MV were 0.935, 0.915, and 0.757, respectively. The proposed deep learning network can achieve simultaneous and accurate segmentation of LA, LV, and MV in multi-section echocardiography, laying a foundation for quantitative measurement of clinical parameters related to mitral regurgitation.
Collapse
|
33
|
Marwick TH, Chandrashekhar Y. Quantification and Selective Use of Multimodality Imaging in the Assessment of Valvular Regurgitation. JACC Cardiovasc Imaging 2022; 15:957-959. [PMID: 35512965 DOI: 10.1016/j.jcmg.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
34
|
Efficacy of Electrical Cardioversion in Relation to Occurrence and Type of Functional Mitral Regurgitation in Patients with Atrial Fibrillation. J Clin Med 2022; 11:jcm11082069. [PMID: 35456162 PMCID: PMC9031715 DOI: 10.3390/jcm11082069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 03/29/2022] [Accepted: 04/04/2022] [Indexed: 12/15/2022] Open
Abstract
Background: Recent studies have changed the perception of rhythm control in the treatment of atrial fibrillation (AF). Functional mitral regurgitation (fMR) can be both a cause and a consequence of AF and may influence rhythm restoration procedures. Materials and methods: A retrospective analysis included 182 consecutive patients with AF on optimal medical therapy (OMT) undergoing electrical cardioversion (CVE). Based on transthoracic echocardiography, the study group was divided into 20 (11%) patients without mitral regurgitation (MR) and 132 (82%) with fMR 77 (58%) with atrial fMR (afMR; left ventricle ejection fraction (LVEF) ≥ 50%, left atrial (LA) dilatation) and 55 (42%) and with ventricular fMR (vfMR; LVEF < 50%). Patients with severe and organic MR were excluded from the study. Results: vfMR patients had a greater incidence of kidney failure (p = 0.01) and coronary heart disease (p = 0.02); more frequent use of diuretics during hospitalization (p < 0.01); greater LA diameter and area (p < 0.01; p < 0.01) than afMR patients. CVE efficiency was high in all four groups (84−95%). The presence and type of fMR did not affect the efficacy of CVE (p = 0.2; p = 0.9) and did not require the use of more energy (p = 0.4; p = 0.8). The independent predictor of successful CVE was the amount of white blood cells (OR 0.74, p < 0.05). Conclusions: Efficacy of CVE is high among AF patients on OMT regardless of the incidence and type of fMR. Subclinical inflammation should be excluded before elective CVE because it may decrease its efficacy.
Collapse
|
35
|
Gomes NFA, Silva VR, Levine RA, Esteves WAM, de Castro ML, Passos LSA, Dal-Bianco JP, Pantaleão AN, da Silva JLP, Tan TC, Dutra WO, Aikawa E, Hung J, Nunes MCP. Progression of Mitral Regurgitation in Rheumatic Valve Disease: Role of Left Atrial Remodeling. Front Cardiovasc Med 2022; 9:862382. [PMID: 35360029 PMCID: PMC8962951 DOI: 10.3389/fcvm.2022.862382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 02/14/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Mitral regurgitation (MR) is the most common valve abnormality in rheumatic heart disease (RHD) often associated with stenosis. Although the mechanism by which MR develops in RHD is primary, longstanding volume overload with left atrial (LA) remodeling may trigger the development of secondary MR, which can impact on the overall progression of MR. This study is aimed to assess the incidence and predictors of MR progression in patients with RHD. Methods Consecutive RHD patients with non-severe MR associated with any degree of mitral stenosis were selected. The primary endpoint was a progression of MR, which was defined as an increase of one grade in MR severity from baseline to the last follow-up echocardiogram. The risk of MR progression was estimated accounting for competing risks. Results The study included 539 patients, age of 46.2 ± 12 years and 83% were women. At a mean follow-up time of 4.2 years (interquartile range [IQR]: 1.2–6.9 years), 54 patients (10%) displayed MR progression with an overall incidence of 2.4 per 100 patient-years. Predictors of MR progression by the Cox model were age (adjusted hazard ratio [HR] 1.541, 95% CI 1.222–1.944), and LA volume (HR 1.137, 95% CI 1.054–1.226). By considering competing risk analysis, the direction of the association was similar for the rate (Cox model) and incidence (Fine-Gray model) of MR progression. In the model with LA volume, atrial fibrillation (AF) was no longer a predictor of MR progression. In the subgroup of patients in sinus rhythm, 59 had an onset of AF during follow-up, which was associated with progression of MR (HR 2.682; 95% CI 1.133–6.350). Conclusions In RHD patients with a full spectrum of MR severity, progression of MR occurs over time is predicted by age and LA volume. LA enlargement may play a role in the link between primary MR and secondary MR in patients with RHD.
Collapse
Affiliation(s)
- Nayana F. A. Gomes
- School of Medicine, Hospital das Clínicas, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Vicente Rezende Silva
- School of Medicine, Hospital das Clínicas, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Robert A. Levine
- Cardiac Ultrasound Lab, Harvard Medical School, Massachusetts General Hospital, Boston, MA, United States
| | - William A. M. Esteves
- School of Medicine, Hospital das Clínicas, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Marildes Luiza de Castro
- School of Medicine, Hospital das Clínicas, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Livia S. A. Passos
- The Center for Excellence in Vascular Biology, Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Jacob P. Dal-Bianco
- Cardiac Ultrasound Lab, Harvard Medical School, Massachusetts General Hospital, Boston, MA, United States
| | | | | | - Timothy C. Tan
- Department of Cardiology, Blacktown Hospital, University of Western Sydney, Penrith, NSW, Australia
| | - Walderez O. Dutra
- Department of Morphology, Institute of Biological Sciences, Federal University of Minas Gerais, and National Institutes for Science and Technology, Belo Horizonte, Brazil
| | - Elena Aikawa
- The Center for Excellence in Vascular Biology, Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Judy Hung
- Cardiac Ultrasound Lab, Harvard Medical School, Massachusetts General Hospital, Boston, MA, United States
| | - Maria Carmo P. Nunes
- School of Medicine, Hospital das Clínicas, Federal University of Minas Gerais, Belo Horizonte, Brazil
- *Correspondence: Maria Carmo P. Nunes
| |
Collapse
|
36
|
Kawamoto N, Fukushima S, Kainuma S, Ikuta A, Tadokoro N, Kakuta T, Fujita T. Mitral valve surgery for atrial functional mitral regurgitation: predicting recurrent mitral regurgitation and mid-term outcome. Gan To Kagaku Ryoho 2022; 70:761-769. [PMID: 35239104 PMCID: PMC9371988 DOI: 10.1007/s11748-022-01793-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 02/16/2022] [Indexed: 11/18/2022]
Abstract
Objectives This study aimed to elucidate the mid-term outcomes and risk factors for recurrent mitral regurgitation after mitral valve (MV) surgery for atrial functional mitral regurgitation (AFMR). Methods and results We retrospectively analyzed data of 50 consecutive patients (median age 74 years; 29 men) who underwent mitral valve surgery for AFMR between January 2001 and January 2019. Mean atrial fibrillation duration was 12 years. During the follow-up period of 4.6 ± 4.4 years, 5 cardiac-related deaths were identified. Five- and 10-year freedom from cardiac-related death rate for all patients was 88.4% and 78.6%. In total, 42 patients underwent MV repair with mitral annuloplasty and 8 underwent MV replacement. Five- and 10-year freedom from cardiac-related death rate in patients who underwent MV repair was 93.1% and 82.7%, which was better than MV replacement (log rank p = 0.04). During the follow-up period, MR recurrence rate was 16.8% at 5 and 10 years for the patients who underwent MV repair. Univariate analysis showed that partial band annuloplasty and preoperative elevated left ventricular end-systolic volume index were risk factors for recurrent MR after MV repair. Multivariate analysis identified partial band annuloplasty as the independent predictor for recurrent MR during long-term follow-up after MV repair for AFMR. Conclusion Patients who underwent MV repair for AFMR could have an acceptable mid-term outcome. However, MVR might not improve the mid-term outcome in patients with AFMR. The use of partial bands for mitral annuloplasty would not be recommended in terms of recurrent MR mid-term. Supplementary Information The online version contains supplementary material available at 10.1007/s11748-022-01793-8.
Collapse
Affiliation(s)
- Naonori Kawamoto
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shinmachi, Suita, Osaka, 564-8565, Japan.
| | - Satsuki Fukushima
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shinmachi, Suita, Osaka, 564-8565, Japan
| | - Satoshi Kainuma
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shinmachi, Suita, Osaka, 564-8565, Japan
| | - Ayumi Ikuta
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shinmachi, Suita, Osaka, 564-8565, Japan
| | - Naoki Tadokoro
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shinmachi, Suita, Osaka, 564-8565, Japan
| | - Takashi Kakuta
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shinmachi, Suita, Osaka, 564-8565, Japan
| | - Tomoyuki Fujita
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shinmachi, Suita, Osaka, 564-8565, Japan
| |
Collapse
|
37
|
Coutinho GF. Reply from author: Atrial fibrillation and functional tricuspid or mitral regurgitation: Which comes first, the egg or the chicken? JTCVS OPEN 2022; 9:95-96. [PMID: 36003473 PMCID: PMC9390176 DOI: 10.1016/j.xjon.2022.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
38
|
Barbieri A, Mantovani F. Atrial functional mitral regurgitation: The concept has evolved, but inconsistencies still remain. J Card Surg 2022; 37:1192-1194. [DOI: 10.1111/jocs.16309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 01/25/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Andrea Barbieri
- Division of Cardiology, Department of Diagnostics Clinical and Public Health Medicine, Policlinico University Hospital of Modena, University of Modena and Reggio Emilia Modena Italy
| | - Francesca Mantovani
- Department of Cardiology Azienda Unità Sanitaria Locale, IRCCS di Reggio Emilia Reggio Emilia Italy
| |
Collapse
|
39
|
Kato Y, Okada A, Amaki M, Nishimura K, Kanzaki H, Kataoka Y, Miyamoto K, Hamatani Y, Amano M, Takahama H, Hasegawa T, Kusano K, Fujita T, Kobayashi J, Yasuda S, Izumi C. Three-dimensional echocardiography for predicting mitral stenosis after MitraClip for functional mitral regurgitation. J Echocardiogr 2022; 20:151-158. [PMID: 35084686 DOI: 10.1007/s12574-022-00564-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/25/2021] [Accepted: 01/09/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Postprocedural mitral stenosis (MS), or increased transmitral mean pressure gradient (TMPG), is one of the limitations of transcatheter edge-to-edge mitral valve repair using MitraClip (Abbott Vascular Inc., Santa Clara, USA); however, the usefulness of three-dimensional transesophageal echocardiography (3D-TEE) for predicting postprocedural MS in functional mitral regurgitation (MR) has not been fully elucidated. METHODS Eighty-two consecutive functional MR patients who underwent transcatheter mitral valve repair using MitraClip were retrospectively studied. Postprocedural MS was defined as TMPG ≥ 5 mmHg by echocardiography. RESULTS Ten patients had postprocedural MS, and 3D-TEE showed that patients with postprocedural MS had smaller preprocedural mitral valve orifice area (MVOA), anteroposterior and mediolateral diameter, leaflet area, and annulus area. Receiver operating characteristic analysis showed that leaflet area (area under the curve (AUC) 0.829), annulus area (AUC 0.813), anteroposterior diameter (AUC 0.797) and mediolateral diameter (AUC 0.803) evaluated using 3D-TEE were predictors of postprocedural MS, and their predictive abilities were higher than those of preprocedural MVOA (AUC 0.756) and preprocedural TMPG (AUC 0.716). Adding leaflet area to TMPG and MVOA resulted in higher C-statistics for predicting postprocedural MS (from 0.716 to 0.845 and from 0.756 to 0.853, respectively). CONCLUSIONS In functional MR patients treated with MitraClip, leaflet area and annulus area evaluated using 3D-TEE had high predictive values for postprocedural MS, and their predictive abilities were higher than those of preprocedural TMPG or MVOA.
Collapse
Affiliation(s)
- Yuta Kato
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Atsushi Okada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan.
| | - Makoto Amaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Kunihiro Nishimura
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Hideaki Kanzaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Yu Kataoka
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Koji Miyamoto
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Yasuhiro Hamatani
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Masashi Amano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Hiroyuki Takahama
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Takuya Hasegawa
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Tomoyuki Fujita
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Junjiro Kobayashi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| |
Collapse
|
40
|
Pausch J, Girdauskas E, Conradi L, Reichenspurner H. Secondary mitral regurgitation repair techniques and outcomes: Subannular repair techniques in secondary mitral regurgitation type IIIb. JTCVS Tech 2022; 10:92-97. [PMID: 34977710 PMCID: PMC8691802 DOI: 10.1016/j.xjtc.2021.09.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 09/02/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- Jonas Pausch
- Department of Cardiovascular Surgery University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Evaldas Girdauskas
- Department of Cardiothoracic Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Lenard Conradi
- Department of Cardiovascular Surgery University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery University Heart & Vascular Center Hamburg, Hamburg, Germany
| |
Collapse
|
41
|
Hahn RT, Saric M, Faletra FF, Garg R, Gillam LD, Horton K, Khalique OK, Little SH, Mackensen GB, Oh J, Quader N, Safi L, Scalia GM, Lang RM. Recommended Standards for the Performance of Transesophageal Echocardiographic Screening for Structural Heart Intervention: From the American Society of Echocardiography. J Am Soc Echocardiogr 2022; 35:1-76. [PMID: 34280494 DOI: 10.1016/j.echo.2021.07.006] [Citation(s) in RCA: 87] [Impact Index Per Article: 43.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Rebecca T Hahn
- Columbia University Irving College of Medicine, New York, New York
| | - Muhamed Saric
- New York University Langone Health, New York, New York
| | | | - Ruchira Garg
- Cedars-Sinai Medical Center, Los Angeles, California
| | | | | | - Omar K Khalique
- Columbia University Irving College of Medicine, New York, New York
| | - Stephen H Little
- Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas
| | | | - Jae Oh
- Mayo Clinic, Rochester, Minnesota
| | | | - Lucy Safi
- Hackensack University Medical Center, Hackensack, New Jersey
| | | | | |
Collapse
|
42
|
Benito-González T, Carrasco-Chinchilla F, Estévez-Loureiro R, Pascual I, Arzamendi D, Garrote-Coloma C, Nombela-Franco L, Pan M, Serrador A, Freixa X, Cid Alvarez AB, Hernández Antolín RA, Andraka L, Cruz-González I, López-Minguez JR, Díez Gil JL, Urbano-Carrillo C, Sanmiguel Cervera D, Sanchís J, Bosa F, Ruíz V, Molina E, Becerra-Muñoz VM, Gualis J, Avanzas P, Li CH, Baz JA, Jimenez-Quevedo P, Mesa D, Amat-Santos IJ, Regueiro A, Trillo R, Domínguez Franco AJ, Alonso-Briales JH, Fernández-Vázquez F. Clinical and echocardiographic outcomes of transcatheter mitral valve repair in atrial functional mitral regurgitation. Int J Cardiol 2021; 345:29-35. [PMID: 34610357 DOI: 10.1016/j.ijcard.2021.09.056] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 09/11/2021] [Accepted: 09/27/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Isolated atrial fibrillation can cause mitral regurgitation (MR) in patients with normal left ventricular systolic function and no organic disease of the mitral valve. Little information is available regarding outcomes of Mitraclip in patients with atrial functional mitral regurgitation (AFMR). We aimed to evaluate 12-month clinical and echocardiographic outcomes of transcatheter mitral valve repair (TMVR) with MitraClip in patients with AFMR compared to those with ventricular functional or degenerative/mixed MR. METHODS Registry-based analysis of all consecutive patients who underwent TMVR and were included in the Spanish Registry of Mitraclip. Changes in MR and NYHA functional class, and a combined endpoint including all-cause mortality and hospitalizations due to heart failure were the main outcomes. RESULTS Overall, 1074 (69.1% male, 73.3 ± 10.2 years-old) patients were analyzed in this report. 48 patients (4.5%) presented AFMR. AFMR was significantly reduced after TMVR, with a procedural success rate of 91.7%, and this reduction persisted at 12-month (p < 0.001). Patients with AFMR showed a significant functional improvement at 6- and 12-month follow-up in our series (baseline: NYHA III 70.8% IV 18.8% vs. 1-year: NYHA III 21.7% IV 0%; p < 0.001). The probability of survival free of readmission for heart failure and all-cause mortality within the first year after TMVR was 74.9%. Procedural and clinical outcomes, as well as recurrent rates of MR were similar acutely and at 1-year compared to other etiologies. CONCLUSION TMVR in patients with AFMR showed no significant differences compared to ventricular functional or degenerative/mixed MR regarding MR reduction or clinical outcomes.
Collapse
Affiliation(s)
| | - Fernando Carrasco-Chinchilla
- Unidad de Gestión Clínica del Corazón, Hospital Universitario Virgen de la Victoria, CIBERCV, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), Málaga, Spain
| | | | - Isaac Pascual
- Heart Area, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Dabit Arzamendi
- Division of Interventional Cardiology, Hospital de la Santa Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
| | | | - Luis Nombela-Franco
- Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Manuel Pan
- Department of Cardiology, Hospital Reina Sofía, Universidad de Córdoba, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain
| | - Ana Serrador
- Department of Cardiology, University Clinic Hospital, CIBERCV, Valladolid, Spain
| | - Xavier Freixa
- Department of Cardiology, Cardiovascular Institute, Hospital Clínic, Barcelona, Spain
| | - Ana Belén Cid Alvarez
- Department of Cardiology, University Clinic Hospital, CIBERCV, Santiago de Compostela, Spain
| | | | - Leire Andraka
- Department of Cardiology, Hospital Universitario de Basurto, Bilbao, Spain
| | - Ignacio Cruz-González
- Department of Cardiology, Hospital Universitario de Salamanca, CIBERCV, IBSAL, Salamanca, Spain
| | | | - José Luis Díez Gil
- Department of Cardiology, Hospital Universitario y Politécnico La FE, Valencia, Spain
| | | | - Darío Sanmiguel Cervera
- Unidad de Hemodinámica y Cardiologia Intervencionista, Hospital General de Valencia, Valencia, Spain
| | - Juan Sanchís
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Universidad de Valencia, CIBERCV, Valencia, Spain
| | - Francisco Bosa
- Department of Cardiology, Hospital Universitario de Canarias, Islas Canarias, Spain
| | - Valeriano Ruíz
- Department of Cardiology, Complejo Hospitalario de Navarra, Navarra, Spain
| | - Eduardo Molina
- Department of Cardiology, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Víctor Manuel Becerra-Muñoz
- Unidad de Gestión Clínica del Corazón, Hospital Universitario Virgen de la Victoria, CIBERCV, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), Málaga, Spain
| | - Javier Gualis
- Department of Cardiology, University Hospital of León, León, Spain
| | - Pablo Avanzas
- Heart Area, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Chi Hion Li
- Division of Interventional Cardiology, Hospital de la Santa Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - José Antonio Baz
- Department of Cardiology, University Hospital Álvaro Cunqueiro, Vigo, Spain
| | | | - Dolores Mesa
- Department of Cardiology, Hospital Reina Sofía, Universidad de Córdoba, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain
| | | | - Ander Regueiro
- Department of Cardiology, Cardiovascular Institute, Hospital Clínic, Barcelona, Spain
| | - Ramiro Trillo
- Department of Cardiology, University Clinic Hospital, CIBERCV, Santiago de Compostela, Spain
| | - Antonio Jesús Domínguez Franco
- Unidad de Gestión Clínica del Corazón, Hospital Universitario Virgen de la Victoria, CIBERCV, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), Málaga, Spain
| | - Juan Horacio Alonso-Briales
- Unidad de Gestión Clínica del Corazón, Hospital Universitario Virgen de la Victoria, CIBERCV, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), Málaga, Spain
| | | |
Collapse
|
43
|
Wu Y, Gao P, Fang Q, Liu Y, Cheng K, Cheng Z, Deng H, Chen T, Yang D. Mitral valve regurgitation is associated with left atrial fibrosis in patients with atrial fibrillation. J Electrocardiol 2021; 70:24-29. [PMID: 34844143 DOI: 10.1016/j.jelectrocard.2021.11.031] [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: 08/09/2021] [Revised: 09/29/2021] [Accepted: 11/16/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Low voltage zones (LVZ) are associated with poor outcomes in patients with atrial fibrillation (AF). The APPLE and DR-FLASH scores predict LVZ in patients undergoing catheter ablation. This study aimed to assess the relationship of mitral valve regurgitation (MR) and LVZ after adjusting for APPLE or DR-FLASH scores. METHODS This was a retrospective study on patients with AF who underwent their first catheter ablation. All patients underwent a transthoracic echocardiographic examination before ablation. The APPLE and DR-FLASH scores were calculated at baseline. LVZ determined by high-density mapping was defined as bipolar voltage amplitude <0.5 mV. LVZ presence was defined as LVZ covering >5% of the left atrial surface area. RESULTS Altogether, 152 patients (mean age 62.0 ± 10.8 years, 65.8% men, and 36.2% with persistent AF) were included. Of the 152 patients, 47 (30.9%) had LVZ. The patients with LVZ had more moderate-to-severe MR (17.0% vs. 3.8%, P = 0.014) and higher APPLE scores (1.7 ± 1.1 vs. 1.2 ± 1.1, P = 0.009) and DR-FLASH scores (3.0 ± 1.5 vs. 2.4 ± 1.4, P = 0.010). Using multivariate logistic regression analysis, we found moderate-to-severe MR was related to LVZ presence after adjusting for the APPLE (OR 4.040, P = 0.034) or DR-FLASH (OR 4.487, P = 0.020) scores. Furthermore, moderate-to-severe MR had an incremental predictive value for LVZ presence in addition to the APPLE (P = 0.03) or DR-FLASH (P = 0.02) scores. CONCLUSION In patients with AF, MR severity was related to LVZ after adjusting the APPLE score or DR-FLASH score.
Collapse
Affiliation(s)
- Yanfang Wu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Peng Gao
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Quan Fang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Yongtai Liu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kangan Cheng
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhongwei Cheng
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hua Deng
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Taibo Chen
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Deyan Yang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| |
Collapse
|
44
|
Transcatheter edge-to-edge mitral valve repair in atrial functional mitral regurgitation: insights from the multi-center MITRA-TUNE registry. Int J Cardiol 2021; 349:39-45. [PMID: 34826500 DOI: 10.1016/j.ijcard.2021.11.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 11/12/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND A-FMR is considered a specific sub-type of secondary MR in patients with atrial fibrillation (AF) and preserved left ventricle ejection fraction (LVEF). Aim of the study was to investigate the acute and mid-term outcomes of transcatheter edge-to-edge mitral valve repair (TMVr) with the MitraClip in atrial functional mitral regurgitation (A-FMR). METHODS The study included patients with A-FMR and concomitant AF who underwent to the MitraClip at 7 Italian Centers. Aim of the study was to assess the safety, efficacy and mid-term cardiovascular outcomes. RESULTS After reviewing 1153 patients with FMR treated with TMVr from 2009 to 2021, 87 patients (median age 81 years, 61% female) with A-FMR were identified. Technical success was achieved in 97%, 30-day device success in 83% and 30-day procedural success in 80%. All-cause death at 30-day was 5%. Estimated two-year freedom from all-cause death and cardiac death was 60% and 77%, respectively, whereas freedom from all-cause death/heart failure hospitalization was 55%. Residual MR ≤ 2+ was encountered in 89% (n = 47/53) and improvement in NYHA class I/II in 79% (n = 48/61). Post-procedural MR ≥ 2+ (HR 5.400, CI 1.371-21.268) and inter-commissural annular diameter ≥ 35 mm (HR 4.159, CI 1.057-16.363) were independent predictors of all-cause death/heart failure hospitalization during the follow-up. Positive reverse remodeling of left atrium and mitral annular dimensions occurred after TMVr during the follow-up. CONCLUSIONS MitraClip resulted to be a safe and effective option to treat A-FMR in elderly patients.
Collapse
|
45
|
Matta M, Ayoub C, Abou Hassan OK, Layoun H, Cremer PC, Hussein A, Schoenhagen P, Saliba WI, Rodriguez LL, Griffin BP, Kapadia SR, Harb SC. Anatomic and Functional Determinants of Atrial Functional Mitral Regurgitation. STRUCTURAL HEART 2021. [DOI: 10.1080/24748706.2021.1943765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
|
46
|
|
47
|
Mesi O, Gad MM, Crane AD, Ramchand J, Puri R, Layoun H, Miyasaka R, Gillinov MA, Wierup P, Griffin BP, Kapadia SR, Harb SC. Severe Atrial Functional Mitral Regurgitation: Clinical and Echocardiographic Characteristics, Management and Outcomes. JACC Cardiovasc Imaging 2021; 14:797-808. [PMID: 33832663 DOI: 10.1016/j.jcmg.2021.02.008] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 02/16/2021] [Accepted: 02/18/2021] [Indexed: 01/04/2023]
Abstract
OBJECTIVES This study was designed to compare the clinical and echocardiographic characteristics, management, and outcomes of severe atrial functional mitral regurgitation (AFMR) to primary mitral regurgitation (PMR). BACKGROUND AFMR remains poorly defined clinically. METHODS Consecutive patients who underwent transesophageal echocardiography at our institution between 2011 and 2018 for severe mitral regurgitation with preserved left ventricular function were screened. We excluded patients with endocarditis, any form of cardiomyopathy, or prior mitral intervention. The absence of leaflet pathology defined AFMR. Outcomes included death and heart failure hospitalizations. RESULTS A total of 283 patients were included (AFMR = 14%, PMR = 86%). Compared to PMR, patients with AFMR had more comorbidities, including hypertension (94.9% vs. 76.2%; p = 0.015), diabetes mellitus (46.2% vs. 18.4%; p < 0.001), long-standing atrial fibrillation (28.2% vs. 13.1%; p = 0.015), prior nonmitral cardiac surgery (25.6% vs. 9.8%; p = 0.004), and pacemaker placement (33.3% vs. 13.5%; p = 0.002). They also had higher average E/e' (median [interquartile range]:16.04 [13.1 to 22.46] vs. 14.1 [10.89 to 19]; p = 0.036) and worse longitudinal left atrial strain peak positive value (16.86 ± 12.15% vs. 23.67 ± 14.09%; p = 0.002) compared to PMR. During follow-up (median: 22 months), patients with AFMR had worse survival (log-rank p = 0.009) and more heart failure hospitalizations (log-rank p = 0.002). They were also less likely to undergo mitral valve intervention (59.0% vs. 83.6%; p = 0.001), although surgery was associated with improved survival (log-rank p = 0.021). On multivariable regression analysis, AFMR was independently associated with mortality [adjusted odds ratio: 2.61, 95% confidence interval: 1.17 to 5.83; p = 0.02]. CONCLUSIONS AFMR constitutes an under-recognized high-risk group, with significant comorbidities, limited therapeutic options, and poor outcomes.
Collapse
Affiliation(s)
- Oltion Mesi
- Department of Internal Medicine, Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mohamed M Gad
- Department of Internal Medicine, Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alejandro D Crane
- Department of Internal Medicine, Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jay Ramchand
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Rishi Puri
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Habib Layoun
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Rhonda Miyasaka
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Marc A Gillinov
- Department of Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Per Wierup
- Department of Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Brian P Griffin
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Serge C Harb
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA.
| |
Collapse
|
48
|
Pasrija C, Quinn RW, Bernstein D, Tran D, Alkhatib H, Rice M, Morales D, Shah A, Ghoreishi M, Strauss ER, Henderson R, D'Ambra MN, Gammie JS. Mitral Valve Translocation: A Novel Operation for the Treatment of Secondary Mitral Regurgitation. Ann Thorac Surg 2021; 112:1954-1961. [PMID: 34419436 DOI: 10.1016/j.athoracsur.2021.07.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 05/04/2021] [Accepted: 07/12/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Conventional annuloplasty repair of secondary (functional) ischemic mitral regurgitation (IMR) is associated with a 60% recurrence of moderate or greater mitral regurgitation at 2 years. We developed a novel repair technique for IMR that addresses the underlying geometric alterations of the mitral valve apparatus and compared outcomes with those of conventional repair in a swine model. METHODS Chronic IMR was induced by percutaneous embolization of the circumflex artery. Swine with severe IMR (median 9 weeks after infarction) underwent undersized rigid annuloplasty (n = 5) or translocation repair (n = 6). Translocation repair consisted of detaching the mitral valve en bloc at the annulus, creating a 1 cm wide frustum-shaped pericardial patch, and suturing the outer circumference of the patch to the annulus and inner circumference to the mitral valve. RESULTS Operative survival was 92% (11 of 12). All animals had none/trace residual central mitral regurgitation, and mean inflow gradients were similar (1 mm Hg [interquartile range, 1 to 2] vs 2 mm Hg [interquartile range, 1 to 2]; P = .75) in the annuloplasty and translocation groups, respectively. Median coaptation length marginally improved in conventional swine (3 to 4 mm, P = .05), but dramatically improved in translocation swine (3 to 8 mm, P = .003). Posterior leaflet angle increased from 39 to 80 degrees (P = .05) in annuloplasty swine but decreased from 50 to 31 degrees (P = .03) in translocation swine. The posterior leaflet was immobile after annuloplasty but had preserved motion after translocation (excursion, 1 degree vs 24 degrees; P = .045). CONCLUSIONS Mitral valve translocation effectively treats mitral regurgitation by relieving leaflet tethering. Compared with annuloplasty, mitral valve translocation creates a larger surface of coaptation and preserves leaflet mobility without compromising diastolic function.
Collapse
Affiliation(s)
- Chetan Pasrija
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Rachael W Quinn
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | | | - Douglas Tran
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Hani Alkhatib
- Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - MaryJoe Rice
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - David Morales
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Aakash Shah
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Mehrdad Ghoreishi
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Erik R Strauss
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Reney Henderson
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Michael N D'Ambra
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - James S Gammie
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland.
| |
Collapse
|
49
|
Van De Heyning CM, Claeys MJ. Annular Dynamics in Patients With Atrial Fibrillation and AFMR: The Next Piece of the Puzzle. JACC Cardiovasc Imaging 2021; 15:14-16. [PMID: 34419397 DOI: 10.1016/j.jcmg.2021.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 07/01/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Caroline M Van De Heyning
- Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium; Department of Cardiovascular Diseases, Department of Genetics, Pharmacology, and Physiopathology of Heart, Blood Vessels, and Skeleton, Antwerp University, Antwerp, Belgium
| | - Marc J Claeys
- Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium; Department of Cardiovascular Diseases, Department of Genetics, Pharmacology, and Physiopathology of Heart, Blood Vessels, and Skeleton, Antwerp University, Antwerp, Belgium.
| |
Collapse
|
50
|
Cichoń M, Wybraniec M, Mizia-Szubryt M, Mizia-Stec K. Functional Mitral Regurgitation in Patients with Preserved Ejection Fraction Qualified for Pulmonary Vein Isolation: A Negative Prognostic Factor for Catheter Ablation Efficacy. MEDICINA-LITHUANIA 2021; 57:medicina57080798. [PMID: 34441004 PMCID: PMC8399362 DOI: 10.3390/medicina57080798] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 07/27/2021] [Accepted: 07/30/2021] [Indexed: 12/28/2022]
Abstract
Background and Objectives: Functional mitral regurgitation (F-MR) observed in patients with atrial fibrillation could affect the effectiveness of the sinus rhythm restoring procedures. The aim of the study was to evaluate the impact of F-MR on pulmonary vein isolation (PVI) efficacy in patient with preserved ejection fraction (EF). Materials and Methods: One hundred and thirty-six patients with EF ≥ 50% (65.4% males; mean age 56 ± 11 years) with symptomatic paroxysmal or persistent AF qualified for PVI were enrolled into the study. F-MR assessment was performed in transthoracic (TTE) and transesophageal (TEE) echocardiography before the PVI procedure. PVI efficacy was evaluated in three-month and long-term follow-up. Results: F-MR was diagnosed in 74.3% patient in transthoracic echocardiography (TTE) (trace: 26.5%, mild: 43.4%, moderate: 3.7%, severe 0.7%) and 94.9% in transesophageal echocardiography (TEE) (trace: 17.6%, mild: 59.6%, moderate: 16.2%, severe: 1.5%). The PVI three-month efficacy was 75.7% in the three-month and 64% in the long-term observation. Severe F-MR in TEE at baseline was associated with lower three-month PVI efficacy (p = 0.012), while moderate to severe F-MR in TEE was related to inefficient PVI assessed in long-term follow-up (p = 0.041). Conclusions: Significant F-MR confirmed by TEE predicts three-month as well as long-term PVI efficacy.
Collapse
|