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Spieker M, Lagarden H, Sidabras J, Veulemans V, Christian L, Bejinariu A, Akhyari P, Rana O, Polzin A, Horn P, Kelm M, Westenfeld R. Prevalence, mechanisms, and prognostic impact of dynamic mitral regurgitation assessed by isometric handgrip exercise. Eur Heart J Cardiovasc Imaging 2024; 25:240-248. [PMID: 37740790 DOI: 10.1093/ehjci/jead230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/26/2023] [Accepted: 09/07/2023] [Indexed: 09/25/2023] Open
Abstract
AIMS The extent of mitral regurgitation (MR) may vary depending on the haemodynamic situation; thus, exercise testing plays an important role in assessing the haemodynamic relevance of MR. We aim to assess prevalence, mechanisms, and prognostic impact of exercise-induced changes in MR in patients with degenerative MR (DegMR) and functional MR (FMR). METHODS AND RESULTS We enrolled 367 patients with at least mild MR who underwent standardized echocardiography at rest and during handgrip exercise. Handgrip exercise led to an increase in MR by one grade or more in 19% of DegMR and 28% of FMR patients. In FMR, patients with exercise-induced increases in MR, handgrip exercise led to a reduction in left ventricular stroke volume index, being maintained in DegMR patients. Exercise-induced changes in systolic pulmonary artery pressure were linked to changes in effective regurgitant orifice area (DegMR: r = 0.456; P < 0.001; FMR: r = 0.326; P < 0.001). Thus, 26% of patients with DegMR and FMR developed pulmonary hypertension during exercise. In both cohorts, a significant proportion of patients with non-severe MR at rest and exercise-induced severe MR underwent mitral valve surgery/intervention during follow-up. In FMR patients (but not in DegMR patients), early mitral valve surgery/intervention was independently associated with lower event rates during follow-up [0.177 (0.027-0.643); P = 0.025]. CONCLUSIONS Handgrip exercise echocardiography provides important information regarding the dynamic nature of MR, exercise-induced changes in left ventricular function, and pulmonary circulation with subsequent consequences for further therapeutic decision making. Thus, it should be considered as a diagnostic tool in symptomatic patients with non-severe MR at rest.
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Affiliation(s)
- Maximilian Spieker
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Hannah Lagarden
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Jonas Sidabras
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Verena Veulemans
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Lucas Christian
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Alex Bejinariu
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Payam Akhyari
- Department of Cardiac Surgery, Medical Faculty, University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Obaida Rana
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Amin Polzin
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Patrick Horn
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Malte Kelm
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
- Cardiovascular Research Institute Duesseldorf, Medical Faculty, Heinrich-Heine University, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Ralf Westenfeld
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
- Abiomed Europe GmbH, Neuenhofer Weg 3, 52074 Aachen, Germany
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Murata R, Kuwata S, Izumo M, Shiokawa N, Sato Y, Okuno T, Koga M, Okuyama K, Tanabe Y, Harada T, Ishibashi Y, Akashi YJ. Changes in exercise stress echocardiographic parameters before and after transcatheter mitral valve edge-to-edge repair. Cardiovasc Interv Ther 2024; 39:74-82. [PMID: 37938532 DOI: 10.1007/s12928-023-00966-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 10/09/2023] [Indexed: 11/09/2023]
Abstract
The safety and feasibility are still not well known for exercise-induced mitral regurgitation (MR). This study is aimed to assess and compare the hemodynamic and symptomatic changes in patients with significant secondary MR during exercise stress echocardiography (ESE) before and after transcatheter edge-to-edge repair (TEER). The study included a total of 15 patients with secondary MR who underwent ESE before and after TEER using the MitraClip system (Abbott, Abbott Park, IL, USA). Echocardiographic data of ESE were collected both before the procedure and during the follow-up visit at 3 months. During the one-year postoperative observation period, the rate of readmission due to heart failure was 13% (n = 2), with no recorded fatalities. Although no significant differences of ESE data were observed in exercise-induced pulmonary hypertension or cardiac output before and after the repair, the severity of MR was significantly improved after the procedure, both at rest (2 [2-3] vs. 1 [1-2], p = 0.0125) and during ESE (3 [3-3] vs. 1 [1-1], p < 0.0001). Furthermore, the New York Heart Association Functional Classification was improved (3 [3-3] vs. 1 [1-1], p < 0.0001) after treatment. For a supplemental analysis, MR during ESE was significantly improved not only in cases with atrial secondary MR but also in ventricular secondary MR. Transcatheter edge-to-edge repair for exercise-induced MR resulted in a significant improvement in postoperative MR severity and subjective symptoms. These results are novel, as they have not been extensively reported previously, particularly among Japanese patients.
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Affiliation(s)
- Risako Murata
- Department of Cardiology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-Ku, Kawasaki, Kanagawa, Japan
| | - Shingo Kuwata
- Department of Cardiology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-Ku, Kawasaki, Kanagawa, Japan.
| | - Masaki Izumo
- Department of Cardiology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-Ku, Kawasaki, Kanagawa, Japan
| | - Noriko Shiokawa
- Ultrasound Center, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Yukio Sato
- Department of Cardiology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-Ku, Kawasaki, Kanagawa, Japan
| | - Taishi Okuno
- Department of Cardiology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-Ku, Kawasaki, Kanagawa, Japan
| | - Masashi Koga
- Department of Cardiology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-Ku, Kawasaki, Kanagawa, Japan
| | - Kazuaki Okuyama
- Department of Cardiology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-Ku, Kawasaki, Kanagawa, Japan
| | - Yasuhiro Tanabe
- Department of Cardiology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-Ku, Kawasaki, Kanagawa, Japan
| | - Tomoo Harada
- Department of Cardiology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-Ku, Kawasaki, Kanagawa, Japan
| | - Yuki Ishibashi
- Department of Cardiology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-Ku, Kawasaki, Kanagawa, Japan
| | - Yoshihiro Johnny Akashi
- Department of Cardiology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-Ku, Kawasaki, Kanagawa, Japan
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Izumo M, Kuwata S, Ishibashi Y, Suzuki T, Ohara H, Watanabe M, Sato Y, Nishikawa H, Okuyama K, Kamijima R, Takai M, Kou S, Harada T, Akashi YJ. Prognostic impact of transcatheter mitral valve repair in patients with exercise-induced secondary mitral regurgitation. Eur Heart J Cardiovasc Imaging 2021; 22:530-538. [PMID: 32856088 DOI: 10.1093/ehjci/jeaa200] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 06/20/2020] [Indexed: 11/12/2022] Open
Abstract
AIMS Although exercise-induced secondary mitral regurgitation (MR) is known to have a poor prognosis, the therapeutic strategy towards this condition remains to be investigated. In the present study, we aimed to investigate the prognostic impact of transcatheter mitral valve repair (TMVr) using the MitraClip in patients with exercise-induced secondary MR. METHODS AND RESULTS Of the 200 consecutive patients with secondary MR who underwent exercise stress echocardiography, 46 (23%) that presented with exercise-induced secondary MR [i.e. increase in effective regurgitant orifice area (EROA) of ≥ 0.13 cm2] were enrolled in the present investigation. The composite endpoints of all-cause mortality and hospitalization for heart failure were evaluated. Of the 46 patients included in the current cohort, 19 (41%) underwent TMVr and 27 (59%) were medically managed (control group). Although the TMVr group tended to present with a greater EROA at rest (0.26 ± 0.10 vs. 0.20 ± 0.08 cm2, P = 0.047), there were no differences in the EROA changes during exercise between the two groups (0.18 ± 0.10 vs. 0.18 ± 0.04 cm2, P = 0.940). While the TMVr group reported a higher event-free survival rate after the 13-month follow-up period (log-rank P = 0.017), the Cox proportional-hazard analysis suggested the TMVr to be associated with clinical outcomes (hazard ratio: 0.419, P = 0.044). CONCLUSION As opposed to the medical management, TMVr treatment was associated with a lower risk of composite endpoints in patients with exercise-induced secondary MR. Exercise stress echocardiography is considered to have played an important role in decision-making for secondary MR.
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Affiliation(s)
- Masaki Izumo
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Shingo Kuwata
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Yuki Ishibashi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Tomomi Suzuki
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Hiroshi Ohara
- Division of Cardiovascular Medicine, Department of Internal Medicine, Toho University Faculty of Medicine, Tokyo, Japan
| | - Mika Watanabe
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Yukio Sato
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Haruka Nishikawa
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Kazuaki Okuyama
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Ryo Kamijima
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Manabu Takai
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Seisyo Kou
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Tomoo Harada
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Yoshihiro J Akashi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
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Kadoglou NPE, Papadopoulos CH, Papadopoulos KG, Karagiannis S, Karabinos I, Loizos S, Theodosis-Georgilas A, Aggeli K, Keramida K, Klettas D, Kounas S, Makavos G, Ninios I, Ntalas I, Ikonomidis I, Sahpekidis V, Stefanidis A, Zaglavara T, Athanasopoulos G, Karatasakis G, Kyrzopoulos S, Kouris N, Patrianakos A, Paraskevaidis I, Rallidis L, Savvatis K, Tsiapras D, Nihoyannopoulos P. Updated knowledge and practical implementations of stress echocardiography in ischemic and non-ischemic cardiac diseases: an expert consensus of the Working Group of Echocardiography of the Hellenic Society of Cardiology. Hellenic J Cardiol 2021; 64:30-57. [PMID: 34329766 DOI: 10.1016/j.hjc.2021.07.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 07/15/2021] [Indexed: 12/15/2022] Open
Abstract
Stress echocardiography (SE) is a well-established and valid technique, widely-used for the diagnostic evaluation of patients with ischemic and non-ischemic cardiac diseases. This statement of the Echocardiography Working Group of the Hellenic Society of Cardiology summarizes the consensus of the writing group regarding the applications of SE, based on the expertise of their members and on a critical review of current medical literature. The main objectives of the consensus document include a comprehensive review of SE methodology and training, focusing on the preparation, the protocols used and the analysis of the SE images and an updated, evidence-based knowledge about SE applications on ischemic and non-ischemic heart diseases, such as in cardiomyopathies, heart failure and valvular heart disease.
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Affiliation(s)
- Nikolaos P E Kadoglou
- Medical School, University of Cyprus, Nicosia, Cyprus; Second Cardiology Department, "Hippokration" Hospital, Aristotle University ofThessaloniki, Greece.
| | | | | | | | | | | | | | - Konstantina Aggeli
- 1st Cardiology Department, Hippokration University Hospital, Athens, Greece
| | - Kalliopi Keramida
- 2nd Cardiology Department, Attikon University Hospital, Athens, Greece
| | | | | | - George Makavos
- 3rd Cardiology Department, Sotiria University Hospital, Athens, Greece
| | - Ilias Ninios
- 2nd Cardiology Department, Interbalkan Center, Thessaloniki, Greece
| | | | | | | | | | | | | | - George Karatasakis
- 1st Cardiology Department, Onassis Cardiosurgical Center, Piraeus, Greece
| | | | - Nikos Kouris
- Cardiology Department, Thriasio Hospital, Elefsina, Greece
| | | | | | | | | | - Dimitrios Tsiapras
- 2nd Cardiology Department, Onassis Cardiosurgical Center, Piraeus, Greece
| | - Petros Nihoyannopoulos
- Metropolitan Hospital Center, Piraeus, Greece; Imperial College London, Hammersmith Hospital, London, UK
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Kagiyama N, Toki M, Yuri T, Aritaka S, Hayashida A, Sengupta PP, Yoshida K. Physiological and prognostic differences between types of exercise stress echocardiography for functional mitral regurgitation. Open Heart 2021; 8:openhrt-2021-001583. [PMID: 33888592 PMCID: PMC8070867 DOI: 10.1136/openhrt-2021-001583] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 03/03/2021] [Accepted: 03/12/2021] [Indexed: 12/11/2022] Open
Abstract
Objective Secondary mitral regurgitation (MR) demonstrates dynamic change during exercise. This prospective observational study aimed to compare exercise stress echocardiography (ESE) where handgrip exercise (handgrip-ESE) or semisupine ergometer exercise was performed (ergometer-ESE) for patients with secondary MR. Methods Handgrip-ESE and symptom-limited ergometer-ESE were performed for 53 patients (median age (IQR): 68 (58–78) years; 70% male) on the same day. Baseline global longitudinal strain (GLS) was 9.2% (6.0%–14.0%) and MR volume was 20 (14–26) mL. All-cause death and cardiac hospitalisation were tracked for median 439 (101–507) days. Results Handgrip-ESE induced slightly but significantly greater degrees of MR increase (median one grade increase; p<0.001) than ergometer-ESE, although the changes in other parameters, including GLS (+1.1% vs −0.6%, p<0.001), were significantly smaller. Correlations between the two examinations with respect to the changes in the echocardiographic parameters were weak. Kaplan-Meier analyses revealed poor improvement in GLS during ergometer-ESE, but not the change in MR, was associated with adverse events (p=0.0065). No echocardiographic change observed during handgrip-ESE was prognostic. After adjusting for a clinical risk score, GLS changes during ergometer-ESE remained significant in predicting the adverse events (HR 0.39, p=0.03) A subgroup analysis in patients with moderate or greater MR at baseline (n=27) showed the same results as in the entire cohort. Conclusions The physiological and prognostic implications of handgrip-ESE and ergometer-ESE findings significantly differ in patients with left ventricular dysfunction and secondary MR. The type of exercise to be performed in ESE should be carefully selected.
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Affiliation(s)
- Nobuyuki Kagiyama
- Department of Cardiology, Sakakibara Heart Institute of Okayama, Okayama, Japan .,Department of Cardiovascular Biology and Medicine, Juntendo University, Tokyo, Japan
| | - Misako Toki
- Department of Clinical Laboratory, Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Takuya Yuri
- Department of Cardiology, Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Shingo Aritaka
- Department of Clinical Laboratory, Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Akihiro Hayashida
- Department of Cardiology, Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Partho P Sengupta
- Heart and Vascular Institute, West Virginia University, Morgantown, West Virginia, USA
| | - Kiyoshi Yoshida
- Department of Cardiology, Sakakibara Heart Institute of Okayama, Okayama, Japan
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Hadjadj S, Marsit O, Paradis JM, Beaudoin J. Pathophysiology, Diagnosis, and New Therapeutic Approaches for Ischemic Mitral Regurgitation. Can J Cardiol 2020; 37:968-979. [PMID: 33347977 DOI: 10.1016/j.cjca.2020.12.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 12/10/2020] [Accepted: 12/12/2020] [Indexed: 01/22/2023] Open
Abstract
Ischemic mitral regurgitation (MR) is a valvular complication frequently seen in patients with coronary artery disease and is associated with increased mortality and morbidity. Ischemic mitral regurgitation has a complex, heterogeneous, and still incompletely understood pathophysiology involving both the mitral valve and the left ventricle. The occurrence of valve regurgitation in patients with ischemic cardiomyopathy in return accelerates left ventricular remodelling and dysfunction, ultimately leading to irreversible heart failure. Diagnostic evaluation of ischemic MR is unique and different from the other causes of MR. The severity thresholds associated with outcomes are different from primary MR, and specific imaging characteristics are potentially useful to guide therapy. The use of imaging modalities such as 3-dimensional echocardiography and cardiac magnetic resonance imaging can refine the diagnostic evaluation and help in choosing the correct management. Although multiple treatments are available to improve ischemic MR, each therapeutic option is associated with limitations and incomplete success. Therapy has therefore to be individualised for each patient. Current options include optimal medical therapy, cardiac resynchronisation therapy, percutaneous or surgical revascularisation, surgical mitral repair or replacement, and new percutaneous interventions. This review aims to discuss the latest insights regarding the pathophysiology, diagnosis, and treatment of ischemic MR.
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Affiliation(s)
- Sandra Hadjadj
- Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Ons Marsit
- Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Jean-Michel Paradis
- Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Jonathan Beaudoin
- Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada.
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7
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Left Atrial Dynamics in Mitral Regurgitation. JACC Cardiovasc Imaging 2020; 13:41-43. [DOI: 10.1016/j.jcmg.2019.02.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 02/13/2019] [Indexed: 11/18/2022]
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Prognostic value of exercise stress echocardiography in patients with secondary mitral regurgitation: a long-term follow-up study. J Echocardiogr 2018; 17:147-156. [DOI: 10.1007/s12574-018-0404-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 10/09/2018] [Accepted: 10/22/2018] [Indexed: 10/28/2022]
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Kubo S, Kawase Y, Hata R, Maruo T, Tada T, Kadota K. Dynamic severe mitral regurgitation on hospital arrival as prognostic predictor in patients hospitalized for acute decompensated heart failure. Int J Cardiol 2018; 273:177-182. [PMID: 30274752 DOI: 10.1016/j.ijcard.2018.09.093] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 08/22/2018] [Accepted: 09/24/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Severe mitral regurgitation (MR) on hospital arrival at the onset of acute decompensated heart failure (ADHF) can improve after ADHF treatment because MR is dynamic in nature. This study investigated the clinical significance of the dynamic severe MR on hospital arrival in ADHF patients. METHODS Transthoracic echocardiography was performed on 784 patients hospitalized for ADHF both on arrival and after ADHF treatment, of whom 563 with at least mild MR after ADHF treatment were enrolled and divided into 3 groups based on the MR severity: severe at both times (persistent MR, n = 106); severe on arrival and improved to mild/moderate after ADHF treatment (dynamic MR, n = 149); and mild/moderate at both times (non-significant MR, n = 308). The primary outcome measure was defined as a composite of cardiac death, rehospitalization for heart failure, and mitral valve intervention within 1-year. RESULTS The incidence of the primary outcome measure in the dynamic MR group (44.8%) was significantly higher than that in the non-significant MR group (22.1%, adjusted hazard ratio [HR]: 0.50, 95% confidence interval [CI]: 0.34-0.73, P < 0.001), and similar to that in the persistent MR group (44.4%, adjusted HR: 1.08, 95% CI: 0.69-1.67, P = 0.75). The risk of dynamic MR was consistent in the subgroups of patients with reduced (<45%) and preserved left ventricular ejection fraction (Pinteraction = 0.56). CONCLUSIONS In patients hospitalized for ADHF, dynamic severe MR on hospital arrival was associated with poorer outcomes than non-significant MR and had similar risk to persistent severe MR. Acute dynamic MR is a potential therapeutic target in ADHF patients.
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Affiliation(s)
- Shunsuke Kubo
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan.
| | - Yuichi Kawase
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Reo Hata
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Takeshi Maruo
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Takeshi Tada
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Kazushige Kadota
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
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Clinical use of submaximal treadmill exercise testing and assessments of cardiac biomarkers NT-proBNP and cTnI in dogs with presymptomatic mitral regurgitation. PLoS One 2018; 13:e0199023. [PMID: 29902265 PMCID: PMC6002043 DOI: 10.1371/journal.pone.0199023] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 05/30/2018] [Indexed: 12/15/2022] Open
Abstract
Exercise intolerance is the first symptom of heart disease. Yet an objective and standardised method in canine cardiology to assess exercise capacity in a clinical setting is lacking. In contrast, exercise testing is a powerful diagnostic tool in humans, providing valuable information on prognosis and impact of therapeutic intervention. To investigate whether an exercise test reveals differences between dogs with early stage mitral regurgitation (MR) and dogs without cardiac disease, 12 healthy beagles (healthy group, HG) and 12 dogs with presymptomatic MR (CHIEF B1 / B2, patient group, PG) underwent a six-stage submaximal exercise test (ET) on a motorised treadmill. They trotted in their individual comfort speed for three minutes per stage, first without incline, afterwards increasing it by 4% for every subsequent stage. Blood samples were taken at rest and during two 3-minute breaks in the course of the test. Further samples were taken after the completion of the exercise test and again after a 3-hour recovery period. Measured parameters included heart rate, lactate and the cardiac biomarkers N-terminal pro-B-Type natriuretic peptide and cardiac Troponin I. The test was performed again under the same conditions in the same dogs three weeks after the first trial to evaluate individual repeatability. Cardiac biomarkers increased significantly in both HG and PG in the course of the test. The increase was more pronounced in CHIEF B1 / B2 dogs than in the HG. N-terminal pro-B-Type natriuretic peptide increased from 435 ± 195 to 523 ± 239 pmol/L (HG) and from 690 to 815 pmol/L (PG). cTnI increased from 0.020 to 0.024 ng/mL (HG) and from 0.06 to 0.08 ng/ml (PG). The present study provides a method to assess exercise-induced changes in cardiac biomarkers under clinical conditions. The increase of NT-proBNP and cTnI is more pronounced in dogs with early-stage MR than in healthy dogs. Results indicate that measuring the parameters before and after exercise is adequate and taking blood samples between the different stages of the ET does not provide additional information. Also, stress echocardiography was inconclusive. It can be concluded that exercise testing, especially in combination with measuring cardiac biomarkers, could be a helpful diagnostic tool in canine cardiology.
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Abstract
Ischemic mitral regurgitation (IMR) is a frequent complication of left ventricular (LV) global or regional pathological remodeling due to chronic coronary artery disease. It is not a valve disease but represents the valvular consequences of increased tethering forces and reduced closing forces. IMR is defined as mitral regurgitation caused by chronic changes of LV structure and function due to ischemic heart disease and it worsens the prognosis. In this review, we discuss on etiology, pathophysiology, and mechanisms of IMR, its classification, evaluation, and therapeutic corrective methods of IMR.
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Affiliation(s)
- Praveen Kerala Varma
- Division of Cardiac Surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham (Amrita University), Kochi, Kerala, India
| | - Neethu Krishna
- Division of Cardiac Surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham (Amrita University), Kochi, Kerala, India
| | - Reshmi Liza Jose
- Division of Anesthesiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham (Amrita University), Kochi, Kerala, India
| | - Ashish Narayan Madkaiker
- Division of Cardiac Surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham (Amrita University), Kochi, Kerala, India
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Lancellotti P, Pellikka PA, Budts W, Chaudhry FA, Donal E, Dulgheru R, Edvardsen T, Garbi M, Ha JW, Kane GC, Kreeger J, Mertens L, Pibarot P, Picano E, Ryan T, Tsutsui JM, Varga A. The Clinical Use of Stress Echocardiography in Non-Ischaemic Heart Disease: Recommendations from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. J Am Soc Echocardiogr 2017; 30:101-138. [DOI: 10.1016/j.echo.2016.10.016] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Lancellotti P, Pellikka PA, Budts W, Chaudhry FA, Donal E, Dulgheru R, Edvardsen T, Garbi M, Ha JW, Kane GC, Kreeger J, Mertens L, Pibarot P, Picano E, Ryan T, Tsutsui JM, Varga A. The clinical use of stress echocardiography in non-ischaemic heart disease: recommendations from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. Eur Heart J Cardiovasc Imaging 2016; 17:1191-1229. [DOI: 10.1093/ehjci/jew190] [Citation(s) in RCA: 206] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 08/12/2016] [Indexed: 12/20/2022] Open
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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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Clinical significance of exercise pulmonary hypertension in secondary mitral regurgitation. Am J Cardiol 2015; 115:1454-61. [PMID: 25784516 DOI: 10.1016/j.amjcard.2015.02.028] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 02/11/2015] [Accepted: 02/11/2015] [Indexed: 11/20/2022]
Abstract
In patients with heart failure, exercise echocardiography can help in risk stratification and decision making. The prognostic significance of exercise pulmonary hypertension (PH) in patients with secondary mitral regurgitation (MR) remains unknown. The aim of the present study was to assess the prognostic value of exercise PH in patients with secondary MR and narrow QRS intervals. From 2005 to 2012, 159 consecutive patients with secondary MR, narrow QRS intervals, left ventricular dysfunction (mean ejection fraction 36 ± 7%), and measurable systolic pulmonary arterial pressure (SPAP) during exercise echocardiography were included. Resting and exercise PH were defined as SPAP >50 and >60 mm Hg, respectively. Exercise PH was more frequent than resting PH (40% vs 13%, p <0.0001). On multivariate logistic regression, the independent determinants of exercise PH were resting SPAP (p <0.0001), exercise MR severity (p <0.0001), and e'-wave velocity (p = 0.004). The incidence of cardiac events during follow-up was significantly higher in patients with exercise PH compared with those without exercise PH (4 years: 40 ± 7% vs 20 ± 5%, p <0.0001). Patients with exercise PH exhibited higher rates of cardiac events and death than those with resting PH. In a multivariate Cox proportional hazards model, exercise PH was independently associated with the occurrence of cardiac events (p <0.0001). In conclusion, in patients with secondary MR, exercise PH is determined mainly by resting SPAP, left ventricular diastolic burden, and exercise MR severity. Exercise PH is a powerful predictor of poor outcomes, with a 5.3-fold increased risk for cardiac-related death during follow-up. These results highlight the added value of exercise echocardiography in secondary MR.
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Duino V, Fiocca L, Musumeci G, D'Elia E, Gori M, Cerchierini E, Valsecchi O, Senni M. An intriguing case report of functional mitral regurgitation treated with MitraClip. Medicine (Baltimore) 2015; 94:e608. [PMID: 25997036 PMCID: PMC4602878 DOI: 10.1097/md.0000000000000608] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Functional mitral regurgitation (FMR) is frequent in patients with heart failure (HF). It develops as a consequence of left ventricle (LV) geometry alterations, causing imbalance between increased tethering forces and decreased closing forces exerted on the mitral valve apparatus during systole.FMR is known to change at rest and during effort, due to preload-afterload changes, myocardial ischemia, and/or LV dysfunction. Despite optimized medical therapy, an FMR can be responsible of shortness of breath limiting quality of life and decompensation. In this report, we present a case of dynamic FMR treated with MitraClip.MitraClip implantation is a successful and innovative opportunity for HF patients with FMR.
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Affiliation(s)
- Vincenzo Duino
- From the Cardiovascular Department (VD, LF, GM, ED, MG, OV, MS), Anesthesiology Department (EC), Hospital Papa Giovanni XXIII, Bergamo, Italy
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Naji P, Patel K, Griffin BP, Desai MY. Stress echocardiography in valvular heart disease: a current appraisal. Expert Rev Cardiovasc Ther 2015; 13:249-62. [DOI: 10.1586/14779072.2015.1013940] [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] [Indexed: 01/01/2023]
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Abstract
Mitral regurgitation (MR) is a common, progressive, and difficult-to-manage disease. MR is dynamic in nature, with physiological fluctuations occurring in response to various stimuli such as exercise and ischaemia, which can precipitate the development of symptoms and subsequent cardiac events. In both chronic primary and secondary MR, the dynamic behaviour of MR can be reliably examined during stress echocardiography. Dynamic fluctuation of MR can also have prognostic value; patients with a marked increase in regurgitant volume or who exhibit increased systolic pulmonary artery pressure during exercise have lower symptom-free survival than those who do not experience significant changes in MR and systolic pulmonary artery pressure during exercise. Identifying patients who have dynamic MR, and understanding the mechanisms underlying the condition, can potentially influence revascularization strategies (such as the surgical restoration of coronary blood flow) and interventional treatment (including cardiac resynchronization therapy and new approaches targeted to the mitral valve).
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Coisne A, Levy F, Malaquin D, Richardson M, Quéré JP, Montaigne D, Tribouilloy C. Feasibility of Doppler hemodynamic evaluation of primary and secondary mitral regurgitation during exercise echocardiography. Int J Cardiovasc Imaging 2014; 31:291-9. [DOI: 10.1007/s10554-014-0550-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 10/07/2014] [Indexed: 11/25/2022]
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Affiliation(s)
- Patrizio Lancellotti
- University of Liège Hospital, GIGA Cardiovascular Sciences, Department of Cardiology, Heart Valve Clinic, University Hospital Sart Tilman, Liège, Belgium
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Jansen R, Kracht PAM, Cramer MJ, Tietge WJ, van Herwerden LA, Klautz RJM, Kluin J, Chamuleau SAJ. The role of exercise echocardiography in the management of mitral valve disease. Neth Heart J 2013; 21:487-496. [PMID: 23959848 PMCID: PMC3824738 DOI: 10.1007/s12471-013-0452-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Exercise echocardiography can assess the dynamic component of mitral valve (MV) disease and may therefore be helpful for the clinical decision-making by the heart team. The purpose of this study is to determine the role of exercise echocardiography in the management of disproportionately symptomatic or otherwise atypical patients with mitral regurgitation (MR) and stenosis (MS) in clinical practice. METHODS Data of 14 MR and 14 MS patients, including echocardiograms at rest, were presented retrospectively to an experienced heart team to determine treatment strategy. Subsequently, exercise echo data were provided whereupon once again the treatment strategy was determined. This resulted in: value of exercise echo by means of 1) alteration or 2) confirmation of treatment strategy or 3) no additional value. RESULTS During exercise the echocardiographic severity of MV disease increased in 9 (64 %) MR and 8 (57 %) MS patients. Based upon alteration or confirmation of the treatment strategy, the value of exercise echocardiography in the management of MR and MS was 86 % and 57 %, respectively. CONCLUSION This study showed that physical exercise echo can have an important role in the clinical decision-making of challenging patients with MV disease. Exercise echocardiography had additional value to the treatment strategy in 71 % of these patients.
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Affiliation(s)
- R. Jansen
- Department of Cardiology, University Medical Center Utrecht, HP E03.511, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - P. A. M. Kracht
- Department of Cardiology, University Medical Center Utrecht, HP E03.511, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - M. J. Cramer
- Department of Cardiology, University Medical Center Utrecht, HP E03.511, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - W. J. Tietge
- Department of Cardiology, Diaconessenhuis Leiden, Houtlaan 55, 2334 CK Leiden, the Netherlands
| | - L. A. van Herwerden
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - R. J. M. Klautz
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - J. Kluin
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - S. A. J. Chamuleau
- Department of Cardiology, University Medical Center Utrecht, HP E03.511, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
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D'Andrea A, Mele D, Nistri S, Riegler L, Galderisi M, Agricola E, Losi MA, Ballo P, Mondillo S, Badano LP. The prognostic impact of dynamic ventricular dyssynchrony in patients with idiopathic dilated cardiomyopathy and narrow QRS. Eur Heart J Cardiovasc Imaging 2013; 14:183-189. [DOI: 10.1093/ehjci/jes154] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/29/2023] Open
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Dulgheru R, Magne J, Lancellotti P, Pierard LA. Dynamic Ischaemic Mitral Regurgitation and the Role of Stress Echocardiography. J Cardiovasc Echogr 2013; 23:10-17. [PMID: 28465878 PMCID: PMC5353439 DOI: 10.4103/2211-4122.117979] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Objective: This paper aims to explain the main mechanisms that cause ischaemic mitral regurgitation (MR), the pathophysiology, and the role played by stress echocardiography in the evaluation of the dynamic component of MR. Introduction: Chronic ischaemic MR is a frequent complication of myocardial infarction (MI), and is associated with a poor prognosis and outcome. The more the severity of ischaemic MR, the lower is the survival rate. In recent times, improvements in the management of the acute phase of MI, has increased the survival rate after MI. This, combined with an increase in the incidence of MI, will probably lead to a higher prevalence of ischemic MR in the next decades. As a consequence, ischaemic MR should be thoroughly understood and promptly identified. Furthermore, it is well recognized that ischaemic MR is dynamic. The best way to explore the dynamic nature of ischaemic MR is exercise stress echocardiography, and this test should probably be integrated in the evaluation and the management of patients with chronic ischaemic MR. Conclusion: Based on our experience, exercise stress echocardiography might be of interest in the following subsets of patients: 1) in patients with left ventricular (LV) dysfunction who present exertional dyspnea out of proportion to the severity of resting LV dysfunction or MR severity, 2) in patients in whom acute pulmonary oedema occurs without any obvious cause; 3) to unmask patients at high risk of mortality and heart failure 4) before surgical revascularization in patients with moderate ischaemic MR and, 5) following surgery, to identify persistence of pulmonary hypertension and explain the absence of functional class improvement.
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Affiliation(s)
- Raluca Dulgheru
- Department of Cardiology, University Hospital, CHU Sart Tilman, Liège, Belgium
| | - Julien Magne
- Department of Cardiology, University Hospital, CHU Sart Tilman, Liège, Belgium
| | | | - Luc A Pierard
- Department of Cardiology, University Hospital, CHU Sart Tilman, Liège, Belgium
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Moraldo M, Cecaro F, Shun-Shin M, Pabari PA, Davies JE, Xu XY, Hughes AD, Manisty C, Francis DP. Evidence-based recommendations for PISA measurements in mitral regurgitation: systematic review, clinical and in-vitro study. Int J Cardiol 2012; 168:1220-8. [PMID: 23245796 PMCID: PMC3819991 DOI: 10.1016/j.ijcard.2012.11.059] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Revised: 09/06/2012] [Accepted: 11/11/2012] [Indexed: 11/05/2022]
Abstract
Background Guidelines for quantifying mitral regurgitation (MR) using “proximal isovelocity surface area” (PISA) instruct operators to measure the PISA radius from valve orifice to Doppler flow convergence “hemisphere”. Using clinical data and a physically-constructed MR model we (A) analyse the actually-observed colour Doppler PISA shape and (B) test whether instructions to measure a “hemisphere” are helpful. Methods and results In part A, the true shape of PISA shells was investigated using three separate approaches. First, a systematic review of published examples consistently showed non-hemispherical, “urchinoid” shapes. Second, our clinical data confirmed that the Doppler-visualized surface is non-hemispherical. Third, in-vitro experiments showed that round orifices never produce a colour Doppler hemisphere. In part B, six observers were instructed to measure hemisphere radius rh and (on a second viewing) urchinoid distance (du) in 11 clinical PISA datasets; 6 established experts also measured PISA distance as the gold standard. rh measurements, generated using the hemisphere instruction significantly underestimated expert values (− 28%, p < 0.0005), meaning rh2 was underestimated by approximately 2-fold. du measurements, generated using the non-hemisphere instruction were less biased (+ 7%, p = 0.03). Finally, frame-to-frame variability in PISA distance was found to have a coefficient of variation (CV) of 25% in patients and 9% in in-vitro data. Beat-to-beat variability had a CV of 15% in patients. Conclusions Doppler-visualized PISA shells are not hemispherical: we should avoid advising observers to measure a hemispherical radius because it encourages underestimation of orifice area by approximately two-fold. If precision is needed (e.g. to detect changes reliably) multi-frame averaging is essential.
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Affiliation(s)
- Michela Moraldo
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, 59-61 North Wharf Road, London W21LA, UK.
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Cagliyan CE, Davutoglu V, Sari I, Turkmen S, Ozer O, Tanboga IH, Tekin K, Balli M, Akilli RE, Aksoy M. Relation of Mitral Annular Dilation with Dynamic Mitral Regurgitation in Patients with Rheumatic Mitral Regurgitation. Echocardiography 2012; 29:1031-7. [DOI: 10.1111/j.1540-8175.2012.01765.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Balfanz G, Arora H, Sheridan BC, Katz JN, Kumar PA. Dynamic Mitral Regurgitation Without Regional Wall Motion Abnormality. J Cardiothorac Vasc Anesth 2012; 26:753-5. [DOI: 10.1053/j.jvca.2012.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Indexed: 11/11/2022]
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Szymanski C, Levine RA, Tribouilloy C, Zheng H, Handschumacher MD, Tawakol A, Hung J. Impact of mitral regurgitation on exercise capacity and clinical outcomes in patients with ischemic left ventricular dysfunction. Am J Cardiol 2011; 108:1714-20. [PMID: 21943932 DOI: 10.1016/j.amjcard.2011.07.045] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Revised: 07/12/2011] [Accepted: 07/12/2011] [Indexed: 10/17/2022]
Abstract
There is uncertainty and debate regarding whether ischemic mitral regurgitation (MR) is a secondary epiphenomenon resulting from left ventricular (LV) dysfunction or confers an independent effect on exercise capacity and outcomes. We tested whether ischemic MR negatively affects exercise capacity and cardiovascular morbidity and mortality in patients with coronary artery disease (CAD) and those with inferior wall motion abnormality independent of LV dysfunction. Clinical follow-up over 5 years was obtained in 77 patients (64 ± 10 years old, LV ejection fraction 54 ± 11%) with at least mild ischemic MR from CAD and evidence of inferior wall motion abnormality who had exercise stress testing with perfusion imaging within 24 hours of echocardiography. Patients with active heart failure, ischemia, intrinsic valve disease, pulmonary and vascular diseases were excluded. Exercise capacity (METs, peak double product) was tested for relation to MR (vena contracta [VC] and jet area), LV size and function, and pulmonary pressures. Cox proportional hazards analysis assessed whether MR predicted cardiovascular events including hospitalization for heart failure, acute coronary syndrome, and myocardial infarction and cardiovascular and total mortalities. Univariate correlation identified MR with VC (r = -0.674, p <0.0001) and MR jet area (r = -0.575, p <0.0001) as determinants of decreased functional capacity evaluated by METs, with VC the stronger predictor. MR VC >2 mm (moderate ischemic MR) and age were independent predictors of cardiovascular events and death (hazard ratio 6.72 for MR, p = 0.04). In conclusion, in patients with CAD and LV inferior wall motion abnormality, MR negatively affects exercise capacity and is associated with increased cardiovascular morbidity and mortality. This effect appears independent of degree of LV dysfunction.
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Kordybach M, Kowalski M, Kowalik E, Hoffman P. Papillary muscle dyssynchrony in patients with systolic left ventricular dysfunction. SCAND CARDIOVASC J 2011; 46:16-22. [PMID: 22035159 DOI: 10.3109/14017431.2011.636452] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Papillary muscles (PM) dyssynchrony is among the crucial mechanisms leading to mitral valve regurgitation (MR). The purpose of this study was to find a potential relationship between the level of PM asynchrony and the degree of MR in patients with ischemic and nonischemic cardiomyopathies (ICM and nICM, respectively). DESIGN Twenty-one ICM and ten nICM patients with EF ≤ 35% and sinus rhythm were enrolled in the study. The parameters describing the degree of MR and the deformation of mitral apparatus and PM function were obtained using standard echocardiography and tissue Doppler imaging, respectively. The difference of 65 ms and more in time to peak strain (ε) between anterolateral and postero-medial PM was considered indicative of PM dyssynchrony. RESULTS PM dyssynchrony correlated with mitral tenting area and left atrial area. The correlation between nICM PM dyssynchrony and nICM LAA was stronger and far exceeded the one observed for ICM patients. The relationship between the PM asynchrony and the remainder of the indices characterizing the degree of MR was weak. CONCLUSIONS PM dyssynchrony did not reflect the degree of MR but seems to be associated with the deformation of mitral apparatus measured by tenting area. The level of haemodynamic consequences of MR can be better characterized by PM dyssynchrony in nICM than in ICM patients.
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Affiliation(s)
- Maria Kordybach
- Department of Congenital Heart Disease in Adults, Institute of Cardiology, Alpejska, Warsaw, Poland.
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Agricola E, D’Amato R, Stella S, Oppizzi M, Slavich M, Ancona MB, Gullace M, Margonato A. Effects of Mild Ischemic Mitral Regurgitation on Ventricular Remodeling and Its Contribution to Congestive Heart Failure. J Am Soc Echocardiogr 2011; 24:1376-82. [DOI: 10.1016/j.echo.2011.09.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Indexed: 10/16/2022]
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Yared K, Lam KMT, Hung J. The use of exercise echocardiography in the evaluation of mitral regurgitation. Curr Cardiol Rev 2011; 5:312-22. [PMID: 21037848 PMCID: PMC2842963 DOI: 10.2174/157340309789317841] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2008] [Revised: 01/21/2009] [Accepted: 01/23/2009] [Indexed: 12/18/2022] Open
Abstract
Mitral regurgitation (MR) is the second most common valvular disease in western countries after aortic stenosis. Optimal management of patients with MR depends on the etiology of the regurgitation and is based predominantly on left ventricular function and functional status. Recent outcome studies report high risk subsets of asymptomatic patients with MR, and practice guidelines underscore the importance of a well-established estimation of exercise tolerance and recommend exercise testing to objectively assess functional status and hemodynamic factors.
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Affiliation(s)
- Kibar Yared
- Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Roşca M, Lancellotti P, Magne J, Piérard LA. Stress testing in valvular heart disease: clinical benefit of echocardiographic imaging. Expert Rev Cardiovasc Ther 2010; 9:81-92. [PMID: 21166530 DOI: 10.1586/erc.10.173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Symptom development represents one of the most important indications for surgical intervention in patients with significant valvular heart disease. Exercise testing has an established role in the assessment of exercise capacity and symptomatic status in patients with severe valvular heart disease who claim to be asymptomatic. In these patients, clinical decision can be influenced by the results of exercise testing. In addition to the assessment of symptomatic response to exercise, stress echocardiography can provide valuable information on exercise-induced changes in valve hemodynamics, ventricular function and pulmonary artery pressure. Abnormal left ventricular response to exercise, increase in pulmonary pressure or change in the hemodynamic severity of the valvular disease adds to the prognostic value of elicited symptoms. In this article we discuss the validated indications, proven prognostic values and potential influence on clinical decisions of stress echocardiography in left valvular heart diseases.
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Affiliation(s)
- Monica Roşca
- Department of Cardiology, University Hospital, CHU Sart Tilman, University of Liège, Liège, Belgium
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Piérard LA, Carabello BA. Ischaemic mitral regurgitation: pathophysiology, outcomes and the conundrum of treatment. Eur Heart J 2010; 31:2996-3005. [PMID: 21123277 DOI: 10.1093/eurheartj/ehq411] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Ischaemic mitral regurgitation is a frequent complication of left ventricular global or regional pathological remodelling due to chronic coronary artery disease. It is not a valve disease but represents the valvular consequences of increased tethering forces (papillary muscles displacement leading to a more apical position of the leaflets and their coaptation point) and reduced closing forces (reduced contractility, dyssynchrony of the papillary muscles, intra-left ventricular dyssynchrony). Although mitral regurgitation has an unloading effect and reduces impedance, the volume overload begets further left ventricular dilatation, increases ventricular wall stress leading to worsened performance. Ischaemic mitral regurgitation is characteristically dynamic: its severity may vary with haemodynamic conditions. Both the severity of ischaemic mitral regurgitation and its dynamic component worsen prognosis. There are numerous possible treatment modalities, but the management of the individual patient remains difficult. Medical therapy is mandatory; revascularization procedures are frequently not sufficient to reduce mitral regurgitation; the role of combined surgical therapy by mitral valve repair is not yet defined in the absence of large randomized trial. Some patients are good candidates for cardiac resynchronization therapy that may reduce the amount of regurgitation. New therapeutic targets are under investigation.
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Affiliation(s)
- Luc A Piérard
- Department of Cardiology, University Hospital Sart Tilman, University of Liège, B-4000, Liège, Belgium.
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Pecini R, Dalsgaard M, Møller DV, Jensen MS, Kofoed KF, Nielsen W, Nielsen OW, Høst N, Elming H, Goetze JP, Hassager C, Køber L. Moderate Exercise Does Not Increase the Severity of Mitral Regurgitation Due to Mitral Valve Prolapse. Echocardiography 2010; 27:1031-7. [DOI: 10.1111/j.1540-8175.2010.01200.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Lancellotti P, Moura L, Pierard LA, Agricola E, Popescu BA, Tribouilloy C, Hagendorff A, Monin JL, Badano L, Zamorano JL. European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 2: mitral and tricuspid regurgitation (native valve disease). EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2010; 11:307-32. [PMID: 20435783 DOI: 10.1093/ejechocard/jeq031] [Citation(s) in RCA: 928] [Impact Index Per Article: 66.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Mitral and tricuspid are increasingly prevalent. Doppler echocardiography not only detects the presence of regurgitation but also permits to understand mechanisms of regurgitation, quantification of its severity and repercussions. The present document aims to provide standards for the assessment of mitral and tricuspid regurgitation.
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Affiliation(s)
- Patrizio Lancellotti
- Department of Cardiology, Valvular Disease Clinic, University Hospital, Université de Liège, CHU du Sart Tilman, 4000 Liège, Belgium.
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Goldberg SL, Siminiak T. Prospects for the percutaneous repair of the mitral valve. Interv Cardiol 2010. [DOI: 10.2217/ica.10.54] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Magne J, Lancellotti P, Piérard LA. Exercise Pulmonary Hypertension in Asymptomatic Degenerative Mitral Regurgitation. Circulation 2010; 122:33-41. [DOI: 10.1161/circulationaha.110.938241] [Citation(s) in RCA: 195] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Current guidelines recommend mitral valve surgery for asymptomatic patients with severe degenerative mitral regurgitation and preserved left ventricular systolic function when exercise pulmonary hypertension (PHT) is present. However, the determinants of exercise PHT have not been evaluated. The aim of this study was to identify the echocardiographic predictors of exercise PHT and the impact on symptoms.
Methods and Results—
Comprehensive resting and exercise transthoracic echocardiography was performed in 78 consecutive patients (age, 61±13 years; 56% men) with at least moderate degenerative mitral regurgitation (effective regurgitant orifice area =43±20 mm
2
; regurgitant volume =71±27 mL). Exercise PHT was defined as a systolic pulmonary arterial pressure (SPAP) >60 mm Hg. Exercise PHT was present in 46% patients. In multivariable analysis, exercise effective regurgitant orifice was an independent determinant of exercise SPAP (
P
<0.0001) and exercise PHT (
P
=0.002). Resting PHT and exercise PHT were associated with markedly reduced 2-year symptom-free survival (36±14% versus 59±7%,
P
=0.04; 35±8% versus 75±7%,
P
<0.0001). After adjustment, although the impact of resting PHT was no longer significant, exercise PHT was identified as an independent predictor of the occurrence of symptoms (hazard ratio=3.4;
P
=0.002). Receiver-operating characteristics curves revealed that exercise PHT (SPAP >56 mm Hg) was more accurate than resting PHT (SPAP >36 mm Hg) in predicting the occurrence of symptoms during follow-up (
P
=0.032).
Conclusions—
Exercise PHT is frequent in patients with asymptomatic degenerative mitral regurgitation. Exercise mitral regurgitation severity is a strong independent predictor of both exercise SPAP and exercise PHT. Exercise PHT is associated with markedly low 2-year symptom-free survival, emphasizing the use of exercise echocardiography. An exercise SPAP >56 mm Hg accurately predicts the occurrence of symptoms.
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Affiliation(s)
- Julien Magne
- From the Department of Cardiology, Heart Valve Disease Clinic, University Hospital Sart Tilman, University of Liège, Liège, Belgium
| | - Patrizio Lancellotti
- From the Department of Cardiology, Heart Valve Disease Clinic, University Hospital Sart Tilman, University of Liège, Liège, Belgium
| | - Luc A. Piérard
- From the Department of Cardiology, Heart Valve Disease Clinic, University Hospital Sart Tilman, University of Liège, Liège, Belgium
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Magne J, Lancellotti P, Piérard LA. Exercise-Induced Changes in Degenerative Mitral Regurgitation. J Am Coll Cardiol 2010; 56:300-9. [DOI: 10.1016/j.jacc.2009.12.073] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2009] [Revised: 12/08/2009] [Accepted: 12/23/2009] [Indexed: 10/19/2022]
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Abstract
REASONS FOR PERFORMING STUDY Although valvular regurgitation is diagnosed frequently by colour Doppler echocardiography in racehorses at rest, there is currently no information about the effect of exercise on valvular regurgitation. OBJECTIVES To investigate the effect of light exercise on valvular regurgitation in a population of trotters. METHODS Standardbred trotters (n = 73) were examined by resting auscultation and echocardiography, of which 50 fullfilled the criteria of the study. Of these, 4 had reduced performance according to the trainers and were not included in the statistical analyses. Horses that showed valvular regurgitations diagnosed by colour Doppler echocardiography at rest, were light exercised and the regurgitant valves were then re-examined by colour Doppler echocardiography. RESULTS Of the 46 horses, 41 (89%) had one or more valvular regurgitations at rest with tricuspid regurgitation present in 83% of horses, mitral regurgitation 46%, pulmonary regurgitation 37% and aortic regurgitation 57%. After exercise, one or more valvular regurgitation persisted for 23 of the 41 horses (56%). The regurgitation decreased significantly for mitral, pulmonary and aortic valves; the mitral regurgitation persisted for 21% of the horses, pulmonary regurgitation persisted for 6% and aortic regurgitation persisted after exercise for 23 % with regurgitation diagnosed at rest. Half of those with tricuspid regurgitation at rest still had tricuspid regurgitation after exercise. CONCLUSIONS The results of this study showed that the majority of small valvular regurgitations disappear after light exercise. However, the severity of tricuspid regurgitation increased in 4 horses. Furthermore, these horses were not performing satisfactorily according to the trainers. POTENTIAL RELEVANCE Studies in man have shown that severity after exercise suggests pathological regurgitation. The present study indicates that echocardiographic examination of valvular regurgitation after exercise might be a relevant examination in horses. However, more studies are needed to evaluate the effect of strenuous exercise on valvular regurgitation in horses.
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Affiliation(s)
- R Buhl
- Department of Large Animal Sciences, The Royal Veterinary andAgricultural University, 48 Dyrlaegevej, DK- 1870 Frederiksberg C, Denmark
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45
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Lancellotti P, Tribouilloy C, Hagendorff A, Moura L, Popescu BA, Agricola E, Monin JL, Pierard LA, Badano L, Zamorano JL. European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 1: aortic and pulmonary regurgitation (native valve disease). EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2010; 11:223-44. [PMID: 20375260 DOI: 10.1093/ejechocard/jeq030] [Citation(s) in RCA: 360] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Patrizio Lancellotti
- Department of Cardiology, Valvular Disease Clinic, University Hospital, Université de Liège, CHU du Sart Tilman, 4000 Liège, Belgium.
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46
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Pecini R, Hammer-Hansen S, Dalsgaard M, Gøtze JP, Hassager C, Køber L. Determinants of Exercise-Induced Increase of Mitral Regurgitation in Patients with Acute Coronary Syndromes. Echocardiography 2010; 27:567-74. [DOI: 10.1111/j.1540-8175.2009.01077.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Abstract
Flash pulmonary edema (FPE) is a general clinical term used to describe a particularly dramatic form of acute decompensated heart failure. Well-established risk factors for heart failure such as hypertension, coronary ischemia, valvular heart disease, and diastolic dysfunction are associated with acute decompensated heart failure as well as with FPE. However, endothelial dysfunction possibly secondary to an excessive activity of renin-angiotensin-aldosterone system, impaired nitric oxide synthesis, increased endothelin levels, and/or excessive circulating catecholamines may cause excessive pulmonary capillary permeability and facilitate FPE formation. Renal artery stenosis particularly when bilateral has been identified has a common cause of FPE. Lack of diurnal variation in blood pressure and a widened pulse pressure have been identified as risk factors for FPE. This review is an attempt to delineate clinical and pathophysiological mechanisms responsible for FPE and to distinguish pathophysiologic, clinical, and therapeutic aspects of FPE from those of acute decompensated heart failure.
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Affiliation(s)
- Stefano F Rimoldi
- Swiss Cardiovascular Center Bern, University Hospital, Bern, Switzerland.
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48
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Buhl R. Valvular regurgitations in the horse: the importance of an exercise ECG. Vet J 2009; 183:117-8. [PMID: 20036587 DOI: 10.1016/j.tvjl.2009.06.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2009] [Accepted: 06/19/2009] [Indexed: 11/25/2022]
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49
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Bigi R, Cortigiani L, Bovenzi F, Fiorentini C. Assessing functional mitral regurgitation with exercise echocardiography: rationale and clinical applications. Cardiovasc Ultrasound 2009; 7:57. [PMID: 20003417 PMCID: PMC2797765 DOI: 10.1186/1476-7120-7-57] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2009] [Accepted: 12/14/2009] [Indexed: 11/10/2022] Open
Abstract
Secondary or functional mitral regurgitation (FMR) represents an increasing feature of mitral valve disease characterized by abnormal function of anatomically normal leaflets in the context of the impaired function of remodelled left ventricles. The anatomic and pathophysiological basis of FMR are briefly analyzed; in addition, the role of exercise echocardiography for the assessment of FMR is discussed in view of its relevance to clinical practice.
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Affiliation(s)
- Riccardo Bigi
- Dipartimento di Scienze Cardiovascolari, Università degli Studi, Milano, Italy.
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50
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Percutaneous mitral annuloplasty device leaves free access to cardiac veins for resynchronization therapy. Catheter Cardiovasc Interv 2009; 74:506-11. [DOI: 10.1002/ccd.22097] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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