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Hiraoka A, Hayashida A, Totusgawa T, Toki M, Chikazawa G, Yoshitaka H, Sakaguchi T. Flow adjusted transmitral pressure gradient as a modified indicator of functional mitral stenosis after repair for degenerative mitral regurgitation. J Card Surg 2022; 37:1827-1834. [PMID: 35234318 PMCID: PMC9311205 DOI: 10.1111/jocs.16373] [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: 12/14/2021] [Accepted: 01/19/2022] [Indexed: 11/28/2022]
Abstract
Background and Aim After repair of degenerative mitral regurgitation (DMR), the focus is on functional mitral stenosis (FMS) when there is a decline of mitral hemodynamics. Yet, the clinical impacts and a standardized definition are still undecided. Since common mitral hemodynamic parameters are influenced by transmitral flow, the aim of this study is to seek the impact of flow adjusted transmitral pressure gradient (TMPG) by left ventricular stroke volume (LVSV) on the midterm outcomes. Methods Three hundred one patients who had undergone isolated mitral valve repair for degenerative lesions with annuloplasty prosthesis between October 2012 and June 2019 were included. Postoperative adverse events occurred in 20 patients (6.6%). Flow adjusted TMPG was defined as TMPG/LVSV. Results Common mitral hemodynamic parameters were not associated with adverse events. By multivariable analysis, patients’ age, left ventricular ejection fraction (LVEF) and mean TMPG/LVSV were isolated as independent predictors (adjusted hazard ratio: 1.05, 0.95, and 1.16; p = .037, .005, and .035). Flow adjusted TMPG was significantly higher in the full ring group compared to the partial band group (0.051 mmHg/ml, [0.038–0.068] vs. 0.041 mmHg/ml, [0.031–0.056]; p < .001) and had a significantly negative correlation with the size of the annuloplasty prosthesis (r = −0.37, p < .001). Conclusions Conventional mitral hemodynamic parameters were not associated with adverse cardiac events after repair for DMR. Adjustment by flow has a potential to advance pressure gradient to a more sensitive indicator of FMS associated with clinical outcomes.
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Affiliation(s)
- Arudo Hiraoka
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Akihiro Hayashida
- Department of Cardiology, The Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Toshinori Totusgawa
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Misako Toki
- Department of Clinical Laboratory, The Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Genta Chikazawa
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Hidenori Yoshitaka
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Taichi Sakaguchi
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan
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Scorsin M, Andreas M, Corona S, Guta AC, Aruta P, Badano LP. Novel transcatheter mitral prosthesis designed to preserve physiological ventricular flow dynamics. Ann Thorac Surg 2021; 113:593-599. [PMID: 33838122 DOI: 10.1016/j.athoracsur.2021.03.067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 02/23/2021] [Accepted: 03/01/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Current mitral bioprostheses are akin to the aortic valve and therefore abolish the left ventricular (LV) physiological vortex. We evaluated the hemodynamic performance and the effects on intraventricular flow dynamics (IFD) of a novel mitral bioprosthesis that presents an innovative design, mimicking the native valve. METHODS A D-shaped self-expandable stent-bovine pericardium monoleaflet valve was designed to provide physiological asymmetric intraventricular flow. Twelve juvenile sheep were consecutively implanted transapically. Post-implant studies were obtained immediately after the implantation and at 3 months to assess the hemodynamic performance of the prostheses, using Doppler echocardiography and IFD using echo particle imaging velocimetry. RESULTS Three deaths occurred during follow-up, one due to valve misplacement because of poor imaging visualization and 2 not valve related. Mean transvalvular gradient and effective orifice area after implantation and at 3 months were 2.2 ± 1.2 mmHg and 4.0 ± 1.1 cm2, and 3.3 ± 1.5 mmHg and 3.5 ± 0.5 cm2, respectively. LV vortex dimension, orientation and physiologic anti-clockwise rotation were preserved compared with pre-operative normal LV flow pattern. One animal showed a moderate paravalvular leak, others mild or none. LV outflow tract obstruction, valve thrombosis or hemolysis were not observed. CONCLUSIONS Our preclinical in vivo results, confirm the good hemodynamic performance of this new transcatheter bioprosthesis with preservation of the physiological IFD. Clinical studies are needed to document whether these characteristics will foster LV recovery and improve the clinical outcome of patients with mitral regurgitation.
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Affiliation(s)
- Marcio Scorsin
- Jilin Heart Hospital, Department of Cardiac Surgery, Changchun, China.
| | - Martin Andreas
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Silvia Corona
- Department of Cardiac Surgery, Centro Cardiologico Monzino, University of Milan, Milan Italy
| | - Andrada Camelia Guta
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Padova, Italy; Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Patrizia Aruta
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Luigi Paolo Badano
- Istituto Auxologico Italiano, IRCCS, Milan, Italy; Department of medicine and surgery, University of Milano-Bicocca, Milan, Italy
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Tonai K, Hiraoka A, Hayashida A, Totsugawa T, Chikazawa G, Yoshitaka H, Yoshida K, Sakaguchi T. Clinical Impact of Flow Adjusted Transmitral Pressure Gradient After Surgical Annuloplasty for Functional Mitral Regurgitation. Semin Thorac Cardiovasc Surg 2021; 34:54-60. [PMID: 33596457 DOI: 10.1053/j.semtcvs.2021.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 02/12/2021] [Indexed: 12/20/2022]
Abstract
Downsizing of mitral annulus due to mitral annuloplasty for ischemic functional mitral regurgitation (FMR) raises a new issue, functional mitral stenosis (FMS), defined as a decline of mitral hemodynamics. However, common mitral hemodynamic parameters are influenced by transmitral flow, therefore, the clinical impacts are still controversial. The aim of this study is to seek mitral hemodynamic indices (including transmitlra pressure gradient [TMPG] adjusted by left ventricular stroke volume [LVSV]) relevant to the mid-term outcomes after annuloplasty for ischemic functional mitral regurgitation (FMR). This study is a retrospective evaluation of mitral valve hemodynamic status by resting echocardiogram at several weeks after surgery. Eighty-one patients underwent mitral annuloplasty for ischemic FMR between September 2012 and June 2019. Postoperative adverse events occurred in 28 patients (34.6%), and the overall 5-year freedom from adverse events rate was 55.9%. Common mitral hemodynamic parameters were not associated with adverse events, but flow adjusted TMPG can be a correlative factor. By multivariable analysis, postoperative systolic pulmonary artery pressure and peak TMPG/LVSV were detected as independent predictors (adjusted hazard ratio 1.07 and 1.08, P < 0.001 and < 0.001). Additionally, risk stratification by peak TMPG (cut-off: 10 mm Hg) and LVSV (cut-off: 35 mL/m2) reflected the mid-term outcomes, perceptively (P = 0.007). Conventional mitral hemodynamic parameters were not associated with adverse cardiac events after annuloplasty for ischemic FMR. However, flow adjusted TMPG was identfied as an independent predictor, and risk stratification by peak TMPG and LVSV reflected the mid-term outcomes, perceptively.
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Affiliation(s)
- Kohei Tonai
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Japan
| | - Arudo Hiraoka
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Japan.
| | - Akihiro Hayashida
- Department of Cardiology, The Sakakibara Heart Institute of Okayama, Japan
| | - Toshinori Totsugawa
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Japan
| | - Genta Chikazawa
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Japan
| | - Hidenori Yoshitaka
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Japan
| | - Kiyoshi Yoshida
- Department of Cardiology, The Sakakibara Heart Institute of Okayama, Japan
| | - Taichi Sakaguchi
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Japan
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Miceli A. Commentary: Understanding the mitral apparatus: Still missing some pieces. JTCVS Tech 2020; 4:136-137. [PMID: 34317987 PMCID: PMC8306214 DOI: 10.1016/j.xjtc.2020.08.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 08/24/2020] [Accepted: 08/28/2020] [Indexed: 11/15/2022] Open
Affiliation(s)
- Antonio Miceli
- Minimally Invasive Cardiac Surgery Department, Istituto Clinico Sant'Ambrogio, Milano, Italy
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Li B, Sun H. Subannular repair for moderate to severe ischemic mitral regurgitation: Still a long way to go. Authors' reply. Cardiol J 2020; 27:223-224. [PMID: 32463102 DOI: 10.5603/cj.2020.0052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 03/25/2020] [Indexed: 11/25/2022] Open
Affiliation(s)
- Baotong Li
- SunState Key Laboratory of Cardiovascular Disease, Department of Adult Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science, Peking Union Medical College, Beijing, China.
| | - Hansong Sun
- SunState Key Laboratory of Cardiovascular Disease, Department of Adult Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science, Peking Union Medical College, Beijing, China
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Vural KM. More decision-making criteria for moderate chronic ischemic mitral regurgitation. J Thorac Cardiovasc Surg 2019; 157:580-581. [PMID: 30669221 DOI: 10.1016/j.jtcvs.2018.07.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 07/16/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Kerem M Vural
- Department of Cardiovascular Surgery, Hacettepe University School of Medicine, Ankara, Turkey
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Wang X, Zhang B, Zhang J, Ying Y, Zhu C, Chen B. Repair or replacement for severe ischemic mitral regurgitation: A meta-analysis. Medicine (Baltimore) 2018; 97:e11546. [PMID: 30075522 PMCID: PMC6081181 DOI: 10.1097/md.0000000000011546] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The best surgical option for severe ischemic mitral regurgitation (IMR) is still controversial. The aim of this study was to perform a meta-analysis to compare the clinical outcomes of mitral valve repair (MVP) with replacement (MVR). METHODS A literature search was conducted in PubMed, Embase, and Medline using the terms "ischemic mitral regurgitation" and "repair or annuloplasty or reconstruction" and "replacement" in the title/abstract field. The primary outcomes of interest were perioperative mortality and long-term survival. Secondary outcomes were mitral regurgitation (MR) recurrence and reoperation. RESULTS Of 276 studies, 13 studies met the inclusion and exclusion criteria. A total of 1993 patients were included in these studies, consisting of 1259 (63%) repair cases, and 734 (37%) replacement cases. Perioperative mortality was lower with MVP compared with MVR [OR 0.61; (95% CI, 0.43-0.87; P < .05)]. There was no difference with respect to long-term survival [HR 0.75; (95% CI, 0.52-1.09; P = .14)] and reoperation [OR 0.77; (95% CI, 0.38-1.57; P = .47)]. MVP is associated with a higher recurrence of MR [OR = 4.09; (95% CI, 1.82-9.19; P < .001)]. CONCLUSION MVP is associated with a lower perioperative mortality but a higher recurrence of MR compared with MVR for severe IMR. No differences were found with respect to long-term survival and reoperation.
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Li B, Wu H, Sun H, Xu J, Song Y, Wang W, Wang S. Predicting functional mitral stenosis after restrictive annuloplasty for ischemic mitral regurgitation. Cardiol J 2018; 26:350-359. [PMID: 29512090 DOI: 10.5603/cj.a2018.0023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 03/02/2018] [Accepted: 01/02/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Although it has been realized that restrictive mitral valve annuloplasty (MVA) may re-sult in clinically significant functional mitral stenosis (MS), it still cannot be predicted. The purpose of this study was to identify risk factors for clinically significant functional MS following restrictive MVA surgery for chronic ischemic mitral regurgitation (CIMR). METHODS One hundred and fourteen patients who underwent restrictive MVA with coronary artery bypass grafting (CABG) for treatment of CIMR were retrospectively reviewed. Clinically significant functional MS was defined as resting transmitral peak pressure gradient (PPG) ≥ 13 mmHg. RESULTS During the follow-up period (range 6-12 months), 28 (24.56%) patients developed clinically significant functional MS. The PPG at follow-up was significantly higher than that measured in the early postoperative stage (3-5 days after surgery). Moreover, there was a linear correlation between the two measurements (r = 0.398, p < 0.001). Annuloplasty size ≤ 27 mm and early postoperative PPG ≥ 7.4 mmHg could predict clinically significant functional MS at 6-12 months postoperatively. CONCLUSIONS Chronic ischemic mitral regurgitation patients treated with restrictive MVA and CABG have significant increases in PPG postoperatively. Annuloplasty size ≤ 27 mm and early postopera-tive PPG ≥ 7.4 mmHg can predict clinically significant functional MS at 6-12 months after surgery.
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Affiliation(s)
- Baotong Li
- State Key Laboratory of Cardiovascular Disease, Department of Adult Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science, Peking Union Medical College, Beijing, China
| | - Hengchao Wu
- State Key Laboratory of Cardiovascular Disease, Department of Adult Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science, Peking Union Medical College, Beijing, China
| | - Hansong Sun
- State Key Laboratory of Cardiovascular Disease, Department of Adult Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science, Peking Union Medical College, Beijing, China.
| | - Jianping Xu
- State Key Laboratory of Cardiovascular Disease, Department of Adult Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science, Peking Union Medical College, Beijing, China
| | - Yunhu Song
- State Key Laboratory of Cardiovascular Disease, Department of Adult Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science, Peking Union Medical College, Beijing, China
| | - Wei Wang
- State Key Laboratory of Cardiovascular Disease, Department of Adult Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science, Peking Union Medical College, Beijing, China
| | - Shuiyun Wang
- State Key Laboratory of Cardiovascular Disease, Department of Adult Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science, Peking Union Medical College, Beijing, China
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Kawamoto N, Fujita T, Fukushima S, Shimahara Y, Kume Y, Matsumoto Y, Yamashita K, Kobayashi J. Late onset of atrial fibrillation in patients undergoing mitral valve repair for type II dysfunction. J Cardiol 2017; 71:346-351. [PMID: 29275952 DOI: 10.1016/j.jjcc.2017.11.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 11/16/2017] [Accepted: 11/29/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND There are few reports regarding factors related to late-onset of atrial fibrillation (Af) after mitral valve repair, which can compromise long-term outcome. We analyzed the risk factors for late Af after mitral valve repair. METHODS AND RESULTS Between 2001 and 2015, 318 patients (214 males; median, 57.7 years) underwent mitral valve repair for degenerative mitral insufficiency (MI) without concomitant aortic valve disease in our institute. Patients with a history of paroxysmal or chronic Af preoperatively were excluded. Serial follow-up echocardiography was used to evaluate cardiac function. The follow-up rate was 99%. The mean follow-up period was 6.0±4.1 years. There was no early death and there were nine late deaths. A total of 29 (9.1%) patients developed late Af. Freedom from late Af was 94.0% at 5 years and 82.9% at 10 years. Small ring annuloplasty, left atrial diameter, and pressure half time, which were measured at follow-up echocardiography, were considered as significant (p<0.05) risk factors for late Af. Patients who had late Af developed recurrent MI more frequently than those who did not (p<0.05). CONCLUSIONS Remodeling of the atrium caused by functional mitral stenosis is important for late Af, as well as recurrent MI. To prevent these problems, avoiding selection of a small ring at primary mitral repair for type II dysfunction and durable repair are required.
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Affiliation(s)
- Naonori Kawamoto
- Department of Cardiac Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Tomoyuki Fujita
- Department of Cardiac Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan.
| | - Satsuki Fukushima
- Department of Cardiac Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yusuke Shimahara
- Department of Cardiac Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yuta Kume
- Department of Cardiac Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yorihiko Matsumoto
- Department of Cardiac Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kizuku Yamashita
- Department of Cardiac Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Junjiro Kobayashi
- Department of Cardiac Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
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Cheng R, Dawkins S, Tat E, Makar M, Hussaini A, Makkar RR, Trento A, Siegel RJ, Kar S. Relation of Residual Mitral Regurgitation Despite Elevated Mitral Gradients to Risk of Heart Failure Hospitalization After MitraClip Repair. Am J Cardiol 2017; 120:1595-1600. [PMID: 29025679 DOI: 10.1016/j.amjcard.2017.07.027] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 06/18/2017] [Accepted: 07/06/2017] [Indexed: 11/18/2022]
Abstract
Achieving minimal residual mitral regurgitation (MR) after percutaneous MitraClip repair is limited by iatrogenic mitral stenosis. It is unknown whether allowing moderately elevated postprocedural mean mitral gradients (MMGs) to achieve < moderate residual MR is preferable to moderate residual regurgitation. Patients with less-than-moderate residual MR but a MMG of ≥5 mm Hg (Group 1) were compared with patients with moderate residual MR (Group 2). The primary end point was heart failure hospitalization. Secondary end points included mortality, subsequent mitral valve surgery, and MR at 1 year. Seventy-eight patients were included in the study. Group 1 included 48 patients (median MMG 6, interquartile range 5-6 mm Hg). Group 2 included 30 patients (median MMG 3.5, interquartile range 2-5 mm Hg). Age, baseline MR severity, and type of MR were not different between groups. Freedom from heart failure hospitalization at 1 year was 91.2 ± 4.2% in Group 1 versus 70.8 ± 8.7% in Group 2 (p = 0.021). Achieved differences in MR reduction between groups persisted at 1 year (p = 0.007). Survival was not different (p = 0.402), and subsequent mitral valve surgery occurred in 4 of 48 (8%) and in 4 of 30 patients (13%) in Group 1 and Group 2, respectively (p = 0.476). By multivariate Cox regression analysis, less-than-moderate residual MR, despite moderately elevated mitral gradients, was associated with a hazard ratio of 0.21 (95% confidence interval 0.04 to 0.96) for subsequent heart failure hospitalization (p = 0.044). In conclusion, patients with less-than-moderate residual MR despite a MMG of ≥5 had a 79% reduction in hazard for subsequent heart failure hospitalization compared with patients with moderate residual MR.
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Affiliation(s)
- Richard Cheng
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Sam Dawkins
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Emily Tat
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Moody Makar
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Asma Hussaini
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Raj R Makkar
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Alfredo Trento
- Division of Cardiothoracic Surgery, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Robert J Siegel
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Saibal Kar
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California.
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Bertrand PB, Schwammenthal E, Levine RA, Vandervoort PM. Exercise Dynamics in Secondary Mitral Regurgitation: Pathophysiology and Therapeutic Implications. Circulation 2017; 135:297-314. [PMID: 28093494 DOI: 10.1161/circulationaha.116.025260] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Secondary mitral valve regurgitation (MR) remains a challenging problem in the diagnostic workup and treatment of patients with heart failure. Although secondary MR is characteristically dynamic in nature and sensitive to changes in ventricular geometry and loading, current therapy is mainly focused on resting conditions. An exercise-induced increase in secondary MR, however, is associated with impaired exercise capacity and increased mortality. In an era where a multitude of percutaneous solutions are emerging for the treatment of patients with heart failure, it becomes important to address the dynamic component of secondary MR during exercise as well. A critical reappraisal of the underlying disease mechanisms, in particular the dynamic component during exercise, is of timely importance. This review summarizes the pathophysiological mechanisms involved in the dynamic deterioration of secondary MR during exercise, its functional and prognostic impact, and the way current treatment options affect the dynamic lesion and exercise hemodynamics in general.
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Affiliation(s)
- Philippe B Bertrand
- From Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium (P.B.B., P.M.V.); Faculty of Medicine and Life Sciences, Hasselt University, Belgium (P.B.B., P.M.V.); Heart Center, Sheba Medical Center, Tel Hashomer, Israel (E.S.); and Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston (R.A.L.).
| | - Ehud Schwammenthal
- From Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium (P.B.B., P.M.V.); Faculty of Medicine and Life Sciences, Hasselt University, Belgium (P.B.B., P.M.V.); Heart Center, Sheba Medical Center, Tel Hashomer, Israel (E.S.); and Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston (R.A.L.)
| | - Robert A Levine
- From Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium (P.B.B., P.M.V.); Faculty of Medicine and Life Sciences, Hasselt University, Belgium (P.B.B., P.M.V.); Heart Center, Sheba Medical Center, Tel Hashomer, Israel (E.S.); and Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston (R.A.L.)
| | - Pieter M Vandervoort
- From Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium (P.B.B., P.M.V.); Faculty of Medicine and Life Sciences, Hasselt University, Belgium (P.B.B., P.M.V.); Heart Center, Sheba Medical Center, Tel Hashomer, Israel (E.S.); and Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston (R.A.L.)
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Bertrand PB, Pettinari M, De Cannière H, Gutermann H, Smeets CJ, Verhaert D, Dion RA, Verdonck P, Vandervoort PM. Effective Orifice Area during Exercise in Bileaflet Mechanical Valve Prostheses. J Am Soc Echocardiogr 2017; 30:404-413. [DOI: 10.1016/j.echo.2016.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Indexed: 10/20/2022]
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13
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Functional mitral regurgitation in patients with heart failure and depressed ejection fraction. Curr Opin Cardiol 2016; 31:483-92. [DOI: 10.1097/hco.0000000000000325] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Nappi F, Nenna A, Spadaccio C, Lusini M, Chello M, Fraldi M, Acar C. Predictive factors of long-term results following valve repair in ischemic mitral valve prolapse. Int J Cardiol 2015; 204:218-28. [PMID: 26681541 DOI: 10.1016/j.ijcard.2015.11.137] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Revised: 11/17/2015] [Accepted: 11/22/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND In patients with ischemic mitral regurgitation, leaflet prolapse requires an accurate evaluation since surgical approach depends on valvular and subvalvular characteristics. This study aims to describe a cohort of patients over a long-term follow up, analyzing survival, reoperation and predictive factors of surgical outcomes. METHODS AND RESULTS From March 1994 to June 2011, 75 patients with ischemic mitral regurgitation and leaflet prolapse underwent surgical myocardial revascularization and mitral valve repair (90.7%) or replacement (9.3%). Our cohort was followed up until April 2015, with a mean follow up of 7 ± 3 years. Cardiac-related deaths occurred in 26 patients, with a mean survival of 114.2 months, including eight patients with in-hospital mortality. Reoperation was performed in 14 patients, due to valve repair failure. Twenty-six patients experienced moderate-to-severe mitral regurgitation. A preoperative LVEDD > 62 mm, LVESD > 52 mm, previous anteroseptal myocardial infarction, diffuse coronary artery disease, papillary anatomy type 1, partial rupture of the papillary muscle, A1-A2 scallop prolapse and postoperative mitral valve configuration (tenting area, tenting height, alfa-1 angle and alfa-2 angle) were identified as independent predictors of poor outcome. An index quantifying the stress on the annulus imparted by annuloplasty was elaborated and predicted endpoints. CONCLUSION Leaflet prolapse is an important entity in patients with ischemic mitral regurgitation, and its pathogenic mechanism mostly relies on papillary muscle lesion or elongation. Perioperative parameters describing geometric features of left ventricle, valvular and subvalvular components should be considered to provide a tailored approach for mitral valve repair, or to opt for immediate replacement in case of unfavorable geometry.
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Affiliation(s)
- Francesco Nappi
- Dept. of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 200, Rome, Italy; Dept. of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Rue des Moulins Gémeaux 36, Saint-Denis, Paris, France.
| | - Antonio Nenna
- Dept. of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 200, Rome, Italy
| | - Cristiano Spadaccio
- Dept. of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 200, Rome, Italy; Dept. of Cardiothoracic Surgery, Golden Jubilee National Hospital, Agamennon Street, Clydebank, Glasgow, UK
| | - Mario Lusini
- Dept. of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 200, Rome, Italy
| | - Massimo Chello
- Dept. of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 200, Rome, Italy
| | - Massimiliano Fraldi
- Dept. of Structures and Interdisciplinary Research, Center of Biomaterials, University of Naples "Federico II", Corso Umberto I, Naples, Italy
| | - Christophe Acar
- Dept. of Department of Cardiothoracic Surgery, Hôpital Pitié-Salpétrière, Boulevard de l' Hôpital 47-83, Paris, France
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15
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Suh YJ, Chang BC, Im DJ, Kim YJ, Hong YJ, Hong GR, Kim YJ. Assessment of mitral annuloplasty ring by cardiac computed tomography: Correlation with echocardiographic parameters and comparison between two different ring types. J Thorac Cardiovasc Surg 2015; 150:1082-90. [DOI: 10.1016/j.jtcvs.2015.07.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Revised: 06/25/2015] [Accepted: 07/03/2015] [Indexed: 01/20/2023]
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16
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Chan V, Mesana TG. Functional mitral stenosis after mitral valve repair is a true anatomic problem that originates from the time of surgery. J Thorac Cardiovasc Surg 2015; 150:1091-2. [PMID: 26349594 DOI: 10.1016/j.jtcvs.2015.08.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Revised: 08/09/2015] [Accepted: 08/10/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Vincent Chan
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada; School of Epidemiology, Public Health, and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
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17
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Raanani E. Ischemic mitral regurgitation: Individualized treatment prevails. J Thorac Cardiovasc Surg 2015; 149:1604-5. [PMID: 25890823 DOI: 10.1016/j.jtcvs.2015.03.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 03/20/2015] [Indexed: 11/25/2022]
Affiliation(s)
- Ehud Raanani
- Department of Cardiac Surgery, Sheba Medical Center, Ramat-Gan, Israel.
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18
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Bertrand PB, Verbrugge FH, Verhaert D, Smeets CJP, Grieten L, Mullens W, Gutermann H, Dion RA, Levine RA, Vandervoort PM. Mitral valve area during exercise after restrictive mitral valve annuloplasty: importance of diastolic anterior leaflet tethering. J Am Coll Cardiol 2015; 65:452-61. [PMID: 25660923 DOI: 10.1016/j.jacc.2014.11.037] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Revised: 10/27/2014] [Accepted: 11/04/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND Restrictive mitral valve annuloplasty (RMA) for secondary mitral regurgitation might cause functional mitral stenosis, yet its clinical impact and underlying pathophysiological mechanisms remain debated. OBJECTIVES The purpose of our study was to assess the hemodynamic and clinical impact of effective orifice area (EOA) after RMA and its relationship with diastolic anterior leaflet (AL) tethering at rest and during exercise. METHODS Consecutive RMA patients (n = 39) underwent a symptom-limited supine bicycle exercise test with Doppler echocardiography and respiratory gas analysis. EOA, transmitral flow rate, mean transmitral gradient, and systolic pulmonary arterial pressure were assessed at different stages of exercise. AL opening angles were measured at rest and peak exercise. Mortality and heart failure readmission data were collected for at least 20 months after surgery. RESULTS EOA and AL opening angle were 1.5 ± 0.4 cm(2) and 68 ± 10°, respectively, at rest (r = 0.4; p = 0.014). EOA increased significantly to 2.0 ± 0.5 cm(2) at peak exercise (p < 0.001), showing an improved correlation with AL opening angle (r = 0.6; p < 0.001). Indexed EOA (EOAi) at peak exercise was an independent predictor of exercise capacity (maximal oxygen uptake, p = 0.004) and was independently associated with freedom from all-cause mortality or hospital admission for heart failure (p = 0.034). Patients with exercise EOAi <0.9 cm(2)/m(2) (n = 14) compared with ≥0.9 cm(2)/m(2) (n = 25) had a significantly worse outcome (p = 0.048). In multivariate analysis, AL opening angle at peak exercise (p = 0.037) was the strongest predictor of exercise EOAi. CONCLUSIONS In RMA patients, EOA increases during exercise despite fixed annular size. Diastolic AL tethering plays a key role in this dynamic process, with increasing AL opening during exercise being associated with higher exercise EOA. EOAi at peak exercise is a strong and independent predictor of exercise capacity and is associated with clinical outcome. Our findings stress the importance of maximizing AL opening by targeting the subvalvular apparatus in future repair algorithms for secondary mitral regurgitation.
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Affiliation(s)
- Philippe B Bertrand
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Frederik H Verbrugge
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - David Verhaert
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | | | - Lars Grieten
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Herbert Gutermann
- Department of Cardiac Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Robert A Dion
- Department of Cardiac Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Robert A Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Pieter M Vandervoort
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium.
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19
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Fino C, Iacovoni A, Ferrero P, Merlo M, Bellavia D, D'Elia E, Miceli A, Senni M, Caputo M, Ferrazzi P, Galletti L, Magne J. Determinants of functional capacity after mitral valve annuloplasty or replacement for ischemic mitral regurgitation. J Thorac Cardiovasc Surg 2015; 149:1595-603. [PMID: 25886713 DOI: 10.1016/j.jtcvs.2015.03.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 02/26/2015] [Accepted: 03/07/2015] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To identify the exercise echocardiographic determinants of long-term functional capacity, in patients with chronic ischemic mitral regurgitation, after restrictive mitral valve annuloplasty (RMA) or mitral valve replacement (MVR). METHODS We retrospectively analyzed 121 patients with significant chronic ischemic mitral regurgitation, who underwent RMA (n = 62) or MVR (n = 59), between 2005 and 2011. Preoperatively, all patients underwent a resting echocardiographic examination, and a 6-minute walking test (6-MWT) to measure distance. Resting and exercise stress echocardiography, and the 6-MWT were repeated at 41 ± 16.5 months. RESULTS After surgery, the 6-MWT distance significantly improved in the MVR group, and decreased in the RMA group (+37 ± 39 m vs -24 ± 49 m, respectively; P < .0001). Exercise indexed effective orifice area was significantly higher in the MVR, versus the RMA, group (MVR: change from 1.3 ± 0.2 cm(2)/m(2) to 1.5 ± 0.3 cm(2)/m(2); RMA: change from 1.1 ± 0.3 cm(2)/m(2) to 1.2 ± 0.3 cm(2)/m(2); P = .001). The mean mitral gradients significantly increased from rest to exercise, in both groups, but to a greater extent in the RMA group (change from 4.4 ± 1.4 to 11 ± 3.6 mm Hg; MVR: change from 4.3 ± 1.8 to 9 ± 3.5 mm Hg; P = .006). On multivariate analysis, MVR and exercise indexed effective orifice area were the main independent determinants of postoperative 6-MWT. In the RMA group, 25 patients experienced late mitral regurgitation recurrence, severe in 9 (14%) of them. The rate of postoperative cardiovascular events was significantly higher in the RMA group (21% vs MVR: 8%; P = .03). Follow-up survival was 83% in the RMA group and 88% in the MVR group (P = .54). CONCLUSIONS For chronic ischemic mitral regurgitation, MVR versus RMA was associated with better postoperative exercise hemodynamic performance and long-term functional capacity.
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Affiliation(s)
- Carlo Fino
- Cardiovascular Department, Ospedale Papa Giovanni XXIII, Bergamo, Italy; Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Attilio Iacovoni
- Cardiovascular Department, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Paolo Ferrero
- Cardiovascular Department, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Maurizio Merlo
- Cardiovascular Department, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Diego Bellavia
- Cardiovascular Department, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Emilia D'Elia
- Cardiovascular Department, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Antonio Miceli
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Michele Senni
- Cardiovascular Department, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Massimo Caputo
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Paolo Ferrazzi
- Cardiovascular Department, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - L Galletti
- Cardiovascular Department, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Julien Magne
- Cardiology Department, Hôpital Dupuytren, Le Centre Hospitalier et Universitaire de Limoges (CHU Limoges), Limoges, France.
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Affiliation(s)
- Luc A Pierard
- Department of Cardiology, Heart Valve Clinic, University of Liège, CHU Sart Tilman, Liège, Belgium
| | - Alec Vahanian
- Department of Cardiology, Bichat Hospital, Paris, France
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Magne J, Pibarot P, Sengupta PP, Donal E, Rosenhek R, Lancellotti P. Pulmonary Hypertension in Valvular Disease. JACC Cardiovasc Imaging 2015; 8:83-99. [DOI: 10.1016/j.jcmg.2014.12.003] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 12/04/2014] [Accepted: 12/05/2014] [Indexed: 10/24/2022]
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