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Yuan H, Wang F, He S, Xiang Z, Zhang X, Jiang L. SUVmean ratios of liver/muscle and lung/muscle from 13N-NH 3 PET perfusion outperformed traditional myocardial viability parameters in predicting survival after CABG. Jpn J Radiol 2024:10.1007/s11604-024-01611-6. [PMID: 38856879 DOI: 10.1007/s11604-024-01611-6] [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: 03/21/2024] [Accepted: 06/03/2024] [Indexed: 06/11/2024]
Abstract
PURPOSE Myocardial viability evaluation in predicting survival after coronary artery bypass graft (CABG) remains debatable. Thus, this study aimed to investigate the role of 13N-NH3/18F-FDG PET myocardial viability scan in predicting treatment outcomes and survival. METHODS 90 patients with CABG and pre-surgical PET-based myocardial viability scan were retrospectively reviewed. Perfusion-metabolism features, myocardium motion parameters, and patient characteristics were recorded. Additionally, the SUVmean of blood pool, lung, liver, spleen, and muscle were measured and the SUVmean ratios were calculated. Factors associated with treatment outcomes and survival were analyzed by Logistic and Cox regressions. Nomogram models were subsequently established to predict ejection fraction (EF) improvement and survival outcomes. RESULTS The mean EF of these 90 patients was 38.1 ± 9.5% and 46.0 ± 9.2% before and after CABG surgery, and 35 patients (38.9%) achieved EF improvement ≥ 10%. EF measurements by PET and echocardiogram showed a reasonable linear correlation (R = 0.752). Sex, pre-surgical EF, mismatch of the left ventricle, total perfusion deficit (TPD), and peak ejection rate (PER) were independent predictive factors of EF improvements. Surgery waiting time, valve damage, and SUVmean ratio of Liver/Muscle were independently predictive of event-free survival (EFS), while valve damage, together with SUVmean ratio of either Liver/Muscle or Lung/Muscle, were independently predictive of overall survival (OS). CONCLUSION Although traditional cardiac parameters from PET-based myocardial viability can effectively predict EF improvements after CABG, SUVmean ratios of liver/muscle and lung/muscle from 13N-NH3 PET perfusion outperformed these parameters in predicting survival.
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Affiliation(s)
- Hui Yuan
- PET Center, Department of Nuclear Medicine, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 106 Zhongshan Er Road, Guangzhou, 510080, China
| | - Fanghu Wang
- PET Center, Department of Nuclear Medicine, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 106 Zhongshan Er Road, Guangzhou, 510080, China
| | - Shanzhen He
- PET Center, Department of Nuclear Medicine, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 106 Zhongshan Er Road, Guangzhou, 510080, China
| | - Zeyin Xiang
- PET Center, Department of Nuclear Medicine, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 106 Zhongshan Er Road, Guangzhou, 510080, China
| | - Xiaochun Zhang
- PET Center, Department of Nuclear Medicine, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 106 Zhongshan Er Road, Guangzhou, 510080, China.
| | - Lei Jiang
- PET Center, Department of Nuclear Medicine, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 106 Zhongshan Er Road, Guangzhou, 510080, China.
- Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangzhou, China.
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Wu H, Zhang W. Should moderate ischemic mitral regurgitation be corrected during coronary artery bypass grafting? a systematic review and meta-analysis. Perfusion 2024; 39:373-381. [PMID: 36480690 DOI: 10.1177/02676591221144558] [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] [Indexed: 12/22/2023]
Abstract
OBJECTIVE Ischemic mitral regurgitation (IMR) is associated with increased risks of mortality and heart failure. However, the optimal management of moderate IMR remains controversial. We conducted a meta-analysis to appraise whether moderate IMR should be corrected during coronary artery bypass grafting (CABG). METHODS We searched PubMed, Embase, and Cochrane databases from its inception up to 15 October 2022 for studies that assessed CABG alone versus CABG with mitral valve (MV) surgery in patients with moderate IMR. The primary outcome was perioperative mortality. RESULTS Four randomized controlled trials and three observational studies with propensity-matched data including 1209 patients assessing CABG alone (n = 598) versus CABG with MV surgery (n = 611) were included. Compared to CABG alone, the addition of MV surgery did not significantly increase perioperative mortality (RR, 1.01; 95% CI, 0.52-1.96; p = 0.98) and stroke (RR, 2.14; 95% CI, 0.97-4.72; p = 0.06), whereas a longer cardiopulmonary bypass duration (MD, 54.91; 95% CI, 42.13-67.68; p < 0.01) and an increased incidence of renal failure were observed in the combined-procedure group. At follow-up, the addition of MV surgery was significantly associated with reduced rates of residual MR (RR, 0.26; 95% CI, 0.13-0.51; p < 0.01) and NYHA class III-IV (RR, 0.54; 95% CI, 0.37-0.78; p < 0.01). However, there was no difference in either mid-term mortality (RR, 1.05; 95% CI, 0.65-1.70; p = 0.82) or late mortality (RR, 91; 95% CI, 0.49-1.71; p = 0.78) between the CABG alone group and the combined-procedure group. CONCLUSIONS In patients with moderate IMR, the addition of MV surgery to CABG did not increase perioperative mortality. Despite the reduced rates of moderate MR and NYHA class III-IV at follow-up, the addition of MV surgery did not translate in a reduction in mid-term or late mortality.
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Affiliation(s)
- Haibo Wu
- Department of Cardiothoracic Surgery, Changzhi People's Hospital, Changzhi, China
| | - Wei Zhang
- Department of Cardiothoracic Surgery, Changzhi People's Hospital, Changzhi, China
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Lee C, Dow S, Shah K, Henkin S, Taub C. Complications of exercise and pharmacologic stress echocardiography. Front Cardiovasc Med 2023; 10:1228613. [PMID: 37600036 PMCID: PMC10435903 DOI: 10.3389/fcvm.2023.1228613] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 07/24/2023] [Indexed: 08/22/2023] Open
Abstract
Stress echocardiography is a diagnostic cardiovascular exam that is commonly utilized for multiple indications, including but not limited to the assessment of obstructive coronary artery disease, valvular disease, obstructive hypertrophic cardiomyopathy, and diastolic function. Stress echocardiography can be performed via both exercise and pharmacologic modalities. Exercise stress is performed with either treadmill or bicycle-based exercise. Pharmacologic stress is performed via either dobutamine or vasodilator-mediated (i.e., dipyridamole, adenosine) stress testing. Each of these modalities is associated with a low overall prevalence of major, life-threatening adverse outcomes, though adverse events are most common with dobutamine stress echocardiography. In light of the recent COVID-19 pandemic, the risk of infectious complications to both the patient and stress personnel cannot be negated; however, when certain precautions are taken, the risk of infectious complications appears minimal. In this article, we review each of the stress echocardiographic modalities, examine major potential adverse outcomes and contraindications, assess the risks of stress testing in the setting of a global pandemic, and examine the utilization and safety of stress testing in special patient populations (i.e., language barriers, pediatric patients, pregnancy).
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Affiliation(s)
| | | | | | | | - Cynthia Taub
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Dartmouth College, Lebanon, NH, United States
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National Trends and Outcomes of Tricuspid Valve Surgery with Concomitant Mitral Valve Surgery: Results From a Ten-year Analysis of the National Inpatient Sample Database. Curr Probl Cardiol 2023; 48:101523. [PMID: 36450330 DOI: 10.1016/j.cpcardiol.2022.101523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 11/25/2022] [Indexed: 11/29/2022]
Abstract
According to an estimate, 20% of patients with heart valve disease have multivalve involvement necessitating combined valve surgery. There is a dearth of data about the clinical outcomes of patients with combined mitral and tricuspid valve disease who go through tricuspid valve surgery with concomitant mitral valve replacement or repair. We utilized National Inpatient Sample (NIS) between January 1, 2004, and December 31, 2014, to analyze the outcomes of patients who underwent tricuspid valve surgery with either mitral valve replacement or repair. We identified 21,141 weighted hospitalizations for combined TVS with MVr (TVS/MVr) or TVS with MVR (TVS/MVR). The overall inpatient mortality in the TVS/MVR cohort was higher than in the TVS/MVr cohort (7.36% vs 5.33%, P < 0.01). There was a trend toward decreased mortality over the years in the TVS/MVr cohort (P = 0.04) while mortality remained unchanged in the TVS/MVR cohort (P = 0.88). Overall, the TVS/MVr cohort had better clinical outcomes profile compared with TVS/MVR cohort.
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Kono T, Onohara D, Amedi A, Corporan D, Padala M. Effect of early versus late onset mitral regurgitation on left ventricular remodeling in ischemic cardiomyopathy in an animal model. J Thorac Cardiovasc Surg 2022; 164:e333-e347. [PMID: 34903384 PMCID: PMC9108127 DOI: 10.1016/j.jtcvs.2021.11.024] [Citation(s) in RCA: 2] [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: 05/03/2021] [Revised: 10/19/2021] [Accepted: 11/05/2021] [Indexed: 01/23/2023]
Abstract
BACKGROUND Patients who survive a myocardial infarction have progressive cardiac dysfunction and ventricular remodeling. Mitral regurgitation is often diagnosed in these patients, and is a risk factor that portends poor prognosis. Whether such postinfarction mitral regurgitation magnifies adverse left ventricular remodeling is unclear, which was studied in an animal model. METHODS Forty-one adult rats were induced with myocardial infarction using left coronary artery ligation and assigned to 3 groups: group 1, myocardial infarction only; group 2, myocardial infarction with severe mitral regurgitation introduced after 4 weeks; and group 3, myocardial infarction with severe mitral regurgitation introduced after 10 weeks. Valve regurgitation was introduced by advancing a transapical ultrasound-guided needle into the mitral valve anterior leaflet. Animals were survived to 20 weeks from the index procedure, with biweekly cardiac ultrasound, and invasive hemodynamics and histology at termination. RESULTS At 20 weeks, end diastolic volume was largest in the groups with mitral regurgitation, compared with the group without the valve lesion (group 1, 760.9 ± 124.6 μL; group 2, 958.0 ± 115.1 μL; group 3, 968.3 ± 214.9 μL). Similarly, end systolic volume was larger in groups with regurgitation (group 1, 431.2 ± 152.6 μL; group 2, 533.2 ± 130.8 μL; group 3, 533.1 ± 177.5 μL). In the infarction-only group, left ventricular remodeling was maximal until 6 weeks and plateaued thereafter. In groups with mitral regurgitation, left ventricular remodeling was significantly elevated at the onset of regurgitation and persisted. CONCLUSIONS Mitral regurgitation is a potent driver of adverse cardiac remodeling after a myocardial infarction, irrespective of the timing of its onset.
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Affiliation(s)
- Takanori Kono
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Emory University Hospital Midtown, Atlanta, Ga
| | - Daisuke Onohara
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Emory University Hospital Midtown, Atlanta, Ga; Division of Cardiothoracic Surgery, Emory University, Atlanta, Ga
| | - Alan Amedi
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Emory University Hospital Midtown, Atlanta, Ga
| | - Daniella Corporan
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Emory University Hospital Midtown, Atlanta, Ga; Division of Cardiothoracic Surgery, Emory University, Atlanta, Ga
| | - Muralidhar Padala
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Emory University Hospital Midtown, Atlanta, Ga; Division of Cardiothoracic Surgery, Emory University, Atlanta, Ga.
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Midterm Outcomes of Isolated CABG in the Setting of Moderate Ischemic Mitral Regurgitation. J Surg Res 2022; 278:317-324. [DOI: 10.1016/j.jss.2022.04.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 03/06/2022] [Accepted: 04/11/2022] [Indexed: 11/22/2022]
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Wang S, Lyu Y, Cheng S, Zhang Y, Gu X, Gong M, Liu J. Smaller left ventricular end-systolic diameter and lower ejection fraction at baseline associated with greater ejection fraction improvement after revascularization among patients with left ventricular dysfunction. Front Cardiovasc Med 2022; 9:967039. [PMID: 36247459 PMCID: PMC9559822 DOI: 10.3389/fcvm.2022.967039] [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: 06/12/2022] [Accepted: 09/13/2022] [Indexed: 11/25/2022] Open
Abstract
Objectives To investigate the predictive roles of pre-operative left ventricular (LV) size and ejection fraction (EF) in EF improvement and outcome following revascularization in patients with coronary artery disease (CAD) and LV dysfunction. Background Revascularization may improve EF and long-term outcomes of patients with LV dysfunction. However, the determinants of EF improvement have not yet been investigated comprehensively. Materials and methods Patients with EF measurements before and 3 months after revascularization were enrolled in a cohort study (No. ChiCTR2100044378). All patients had baseline EF ≤ 40%. EF improvement was defined as absolute increase in EF > 5%. According to LV end-systolic diameter (LVESD) (severely enlarged or not) and EF (≤35% or of 36–40%) at baseline, patients were categorized into four groups. Results A total of 939 patients were identified. A total of 549 (58.5%) had EF improved. Both LVESD [odds ratio (OR) per 1 mm decrease, 1.05; 95% CI, 1.04–1.07; P < 0.001] and EF (OR per 1% decrease, 1.06; 95% CI, 1.03–1.10; P < 0.001) at baseline were predictive of EF improvement after revascularization. Patients with LVESD not severely enlarged and EF ≤ 35% had higher odds of being in the EF improved group in comparison with other three groups both in unadjusted and adjusted analysis (all P < 0.001). The median follow-up time was 3.5 years. Patients with LVESD not severely enlarged and EF ≤ 35% had significantly lower risk of all-cause death in comparison with patients with LVESD severely enlarged and EF ≤ 35% [hazard ratio (HR), 2.73; 95% CI, 1.28–5.82; P = 0.009], and tended to have lower risk in comparison with patients with LVESD severely enlarged and EF of 36–40% (HR, 2.00; 95% CI, 0.93–4.27; P = 0.074). Conclusion Among CAD patients with reduced EF (≤ 40%) who underwent revascularization, smaller pre-operative LVESD and lower EF had greatest potential to have EF improvement and better outcome. Our findings imply the indication for revascularization in patients with LV dysfunction who presented with lower EF but smaller LV size.
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Affiliation(s)
- Shaoping Wang
- Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
| | - Yi Lyu
- Department of Anesthesiology, Minhang Hospital, Fudan University, Shanghai, China
| | - Shujuan Cheng
- Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
| | - Yuchao Zhang
- Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
| | - Xiaoyan Gu
- Department of Echocardiography, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
| | - Ming Gong
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
| | - Jinghua Liu
- Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
- *Correspondence: Jinghua Liu,
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Wang S, Cheng S, Zhang Y, Lyu Y, Liu J. Extent of Ejection Fraction Improvement After Revascularization Associated with Outcomes Among Patients with Ischemic Left Ventricular Dysfunction. Int J Gen Med 2022; 15:7219-7228. [PMID: 36124105 PMCID: PMC9482409 DOI: 10.2147/ijgm.s380276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 08/29/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Ejection fraction (EF) has been reported to be a major predictor of improved survival in patients with heart failure. However, it is largely unknown whether the extent of improvement in EF affects the subsequent risk of mortality. This study sought to investigate change in EF after revascularization and the implication of these changes on clinical outcomes among patients with ischemic left ventricular dysfunction. Patients and Methods We conducted a cohort study (No. ChiCTR2100044378) of patients with reduced EF (≤40%) who received revascularization and had EF reassessment by echocardiography 3 months after revascularization. Patients were categorized according to the absolute change in EF: 1) EF worsened group (absolute decrease in EF >5%); 2) EF unchanged group (absolute change in EF −5% to 5%); 3) EF improved group (absolute increase in EF >5%). Results Of 974 patients, 84 (8.6%) had EF worsened, 317 (32.5%) had EF unchanged and 573 (58.8%) had EF improved. The median follow-up time was 3.5 years, during which 143 patients died. For each 5-unit increments in EF, the risk of death decreased by 20% (hazard ratio, HR, per 5% increases, 0.80; 95% CI, 0.73–0.86; P<0.001). Compared with EF improvement group, patients with EF worsened (HR, 3.35; 95% CI, 2.07–5.42; P<0.001) and patients with EF unchanged (HR, 2.05; 95% CI, 1.40–3.01; P<0.001) had significantly higher risk of all-cause death. Conclusion Changes in EF were inversely associated with the risk of mortality. The extent of EF improvement after revascularization might be a potential factor which defines clinical outcomes.
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Affiliation(s)
- Shaoping Wang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, People’s Republic of China
| | - Shujuan Cheng
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, People’s Republic of China
| | - Yuchao Zhang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, People’s Republic of China
| | - Yi Lyu
- Department of Anesthesiology, Minhang Hospital, Fudan University, Shanghai, People’s Republic of China
- Yi Lyu, Department of Anesthesiology, Minhang Hospital, Fudan University, No. 180 Xinsong Road, Minhang District, Shanghai, 201199, People’s Republic of China, Email
| | - Jinghua Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, People’s Republic of China
- Correspondence: Jinghua Liu, Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Road, Chaoyang District, Beijing, 100029, People’s Republic of China, Tel +86 10 64456998, Fax +86 1064456998, Email
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Ishigaki T, Wakasa S, Shingu Y, Ohkawa Y, Yamada A, Anzai T, Matsui Y. Reduction of tethering distance by papillary muscle tugging approximation with mitral valve replacement for non-ischemic functional mitral regurgitation induces left ventricular reverse remodeling. J Cardiol 2021; 79:530-536. [PMID: 34774388 DOI: 10.1016/j.jjcc.2021.10.017] [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: 05/20/2021] [Revised: 08/27/2021] [Accepted: 10/18/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Functional mitral regurgitation (FMR) is caused by left ventricular (LV) remodeling and subsequent tethering of the mitral valve (MV). If LV remodeling is irreversibly advanced, it could not be attenuated by the MV procedure alone, although the additional subvalvular procedure could induce LV reverse remodeling by forcibly reducing MV tethering. This study aimed to assess the anti-tethering effect of papillary muscle tugging approximation (PMTA) on LV reverse remodeling after mitral valve replacement (MVR) for non-ischemic FMR. METHODS The study subjects were 19 patients who underwent MVR with and without PMTA [MVR + PMTA (n = 11) and MVR alone (n = 8), respectively] for non-ischemic FMR. The tethering distance (TD) and LV end-systolic volume (ESV) at the preoperative, postoperative, and follow-up periods were assessed in terms of their correlation and time-dependent changes. The intra-LV energy efficiency was also evaluated through vector flow mapping analysis. RESULTS TD and ESV were comparable between both procedures preoperatively and did not change after MVR alone. In MVR + PMTA, however, a significant decrease was identified in TD and ESV at the early postoperative and follow-up periods, respectively [TD = 48, 30, and 31 mm (p < 0.001) and ESV = 159, 133, and 82 mL (p < 0.001) at the preoperative, postoperative, and follow-up periods, respectively]. Finally, at follow-up, the extent of change from the preoperative value in ESV significantly correlated with that in TD (ρ = 0.81, p < 0.001 for overall; ρ = 0.93, p < 0.001 for MVR + PMTA; ρ = 0.86, p = 0.011 for MVR alone). The ratio of TD to ESV was also significantly correlated with systolic energy loss to LV stroke work after MVR + PMTA (ρ = 0.81, p = 0.015). CONCLUSIONS PMTA for non-ischemic FMR could induce LV reverse remodeling depending on the extent of postoperative TD reduction. A smaller TD to ESV was associated with a higher intra-LV energy efficiency after PMTA + MVR.
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Affiliation(s)
- Takahiro Ishigaki
- Department of Cardiovascular and Thoracic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo 060-8638, Japan
| | - Satoru Wakasa
- Department of Cardiovascular and Thoracic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo 060-8638, Japan.
| | - Yasushige Shingu
- Department of Cardiovascular and Thoracic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo 060-8638, Japan
| | - Yohei Ohkawa
- Department of Cardiovascular Surgery, Hokkaido Ohno Memorial Hospital, Sapporo, Japan
| | - Akira Yamada
- Department of Cardiovascular Surgery, Teine Keijinkai Hospital, Sapporo, Japan
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yoshiro Matsui
- Department of Cardiovascular and Thoracic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo 060-8638, Japan; Department of Cardiovascular Surgery, Hanaoka Seishu Memorial Hospital, Sapporo, Japan
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Exploring the Operative Strategy for Secondary Mitral Regurgitation: A Systematic Review. BIOMED RESEARCH INTERNATIONAL 2021; 2021:3466813. [PMID: 34258260 PMCID: PMC8245239 DOI: 10.1155/2021/3466813] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/05/2021] [Accepted: 06/16/2021] [Indexed: 01/16/2023]
Abstract
Background Mitral valve disease surgery is an evolving field with multiple possible interventions. There is an increasing body of evidence regarding the optimal strategy in secondary mitral regurgitation where the pathology lies within the ventricle. We conducted a systematic review to identify the benefits and limitations of each surgical option. Methods A systematic review of the literature was performed to identify pertinent randomized controlled trials (RCTs), propensity-matched observational series, and meta-analyses which were considered initially and followed by unmatched observational series using the MEDLINE, Ovid EMBASE, and Cochrane Library. Results We identified 6 different strategies for treating secondary mitral valve regurgitation: mitral valve replacement, restrictive mitral annuloplasty, surgical revascularization (with and without mitral annuloplasty), subvalvular procedures (papillary muscle approximation, papillary muscle relocation, ring and string procedure), and procedures directly targeting the mitral valve (edge-to-edge repair and anterior leaflet enlargement) alongside transcatheter heart valve therapy. We also highlighted the role of left ventricular assist devices in the management of this condition. The benefits and limitations of each intervention are highlighted. Conclusion There is currently no unanimous and shared strategy for the optimal treatment of patients with secondary IMR. The management of patients with secondary mitral regurgitation must be entrusted to a multidisciplinary Heart Team to ensure ideal intervention and patient matching for the best outcomes.
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2020 ACC/AHA guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2021; 162:e183-e353. [PMID: 33972115 DOI: 10.1016/j.jtcvs.2021.04.002] [Citation(s) in RCA: 90] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 143:e72-e227. [PMID: 33332150 DOI: 10.1161/cir.0000000000000923] [Citation(s) in RCA: 555] [Impact Index Per Article: 185.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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13
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 77:e25-e197. [PMID: 33342586 DOI: 10.1016/j.jacc.2020.11.018] [Citation(s) in RCA: 837] [Impact Index Per Article: 279.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Gaudino M, Bagiella E, Chang HL, Kurlansky P. Randomized trials, observational studies, and the illusive search for the source of truth. J Thorac Cardiovasc Surg 2020; 163:757-762. [PMID: 33277031 DOI: 10.1016/j.jtcvs.2020.10.120] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 10/29/2020] [Accepted: 10/31/2020] [Indexed: 01/25/2023]
Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Emilia Bagiella
- Center for Biostatistics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Helena L Chang
- Center for Biostatistics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Paul Kurlansky
- Department of Surgery, Center for Innovation and Outcomes Research, Columbia University Medical Center, New York, NY.
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Sarkar K, Patra S. Ischemic mitral regurgitation: the way ahead is a step back. Indian J Thorac Cardiovasc Surg 2020; 36:344-346. [PMID: 33061141 DOI: 10.1007/s12055-019-00903-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 10/18/2019] [Accepted: 11/07/2019] [Indexed: 01/12/2023] Open
Abstract
Ischemic mitral regurgitation (IMR) has a profound negative effect on survival of patients following myocardial infarction. It occurs when the closing forces are overpowered by the tethering forces as a consequence of ventricular remodeling. Surgeons sought to correct moderate and severe IMR by mitral annuloplasty. Though short-term results were encouraging, survival after 2 years were not so. Higher recurrence rates were also noted with severe mitral regurgitation (MR). Parameters defining severity of IMR were initially formulated in 2003. These were revised enabling intervention in moderate MR in 2014. With the lack of positive medium and long-term evidence, 2017 guidelines have raised the bar, discouraging intervention in moderate IMR. Current guidelines have taken a conservative stance in advocating repair only for severe MR and very symptomatic patients. Till emergence of fresh evidence surgical enthusiasm for repair of IMR has to be restrained.
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Affiliation(s)
- Kunal Sarkar
- Medica Superspecialty Hospital, Kolkata, 700099 India
| | - Soumya Patra
- Medica Superspecialty Hospital, Kolkata, 700099 India
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Gimpel D, Cheung M, Bassin L, Jennings S, Weiss B, Akhunji Z, Grant P, Wolfenden H. Operative Results of Mitral Valve Repair and Replacement in Chronic Ischaemic Mitral Valve Regurgitation. Heart Lung Circ 2020; 29:1713-1724. [PMID: 32493579 DOI: 10.1016/j.hlc.2020.03.007] [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: 09/17/2019] [Revised: 01/10/2020] [Accepted: 03/10/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Ischaemic mitral regurgitation (IMR) carries significant morbidity and mortality. Surgical management includes coronary artery bypass surgery alone or concomitant with mitral valve repair or replacement. There is ongoing debate regarding the appropriate approach to the mitral valve in relation to long-term outcomes. This review examines our early and late follow-up, with operative and echocardiographic outcomes for mitral valve repair and mitral replacement for chronic IMR. METHODS A retrospective review was performed on prospectively collected data of 119 consecutive patients who either underwent mitral repair (n=101) or mitral replacement (n=18) for chronic IMR at Prince Henry and The Prince of Wales hospitals in Sydney between 1999-2016. All patients had pre and postoperative transthoracic echocardiograms. Follow-up echocardiographic data was obtained from the most recent clinical appointment. Follow-up mortality outcomes were obtained with ethics approval from the Australian National Death Index (NDI). RESULTS There was no statistical difference between cardiopulmonary bypass (CPB) time, cross-clamp time, time spent in intensive care unit (ICU) and time to discharge between cohorts. The replacement cohort was noted to have higher preoperative pulmonary artery (PA) pressures and a higher severity of IMR. Seven (7) deaths were in the mitral valve (MV) repair group within 30 days (6.9%) and three deaths in the MV replacement group within 30 days (16.7%). Echocardiographic follow-up was complete in 78% of the MV repair cohort at an average of 4.06±2.66 years, and 73% complete in the MV replacement cohort at an average of 6.09±4.3 years. Three (3) patients had prior MV repair before MV replacement early at days zero and 17, and late at 8 years respectively. Follow-up echocardiography showed mitral regurgitation (MR) in the mitral valve repair cohort as ≤ mild in 83.5% and ≤ trivial in 35.6%. In the MV replacement cohort MR ≤ mild in 100% and ≤ trivial in 82% with no moderate or severe MR. Preoperative tricuspid regurgitation (TR) and a flexible annuloplasty were predictive of an MR grade > mild in the repair cohort at discharge. Five-year (5-year) survival for the repair cohort was 85% with a mean follow-up time of 7.1±3.83 years. For the replacement cohort, five-year survival was 77.8% with a mean follow-up time of 5.35±1.54 years. CONCLUSIONS Mitral valve repair and replacement for chronic IMR has acceptable mortality, reintervention rates and excellent postoperative echocardiographic degrees of IMR in this cohort. Further evaluation is required into quality of life post intervention for IMR and of preoperative predictive factors of significant MR postoperatively to help guide the appropriate choice of treatment. The presence of preoperative tricuspid regurgitation of moderate grade or higher, and the use of a flexible annuloplasty may indicate patients more likely to have a higher grade of MR at follow-up following mitral valve repair in patients with IMR.
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Affiliation(s)
- Damian Gimpel
- School of Medicine Sydney, University of Notre Dame Australia, Sydney, NSW, Australia; Department of Cardiothoracic Surgery, The Prince of Wales Hospital, Sydney, NSW, Australia.
| | - Michael Cheung
- School of Medicine Sydney, University of Notre Dame Australia, Sydney, NSW, Australia
| | - Levi Bassin
- Department of Cardiothoracic Surgery, The Prince of Wales Hospital, Sydney, NSW, Australia
| | - Scott Jennings
- Department of Cardiothoracic Surgery, The Prince of Wales Hospital, Sydney, NSW, Australia
| | - Beatrix Weiss
- School of Medicine Sydney, University of Notre Dame Australia, Sydney, NSW, Australia; Department of Cardiothoracic Surgery, The Prince of Wales Hospital, Sydney, NSW, Australia
| | - Zakir Akhunji
- Department of Cardiothoracic Surgery, The Prince of Wales Hospital, Sydney, NSW, Australia
| | - Peter Grant
- Department of Cardiothoracic Surgery, The Prince of Wales Hospital, Sydney, NSW, Australia
| | - Hugh Wolfenden
- Department of Cardiothoracic Surgery, The Prince of Wales Hospital, Sydney, NSW, Australia
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Treatment options for ischemic mitral regurgitation: A meta-analysis. J Thorac Cardiovasc Surg 2020; 163:607-622.e14. [PMID: 32713629 DOI: 10.1016/j.jtcvs.2020.05.041] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 05/12/2020] [Accepted: 05/15/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Treatment of ischemic mitral regurgitation (IMR) is in evolution, as percutaneous procedures and complex surgical repair have been recently investigated in randomized clinical trials and matched studies. This study aims to review and compare the current treatment options for IMR. METHODS A comprehensive literature search was conducted using electronic databases. The primary outcome was all-cause long-term mortality. The secondary outcomes were perioperative mortality, unplanned rehospitalization, reoperation, and composite end points as defined in the original articles. RESULTS A total of 12 articles met the inclusion criteria and were included in the final meta-analysis. The MitraClip procedure did not confer a significant benefit in mortality and repeated hospitalization compared with medical therapy alone. In patients with moderate IMR, the adjunct of mitral procedure over coronary artery bypass graft is not associated with clinical improvements. When evaluating mitral valve (MV) replacement versus repair, hospital mortality was greater among patients undergoing replacement (odds ratio [OR], 1.91; P = .009), but both reoperation and readmission rates were lower (OR, 0.60, P = .05; and OR, 0.45, P < .02, respectively). Comparing restrictive annuloplasty alone with adjunctive subvalvular repair, subvalvular procedures resulted in fewer readmissions (OR, 0.50; P = .06) and adverse composite end points (P = .009). CONCLUSIONS MitraClip procedure is not associated with improved outcomes compared with medical therapy. MV replacement is associated with increased early mortality but reduced reoperation rate and readmission rate compared with MV repair using annuloplasty in moderate-to-severe IMR. Despite no significant benefit in isolated outcomes comparing annular and adjunct subvalvular procedures, the adjunct of subvalvular procedures reduces the risk of major postoperative adverse events.
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Ji Q, Qi XM, Shen JQ, Wang YL, Yang Y, Ding WJ, Xia LM, Wang CS. Patients over 70 years of age with moderate ischemic mitral regurgitation undergoing surgical revascularization plus mitral valve repair: insights from a single-center study of propensity-matched data. Cardiovasc Diagn Ther 2020; 9:568-577. [PMID: 32038946 DOI: 10.21037/cdt.2019.10.06] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Elderly patients, compared with the young, have a higher burden of surgical risk factors with reduced functional capacity and increased comorbidities conditions, and may have worse clinical outcomes. So far, few reports have focused on clinical outcomes of patients over 70 years of age with moderate chronic ischemic mitral regurgitation (IMR) undergoing mitral valve repair at the time of coronary artery bypass grafting (CABG). This single-center study of propensity-matched data attempts to answer a question: compared with patients with age of 70 or less, whether patients over 70 years of age with moderate IMR undergoing CABG plus mitral valve repair receive poor outcomes. Methods All eligible patients were included in this study and were entered into either an elderly group (n=142) or a control group (n=182) according to patients' age. In-hospital outcomes (consisting of surgical mortality and major postoperative morbidity) and midterm clinical outcomes (including all-cause mortality and recurrent mitral regurgitation) were compared after propensity score matching (1:1). Results Using propensity-score matching, 103 pairs of patients were successfully established in a 1:1 ratio. No significant differences between the two matched groups were found with regard to surgical mortality (5.8% vs. 3.9%, P=0.754) and major postoperative morbidity. A total of 184 patients (91 in the elderly group and 93 in the control group) received regular follow-up visit with the median duration of 38 months [interquartile range (IQR), 27-56 months]. There were not any significant differences between the two matched groups regarding overall survival and recurrent IMR-free survival (stratified log-rank P=0.185 and stratified log-rank P=0.453, respectively). The elderly group as compared to the control group did not affect midterm mortality via cox proportional hazard regression (propensity score adjusted hazard ratio, 1.143; 95% confidence interval, 0.761-1.943; P=0.285). Conclusions Patients over 70 years of age with moderate chronic IMR undergoing combined CABG and mitral valve repair may receive favorable in-hospital and midterm clinical outcomes.
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Affiliation(s)
- Qiang Ji
- Department of Cardiovascular Surgery of Zhongshan Hospital Fudan University, Shanghai 200032, China
| | - Xiao-Min Qi
- Shanghai Municipal Institute of Cardiovascular Diseases, Shanghai 200032, China
| | - Jin-Qiang Shen
- Department of Cardiovascular Surgery of Zhongshan Hospital Fudan University, Shanghai 200032, China
| | - Yu-Lin Wang
- Department of Cardiovascular Surgery of Zhongshan Hospital Fudan University, Shanghai 200032, China
| | - Ye Yang
- Department of Cardiovascular Surgery of Zhongshan Hospital Fudan University, Shanghai 200032, China
| | - Wen-Jun Ding
- Department of Cardiovascular Surgery of Zhongshan Hospital Fudan University, Shanghai 200032, China
| | - Li-Min Xia
- Department of Cardiovascular Surgery of Zhongshan Hospital Fudan University, Shanghai 200032, China.,Department of Cardiovascular Surgery of Xiamen Branch of Zhongshan Hospital Fudan University, Xiamen 510530, China
| | - Chun-Sheng Wang
- Shanghai Municipal Institute of Cardiovascular Diseases, Shanghai 200032, China
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Ji Q, Zhao Y, Shen J, Ding W, Xia L, Wang C. Predictors of ischemic mitral regurgitation improvement after surgical revascularization plus mitral valve repair for moderate ischemic mitral regurgitation. J Card Surg 2020; 35:528-535. [DOI: 10.1111/jocs.14455] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Qiang Ji
- Department of Cardiovascular Surgery, Zhongshan HospitalFudan University Shanghai China
| | - Yun Zhao
- Cardiovascular SurgeryShanghai Municipal Institute for Cardiovascular Diseases Shanghai China
| | - JinQiang Shen
- Department of Cardiovascular Surgery, Zhongshan HospitalFudan University Shanghai China
| | - WenJun Ding
- Department of Cardiovascular Surgery, Zhongshan HospitalFudan University Shanghai China
| | - LiMin Xia
- Department of Cardiovascular Surgery, Zhongshan HospitalFudan University Shanghai China
- Department of Cardiovascular Surgery, Zhongshan Hospital, Xiamen BranchFudan University Xiamen China
| | - ChunSheng Wang
- Cardiovascular SurgeryShanghai Municipal Institute for Cardiovascular Diseases Shanghai China
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Elderly Patients with Moderate Chronic Ischemic Mitral Regurgitation: Coronary Artery Bypass Grafting Alone or Concomitant Mitral Annuloplasty? Cardiol Res Pract 2020; 2019:1846904. [PMID: 31929898 PMCID: PMC6935804 DOI: 10.1155/2019/1846904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 10/29/2019] [Accepted: 11/25/2019] [Indexed: 11/17/2022] Open
Abstract
Background An increasing number of elderly patients with ischemic mitral regurgitation (IMR) are referred for coronary artery bypass grafting (CABG). However, data about the management of elderly patients with moderate IMR are scanty. This study evaluates the impacts of two surgical approaches (CABG alone or concomitant mitral annuloplasty (MAP)) on in-hospital and midterm outcomes, to attempt to determine an appropriate treatment option for elderly patients with moderate chronic IMR. Methods All eligible patients over 65 years of age were included and were entered into either a MAP group (patients undergoing CABG plus MAP, n = 96) or a CABG group (patients receiving CABG alone, n = 104). Baseline and surgical characteristics were analyzed, and in-hospital and midterm outcomes between groups were compared after propensity score-matching (1 : 1). Results Using propensity score-matching, 82 pairs of patients were successfully established in a 1 : 1 ratio. No significant differences between the two matched groups were found regarding surgical mortality (4.9% vs. 1.2%, p=0.173) and major postoperative morbidity. 150 patients (76 in the MAP group and 74 in the CABG group) received regular follow-up visit with the median duration of 37 months. Compared with the CABG group, the MAP group received a similar overall survival but a better recurrent MR-free survival (stratified log-rank p, 0.492 and < 0.001, respectively). Using Cox regression, the MAP group as compared with the CABG group did not affect midterm survival probability (propensity score-adjusted hazard ratio, 0.854; 95% confidence interval, 0.571–2.729, p=0.630). Additionally, patients in the MAP group had a significantly lower ratio of NYHA class III-IV at the latest follow-up by comparison with patients in the CABG group (19.7% vs. 35.5%, p=0.033). Conclusion Compared with CABG alone, concomitant mitral annuloplasty is associated with improved midterm outcomes (including reduced IMR recurrence and improved cardiac functional class) but shares similar surgical mortality and major postoperative morbidity and may be a promising treatment option for elderly patients with moderate chronic IMR.
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Ji Q, Zhao Y, Shen J, Wang Y, Yang Y, Ding W, Xia L, Wang C. Risk Factors for Moderate or More Residual Regurgitation in Patients with Moderate Chronic Ischemic Mitral Regurgitation Undergoing Surgical Revascularization Alone. Int Heart J 2019; 60:1268-1275. [DOI: 10.1536/ihj.19-054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Qiang Ji
- Department of Cardiovascular Surgery, Zhongshan Hospital Fudan University
| | - Yun Zhao
- Shanghai Institute of Cardiovascular Diseases
| | - JinQiang Shen
- Department of Cardiovascular Surgery, Zhongshan Hospital Fudan University
| | - YuLin Wang
- Department of Cardiovascular Surgery, Zhongshan Hospital Fudan University
| | - Ye Yang
- Department of Cardiovascular Surgery, Zhongshan Hospital Fudan University
| | - WenJun Ding
- Department of Cardiovascular Surgery, Zhongshan Hospital Fudan University
| | - LiMin Xia
- Department of Cardiovascular Surgery, Zhongshan Hospital Fudan University
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22
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Karevа YE, Efendiev VU, Rakhmonov SS, Chernyavsky AM, Lukinov VL. [Long-Term Survival of Patients with Ischemic Heart Disease After Surgical Correction of Moderate Ischemic Mitral Regurgitation]. ACTA ACUST UNITED AC 2019; 59:13-19. [PMID: 31540572 DOI: 10.18087/cardio.2019.9.2635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 09/20/2019] [Indexed: 11/18/2022]
Abstract
AIM to assess effect of correction of moderate ischemic mitral regurgitation (IMR) in patients with ischemic cardiomyopathy (IMC) in immediate and remote period. MATERIALS AND METHODS We included in a single center prospective study 76 patients with IMC, left ventricular ejection fraction ≤35 %, and moderate IMR. Patients with indications to postinfarction aneurism repair were not included. For randomization we used the method of envelopes. Thirty-eight patients were randomized in the group where coronary artery bypass grafting (CABG) was combined with of mitral valve repair (MVR), and 38 patients in the control group of isolated CABG. Mean age of patients was 57±8 (from 30 to 75 лет) years. For IMR correction we used rigid MEDENG ring. Results. Inhospital mortality was 5.4 % (n=2) after isolated CABG and 10.81 % (n=4) after CABG + MVR. Main cause of death was acute heart failure. One- and 2‑year survival was 84 and 78 %, respectively, after CABG+MVR, and 84 and 71 % after isolated CABG. There was significant difference in three-year survival between groups (hazard ratio [HR] of death 0.457, p=0.04). Five-year survival was 45 and 74 % after isolated CABG and CABG+MVR, respectively (р=0.037). Factors associated with inhospital mortality were pulmonary hypertension (HR 2.177, 95 % confidence interval [CI] 2.299 to 9.831; p=0.043), NYHA class IV chronic heart failure (HR 3.027, 95 % CI 1.605 to 5.707; р=0.001), negative result of stress test echocardiography (HR 0.087, 95 %CI 0.041 to 0.186; р<0.001), atrial fibrillation (HR 4.754, 95 %CI 2.299 to 9.831; р<0.001). CONCLUSION Correction of moderate IMR in patients with IMC leads to improvement of parameters of survival in remote period. Five-year survival after isolated CABG was 45 %, while after CABG+MVR - 74 % (р=0.037).
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Affiliation(s)
- Yu E Karevа
- National Medical Research Center named after acad. E. N. Meshalkin
| | - V U Efendiev
- Murmansk Regional Clinical Hospital named after P. A. Bayandin
| | - S S Rakhmonov
- National Medical Research Center named after acad. E. N. Meshalkin
| | - A M Chernyavsky
- National Medical Research Center named after acad. E. N. Meshalkin
| | - V L Lukinov
- Institute of Computational Mathematics and Mathematical Geophysics, Siberian State University of Telecommunications and Information Sciences
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Nappi F, Avtaar Singh SS, Padala M, Attias D, Nejjari M, Mihos CG, Benedetto U, Michler R. The Choice of Treatment in Ischemic Mitral Regurgitation With Reduced Left Ventricular Function. Ann Thorac Surg 2019; 108:1901-1912. [PMID: 31445916 DOI: 10.1016/j.athoracsur.2019.06.039] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 05/15/2019] [Accepted: 06/10/2019] [Indexed: 01/26/2023]
Abstract
BACKGROUND Ischemic mitral regurgitation is a condition characterized by mitral insufficiency secondary to an ischemic left ventricle. Primarily, the pathology is the result of perturbation of normal regional left ventricular geometry combined with adverse remodeling. We present a comprehensive review of contemporary surgical, medical, and percutaneous treatment options for ischemic mitral regurgitation, rigorously examined by current guidelines and literature. METHODS We conducted a literature search of the PubMed database, Embase, and the Cochrane Library (through November 2018) for studies reporting perioperative or late mortality and echocardiographic outcomes after surgical and nonsurgical intervention for ischemic mitral regurgitation. RESULTS Treatment of this condition is challenging and often requires a multimodality approach. These patients usually have multiple comorbidities that may preclude surgery as a viable option. A multidisciplinary team discussion is crucial in optimizing outcomes. There are several options for treatment and management of ischemic mitral regurgitation with differing benefits and risks. Guideline-directed medical therapy for heart failure is the treatment choice for moderate and severe ischemic mitral regurgitation, with consideration of coronary revascularization, mitral valve surgery, cardiac resynchronization therapy, or a combination of these, in appropriate candidates. The use of transcatheter mitral valve therapy is considered appropriate in high-risk patients with severe ischemic mitral regurgitation, heart failure, and reduced left ventricular ejection fraction, especially in those with hemodynamic instability. CONCLUSIONS The role of mitral valve surgery and transcatheter mitral valve therapy continues to evolve.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France.
| | | | - Muralidhar Padala
- Structural Heart Research & Innovation, Laboratory, Carlyle Fraser Heart Center, Division of Cardiothoracic Surgery, Emory University, Atlanta, Georgia
| | - David Attias
- Department of Cardiology, Centre Cardiologique du Nord, Saint-Denis, France
| | - Mohammed Nejjari
- Department of Cardiology, Interventional Cardiology Centre Cardiologique du Nord, Saint-Denis, France
| | - Christos G Mihos
- Echocardiography Laboratory, Division of Cardiology, Columbia University, Mount Sinai Heart Institute, Miami Beach, Florida
| | - Umberto Benedetto
- Department of Cardiothoracic Surgery, Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Robert Michler
- Department of Surgery and Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York
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Shen J, Xia L, Song K, Wang Y, Yang Y, Ding W, Ji Q, Wang C. Moderate Chronic Ischemic Mitral Regurgitation. Int Heart J 2019; 60:796-804. [PMID: 31308329 DOI: 10.1536/ihj.18-613] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The benefits of concomitant mitral valve procedure (MVP) for treating moderate chronic ischemic mitral regurgitation (IMR) during coronary artery bypass grafting (CABG) have not been clearly established. This study aimed to determine the incidence of moderate or more residual mitral regurgitation (MR) following CABG plus MVP for moderate chronic IMR, and to evaluate the impacts of concomitant MVP vs. CABG alone on clinical outcomes based on propensity-matched data.All eligible patients were entered into either the MVP group (CABG plus MVP, n = 184) or CABG group (CABG alone, n = 162). Moderate or more residual MR rate was investigated, and in-hospital and follow-up outcomes between the groups were compared after matching.Moderate or more residual MR rate was 11.4% at 1 year and 22.9% at 2 years after CABG plus MVP, respectively. Patients in the MVP group as compared with the CABG group had significantly lower moderate or more residual MR rates at various postoperative time points (all P < 0.001). Grouping was not an independent risk factor for in-hospital adverse events in multivariate logistic regression analysis. Also, grouping was a significant variable related to moderate or more residual MR rate and NYHA class III-IV at the latest follow-up in Cox regression analysis (HR = 0.391, 95% CI 0.114-0.628; HR = 0.419, 95% CI 0.233-0.819, respectively).Concomitant MVP as compared with CABG alone for treating moderate chronic IMR was associated with a reduction in moderate or more residual MR rate and an improvement in NYHA functional status, with no increase in in-hospital adverse events or follow-up death.
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Affiliation(s)
- JinQiang Shen
- Department of Cardiovascular Surgery, Zhongshan Hospital Fudan University
| | - LiMin Xia
- Shanghai Institute of Cardiovascular Disease
| | - Kai Song
- Shanghai Institute of Cardiovascular Disease
| | - YuLin Wang
- Department of Cardiovascular Surgery, Zhongshan Hospital Fudan University
| | - Ye Yang
- Department of Cardiovascular Surgery, Zhongshan Hospital Fudan University
| | - WenJun Ding
- Department of Cardiovascular Surgery, Zhongshan Hospital Fudan University
| | - Qiang Ji
- Department of Cardiovascular Surgery, Zhongshan Hospital Fudan University
| | - ChunSheng Wang
- Department of Cardiovascular Surgery, Zhongshan Hospital Fudan University
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Renew JR, Martin AK, Murray AW, Pollak PM, Ramakrishna H. Functional Mitral Regurgitation: Interventions and Outcomes. J Cardiothorac Vasc Anesth 2019; 33:2053-2064. [DOI: 10.1053/j.jvca.2018.07.043] [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: 07/28/2018] [Indexed: 12/19/2022]
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Báez-Ferrer N, Izquierdo-Gómez MM, Marí-López B, Montoto-López J, Duque-Gómez A, García-Niebla J, Miranda-Bacallado J, de la Rosa Hernández A, Laynez-Cerdeña I, Lacalzada-Almeida J. Clinical manifestations, diagnosis, and treatment of ischemic mitral regurgitation: a review. J Thorac Dis 2018; 10:6969-6986. [PMID: 30746243 DOI: 10.21037/jtd.2018.10.64] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Ischemic mitral regurgitation (IMR) is a frequent complication after acute myocardial infarction (AMI) associated with a worse prognosis. The pathophysiological mechanisms of IMR are not fully understood, but it is known to be a complex process in which ventricular remodelling is the main causal factor. The various imaging techniques in cardiology and echocardiography fundamentally have contributed significantly to clarify the mechanisms that cause and progressively aggravate IMR. At present, different therapeutic options, the most important of which are cardio-surgical, address this problem. Nowadays the improvement in cardiac surgery and transcatheter therapies, have shown a therapeutic advance in IMR management. IMR is a predictor of poor prognosis in patients with heart failure and depressed left ventricular (LV) systolic function. However, it remains controversial whether mitral regurgitation (MR) in these patients is a consequence of dilation and dysfunction of the LV, or whether it contributes to worsening the prognosis of the ventricular dysfunction. Given that echocardiography has a fundamental reference role in the identification, graduation of severity and evaluation of the therapeutics used in the treatment of MR, we are going to focus on it over the rest of the imaging techniques. In contrast to primary MR the benefits of mitral surgery in patients with secondary MR are uncertain. Therefore, we will comment fundamentally on the role of mitral surgery in patients with IMR, with an update of the different surgical interventions available, without forgetting to mention the other therapeutic options currently available.
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Affiliation(s)
- Néstor Báez-Ferrer
- Department of Cardiology, Hospital Universitario de Canarias, Tenerife, Spain
| | | | - Belén Marí-López
- Department of Cardiology, Hospital Universitario de Canarias, Tenerife, Spain
| | - Javier Montoto-López
- Department of Cardiovascular Surgery, Hospital Universitario de Canarias, Tenerife, Spain
| | - Amelia Duque-Gómez
- Department of Cardiology, Hospital Universitario de Canarias, Tenerife, Spain
| | - Javier García-Niebla
- Servicios Sanitarios del Área de Salud de El Hierro, Valle del Golfo Health Center, El Hierro, Spain
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National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018. Heart Lung Circ 2018; 27:1123-1208. [DOI: 10.1016/j.hlc.2018.06.1042] [Citation(s) in RCA: 203] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Mid-term results of mitral valve repair for ischemic mitral regurgitation adjusted according to the degree of remodeling progression. Gen Thorac Cardiovasc Surg 2018; 66:707-715. [DOI: 10.1007/s11748-018-1000-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 08/12/2018] [Indexed: 11/26/2022]
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Kim BJ, Kim YS, Kim HJ, Ju MH, Kim JB, Jung SH, Choo SJ, Chung CH. Concomitant mitral valve surgery in patients with moderate ischemic mitral regurgitation undergoing coronary artery bypass grafting. J Thorac Dis 2018; 10:3632-3642. [PMID: 30069361 DOI: 10.21037/jtd.2018.05.148] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The clinical benefits of a concomitant mitral valve (MV) surgery in patients with moderate ischemic mitral regurgitation (iMR) undergoing coronary artery bypass grafting (CABG) remain controversial. Methods The study involved 710 patients (mean age, 65.0±8.9 years; 504 males) with moderate iMR undergoing CABG between 1990 and 2015. Of these, 116 (16.3%) patients underwent a concomitant MV surgery (MVS; replacement in 10, repair in 106) and 594 (83.7%) underwent CABG only. Clinical and echocardiographic outcomes were compared before and after adjustment with the use of propensity score (PS) analyses. Results Early mortality occurred in 22 (3.7%) and 13 (11.2%) patients in CABG-only and CABG with MVS group, respectively (P=0.001). After adjustment, CABG with MVS group showed significantly increased risks of early death (P<0.001), low cardiac output syndrome (LCOS) (P=0.001) and surgical bleeding (P=0.014). During a median follow-up of 78.0 months (quartile 1-3, 33.6-115.9 months), overall mortality occurred in 286 (40.3%) patients. The addition of an MV surgery showed an increased risk of overall mortality [hazard ratio (HR), 1.34; 95% confidence interval (CI), 0.99-1.80; P=0.055], which became comparable 1 year after surgery on landmark survival analysis (HR, 0.94; 95% CI, 0.64-1.39; P=0.772). Improved left ventricular (LV) ejection fraction and LV reverse remodeling were observed in both groups without significant intergroup differences. Conclusions The addition of a concomitant MV surgery increased the risk of early mortality and complications in patients with moderate iMR undergoing CABG. In long-term clinical and echocardiographic outcomes, a concomitant MV surgery seemed to confer no significant clinical benefits.
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Affiliation(s)
- Byung Jin Kim
- Medical Sciences Division, University of Oxford, Oxford, UK
| | - Yun Seok Kim
- Department of Thoracic and Cardiovascular Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Ho Jin Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Min Ho Ju
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Busan, Republic of Korea
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Ho Jung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Suk Jung Choo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Cheol Hyun Chung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Salmasi MY, Harky A, Chowdhury MF, Abdelnour A, Benjafield A, Suker F, Hubbard S, Vohra HA. Should the mitral valve be repaired for moderate ischemic mitral regurgitation at the time of revascularization surgery? J Card Surg 2018; 33:374-384. [PMID: 29888544 DOI: 10.1111/jocs.13722] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Ischemic mitral regurgitation (IMR) is associated with increased mortality and recurrent congestive heart failure following coronary artery bypass graft (CABG) surgery. While mitral surgery should be undertaken for severe MR during CABG, the treatment of moderate IMR remains controversial. We conducted a meta-analysis to determine the outcomes of CABG alone and combine with mitral valve repair (MVr) in moderate IMR. METHODS A literature search was conducted by Pubmed, Ovid, and Embase, which included 643 articles. Eleven studies (seven observational studies and four randomized controlled trials) with a total of 1406 patients were included (CABG alone = 864 and CABG plus MVr = 542). RESULTS There was no difference in operative mortality (odds ratio 1.56, 95% confidence interval [CI] 0.92-2.71) or long-term survival at 1 or 5 years (hazard ratio 0.98, 95%CI 0.71-1.35, P = 0.49) between the two groups, and little evidence of heterogeneity was found in the studies (I2 = 0.0, P = 0.562). There was significantly greater improvement in MR grade (weighted mean difference [WMD] -1.15, 95%CI -1.67 to -0.064, P = < 0.001) and left ventricular systolic diameter (WMD -3.02, 95%CI -4.85 to -1.18, P = 0.001) following CABG and MVr compared to CABG alone. No difference in postoperative functional class or ejection fraction was found. CONCLUSIONS Our results show that in the presence of moderate IMR, adding MVr to revascularization reduces MR grade on follow-up echocardiography and promotes ventricular remodeling, with no improvement in long-term survival or functional class.
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Affiliation(s)
- Mohammad Y Salmasi
- Department of Cardiothoracic Surgery, University Hospitals of Leicester, Leicester, UK
| | - Amer Harky
- Department of Cardiac Surgery, St Bartholemew's Hospital, London, UK
| | - Mohammed F Chowdhury
- Department of Cardiothoracic Surgery, University Hospitals of Leicester, Leicester, UK
| | - Ali Abdelnour
- Department of Cardiac Surgery, Royal Hospitals, Belfast, UK
| | | | - Farah Suker
- Department of Medical Sciences, University of Nottingham, Nottingham, UK
| | - Stephanie Hubbard
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Hunaid A Vohra
- Bristol Heart Institute, Bristol Royal Infirmary, Bristol, UK
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Capoulade R, Piriou N, Serfaty JM, Le Tourneau T. Multimodality imaging assessment of mitral valve anatomy in planning for mitral valve repair in secondary mitral regurgitation. J Thorac Dis 2017; 9:S640-S660. [PMID: 28740719 PMCID: PMC5505945 DOI: 10.21037/jtd.2017.06.99] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Accepted: 06/13/2017] [Indexed: 12/23/2022]
Abstract
Secondary mitral regurgitation (MR) is frequent valvular heart disease and conveys worse prognostic. Therapeutic surgical or percutaneous options are available in the context of severe symptomatic secondary MR, but the best approach to treat these patients remains unclear, given the lack of clear clinical evidence of benefit. A comprehensive evaluation of the mitral valve apparatus and the left ventricle (LV) has the ability to clearly define and characterize the disease, and thus determine the best option for the patient to improve its clinical outcomes, as well as quality of life and symptoms. The current report reviews the mitral valve (MV) anatomy, the underlying mechanisms associated with secondary MR, the related therapeutic options available, and finally the usefulness of a multimodality imaging approach for the planning of surgical or percutaneous mitral valve intervention.
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Affiliation(s)
- Romain Capoulade
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Institut du Thorax, CHU Nantes, Nantes University, Nantes, France
| | - Nicolas Piriou
- Institut du Thorax, CHU Nantes, Nantes University, Nantes, France
- Department of Nuclear Medicine, CHU Nantes, Nantes University, Nantes, France
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32
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Charles EJ, Kron IL. Data, not dogma, for ischemic mitral regurgitation. J Thorac Cardiovasc Surg 2017; 154:137-138. [PMID: 28457538 DOI: 10.1016/j.jtcvs.2017.03.101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 03/24/2017] [Indexed: 11/18/2022]
Affiliation(s)
- Eric J Charles
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Irving L Kron
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Va.
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