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Mentias A, Desai MY. Markers of increased risk in primary mitral regurgitation. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:338. [PMID: 28861435 DOI: 10.21037/atm.2017.04.08] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Amgad Mentias
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Milind Y Desai
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
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Mentias A, Naji P, Gillinov AM, Rodriguez LL, Reed G, Mihaljevic T, Suri RM, Sabik JF, Svensson LG, Grimm RA, Griffin BP, Desai MY. Strain Echocardiography and Functional Capacity in Asymptomatic Primary Mitral Regurgitation With Preserved Ejection Fraction. J Am Coll Cardiol 2016; 68:1974-1986. [DOI: 10.1016/j.jacc.2016.08.030] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 07/22/2016] [Accepted: 08/01/2016] [Indexed: 11/26/2022]
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Smith AAH, Newman RV, Thompson PA, Farkas SI, Wynne J. Mitral Valve Repair Outcomes in a Community Hospital: A Retrospective Analysis. Heart Lung Circ 2015; 25:499-504. [PMID: 26777857 DOI: 10.1016/j.hlc.2015.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 10/05/2015] [Accepted: 10/19/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND The results of mitral valve repair operations conducted at community hospitals in rural states are not well studied or reported in the literature. METHODS We retrospectively assessed consecutive patients who underwent isolated mitral valve repair operations performed by a single experienced cardiothoracic surgeon at a large community hospital from May 1, 2006 - April 30, 2010. Patients were monitored for up to three years (average 2.2 years) following surgery for a variety of surgical variables, including morbidity, mortality, and serial two-dimensional transthoracic echocardiographic findings. Comparisons were made with the Society of Thoracic Surgeons Adult Cardiac Surgery Database (ACSD). RESULTS Sixty-three consecutive patients underwent isolated complex mitral repair operations. Echocardiographic and morbidity data demonstrated successful outcomes, with no operative mortality and a single cardiac-related death within three years postoperatively. Other variables, especially those that relate to post-repair outcomes, showed no significant differences between our patients and comparison data from the ASCD. CONCLUSIONS Our study demonstrates equivalent risks and outcomes for complex mitral valve repair performed in a community hospital setting as those found in a national database. The appropriate institutional setting for performing highly complex procedures has substantial implications for health policy, especially regarding access and quality issues.
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Affiliation(s)
- Aaron A H Smith
- University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota, USA.
| | - Roxanne V Newman
- University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota, USA; Department of Cardiothoracic Surgery, Sanford Health, Fargo, North Dakota, USA
| | - Paul A Thompson
- Department of Research, Sanford Health, Sioux Falls, South Dakota, USA
| | - Susan I Farkas
- University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota, USA; Department of Cardiology, Sanford Health, Fargo, North Dakota, USA
| | - Joshua Wynne
- University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota, USA; Department of Cardiology, Sanford Health, Fargo, North Dakota, USA
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Naji P, Asfahan F, Barr T, Rodriguez LL, Grimm RA, Agarwal S, Thomas JD, Gillinov AM, Mihaljevic T, Griffin BP, Desai MY. Impact of duration of mitral regurgitation on outcomes in asymptomatic patients with myxomatous mitral valve undergoing exercise stress echocardiography. J Am Heart Assoc 2015; 4:jah3819. [PMID: 25672368 PMCID: PMC4345867 DOI: 10.1161/jaha.114.001348] [Citation(s) in RCA: 7] [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] [Indexed: 11/16/2022]
Abstract
Background Significant mitral regurgitation (MR) typically occurs as holosystolic (HS) or mid‐late systolic (MLS), with differences in volumetric impact on the left ventricle (LV). We sought to assess outcomes of degenerative MR patients undergoing exercise echocardiography, separated based on MR duration (MLS versus HS). Methods and Results We included 609 consecutive patients with ≥III+myxomatous MR undergoing exercise echocardiography: HS (n=487) and MLS (n=122). MLS MR was defined as delayed appearance of MR signal during mid‐late systole on continuous‐wave Doppler while HS MR occurred throughout systole. Composite events of death and congestive heart failure were recorded. Compared to MLS MR, HS MR patients were older (60±14 versus 53±14 years), more were males (72% versus 53%), and had greater prevalence of atrial fibrillation (16% versus 7%; all P<0.01). HS MR patients had higher right ventricular systolic pressure (RVSP) at rest (33±11 versus 27±9 mm Hg), more flail leaflets (36% versus 6%), and a lower number of metabolic equivalents (METs) achieved (9.5±3 versus 10.5±3), compared to the MLS MR group (all P<0.05). There were 54 events during 7.1±3 years of follow‐up. On step‐wise multivariable analysis, HS versus MLS MR (HR 4.99 [1.21 to 20.14]), higher LV ejection fraction (hazard ratio [HR], 0.94 [0.89 to 0.98]), atrial fibrillation (HR, 2.59 [1.33 to 5.11]), higher RVSP (HR, 1.05 [1.03 to 1.09]), and higher percentage of age‐ and gender‐predicted METs (HR, 0.98 [0.97 to 0.99]) were independently associated with adverse outcomes (all P<0.05). Conclusion In patients with ≥III+myxomatous MR undergoing exercise echocardiography, holosystolic MR is associated with adverse outcomes, independent of other predictors.
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Affiliation(s)
- Peyman Naji
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (P.N., F.A., T.B., L.R., R.A.G., S.A., J.D.T., M.G., T.M., B.P.G., M.Y.D.)
| | - Fadi Asfahan
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (P.N., F.A., T.B., L.R., R.A.G., S.A., J.D.T., M.G., T.M., B.P.G., M.Y.D.)
| | - Tyler Barr
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (P.N., F.A., T.B., L.R., R.A.G., S.A., J.D.T., M.G., T.M., B.P.G., M.Y.D.)
| | - L Leonardo Rodriguez
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (P.N., F.A., T.B., L.R., R.A.G., S.A., J.D.T., M.G., T.M., B.P.G., M.Y.D.)
| | - Richard A Grimm
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (P.N., F.A., T.B., L.R., R.A.G., S.A., J.D.T., M.G., T.M., B.P.G., M.Y.D.)
| | - Shikhar Agarwal
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (P.N., F.A., T.B., L.R., R.A.G., S.A., J.D.T., M.G., T.M., B.P.G., M.Y.D.)
| | - James D Thomas
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (P.N., F.A., T.B., L.R., R.A.G., S.A., J.D.T., M.G., T.M., B.P.G., M.Y.D.)
| | - A Marc Gillinov
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (P.N., F.A., T.B., L.R., R.A.G., S.A., J.D.T., M.G., T.M., B.P.G., M.Y.D.)
| | - Tomislav Mihaljevic
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (P.N., F.A., T.B., L.R., R.A.G., S.A., J.D.T., M.G., T.M., B.P.G., M.Y.D.)
| | - Brian P Griffin
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (P.N., F.A., T.B., L.R., R.A.G., S.A., J.D.T., M.G., T.M., B.P.G., M.Y.D.)
| | - Milind Y Desai
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (P.N., F.A., T.B., L.R., R.A.G., S.A., J.D.T., M.G., T.M., B.P.G., M.Y.D.)
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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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Quintana E, Suri RM, Thalji NM, Daly RC, Dearani JA, Burkhart HM, Li Z, Enriquez-Sarano M, Schaff HV. Left ventricular dysfunction after mitral valve repair—the fallacy of “normal” preoperative myocardial function. J Thorac Cardiovasc Surg 2014; 148:2752-60. [DOI: 10.1016/j.jtcvs.2014.07.029] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 06/26/2014] [Accepted: 07/05/2014] [Indexed: 11/29/2022]
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Naji P, Griffin BP, Barr T, Asfahan F, Gillinov AM, Grimm RA, Rodriguez LL, Mihaljevic T, Stewart WJ, Desai MY. Importance of exercise capacity in predicting outcomes and determining optimal timing of surgery in significant primary mitral regurgitation. J Am Heart Assoc 2014; 3:e001010. [PMID: 25213567 PMCID: PMC4323806 DOI: 10.1161/jaha.114.001010] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In primary mitral regurgitation (MR), exercise echocardiography aids in symptom evaluation and timing of mitral valve (MV) surgery. In patients with grade ≥3 primary MR undergoing exercise echocardiography followed by MV surgery, we sought to assess predictors of outcomes and whether delaying MV surgery adversely affects outcomes. METHODS AND RESULTS We studied 576 consecutive such patients (aged 57±13 years, 70% men, excluding prior valve surgery and functional MR). Clinical, echocardiographic (MR, LVEF, indexed LV dimensions, RV systolic pressure) and exercise data (metabolic equivalents) were recorded. Composite events of death, MI, stroke, and congestive heart failure were recorded. Mean LVEF was 58±5%, indexed LV end-systolic dimension was 1.7±0.5 mm/m(2), rest RV systolic pressure was 32±13 mm Hg, peak-stress RV systolic pressure was 47±17 mm Hg, and percentage of age- and gender-predicted metabolic equivalents was 113±27. Median time between exercise and MV surgery was 3 months (MV surgery delayed ≥1 year in 28%). At 6.6±4 years, there were 53 events (no deaths at 30 days). On stepwise multivariable survival analysis, increasing age (hazard ratio of 1.07 [95% confidence interval, 1.03 to 1.12], P<0.01), lower percentage of age- and gender-predicted metabolic equivalents (hazard ratio of 0.82 [95% confidence interval, 0.71 to 0.94], P=0.007), and lower LVEF (0.94 [0.89 to 0.99], P=0.04) independently predicted outcomes. In patients achieving >100% predicted metabolic equivalents (n=399), delaying surgery by ≥1 year (median of 28 months) did not adversely affect outcomes (P=0.8). CONCLUSION In patients with primary MR that underwent exercise echocardiography followed by MV surgery, lower achieved metabolic equivalents were associated with worse long-term outcomes. In those with preserved exercise capacity, delaying MV surgery by ≥1 year did not adversely affect outcomes.
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Affiliation(s)
- Peyman Naji
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (P.N., B.P.G., T.B., F.A., M.G., R.A.G., L.R., T.M., W.J.S., M.Y.D.)
| | - Brian P Griffin
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (P.N., B.P.G., T.B., F.A., M.G., R.A.G., L.R., T.M., W.J.S., M.Y.D.)
| | - Tyler Barr
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (P.N., B.P.G., T.B., F.A., M.G., R.A.G., L.R., T.M., W.J.S., M.Y.D.)
| | - Fadi Asfahan
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (P.N., B.P.G., T.B., F.A., M.G., R.A.G., L.R., T.M., W.J.S., M.Y.D.)
| | - A Marc Gillinov
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (P.N., B.P.G., T.B., F.A., M.G., R.A.G., L.R., T.M., W.J.S., M.Y.D.)
| | - Richard A Grimm
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (P.N., B.P.G., T.B., F.A., M.G., R.A.G., L.R., T.M., W.J.S., M.Y.D.)
| | - L Leonardo Rodriguez
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (P.N., B.P.G., T.B., F.A., M.G., R.A.G., L.R., T.M., W.J.S., M.Y.D.)
| | - Tomislav Mihaljevic
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (P.N., B.P.G., T.B., F.A., M.G., R.A.G., L.R., T.M., W.J.S., M.Y.D.)
| | - William J Stewart
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (P.N., B.P.G., T.B., F.A., M.G., R.A.G., L.R., T.M., W.J.S., M.Y.D.)
| | - Milind Y Desai
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (P.N., B.P.G., T.B., F.A., M.G., R.A.G., L.R., T.M., W.J.S., M.Y.D.)
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Maniar HS, Brady BD, Lee U, Cupps BP, Kar J, Wallace KM, Pasque MK. Early left ventricular regional contractile impairment in chronic mitral regurgitation occurs in a consistent, heterogeneous pattern. J Thorac Cardiovasc Surg 2014; 148:1694-9. [PMID: 25260278 DOI: 10.1016/j.jtcvs.2014.05.088] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 05/08/2014] [Accepted: 05/23/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The clinical guidelines for asymptomatic patients with chronic mitral regurgitation (MR) use the ejection fraction (EF) to trigger surgical referral. We hypothesized that the EF is not sensitive enough to detect the earliest contractile injury in chronic MR and that the injury associated with chronic MR is not global but heterogeneous, occurring regionally and predictably, before the onset of global left ventricular (LV) dysfunction. METHODS Fifteen patients with chronic MR and normal LVEF by echocardiography underwent cardiac magnetic resonance imaging with tissue tagging. Point-specific comparisons (at 15,300 LV grid points) of multiple strain parameters to a normal human strain database allowed normalization of patient-specific regional contractile function. Data were mapped over patient-specific 3-dimensional geometry and averaged across 6 LV regions. RESULTS Global LV longitudinal and circumferential myocardial strains were normal for all 15 patients with MR compared with normal controls (P>.05). Despite preserved global function, the anteroseptum and posteroseptum demonstrated significantly worse contractile function compared with other LV regions (P=.003 and P=.035, respectively). Hypercontractile regions (lateral walls) appeared to compensate (P=.002) for the reduced septal contractile function, masking injury detection by global indexes. CONCLUSIONS The earliest contractile injury seen in patients with MR is heterogeneous and consistently distributed along the LV septum. Compensatory responses include hypercontractility of other regions. These data suggest that rather than relying on global LV contractile metrics, which cannot detect early injury, patients might be better served by undergoing directed surveillance of "sentinel" LV regions (LV septum) with high-resolution metrics of regional contractile function.
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Affiliation(s)
- Hersh S Maniar
- Department of Surgery, Washington University School of Medicine, St Louis, Mo.
| | - Beckah D Brady
- Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Urvi Lee
- Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Brian P Cupps
- Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Julia Kar
- Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Kathleen M Wallace
- Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Michael K Pasque
- Department of Surgery, Washington University School of Medicine, St Louis, Mo
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Bellitti R, Petrone G, Buonocore M, Nappi G, Santé P. Anatomic Reconstruction in Degenerative Mitral Valve Bileaflet Prolapse: Long-Term Results. Ann Thorac Surg 2014; 97:563-8. [DOI: 10.1016/j.athoracsur.2013.08.061] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Revised: 08/26/2013] [Accepted: 08/27/2013] [Indexed: 11/26/2022]
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Predictive Value of Global Longitudinal Strain in a Surgical Population of Organic Mitral Regurgitation. J Am Soc Echocardiogr 2012; 25:766-72. [DOI: 10.1016/j.echo.2012.04.009] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2011] [Indexed: 12/28/2022]
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Affiliation(s)
- T. Sloane Guy
- Department of Surgery, Temple University, Philadelphia, Pennsylvania 19140;
| | - Arthur C. Hill
- University of California, San Francisco, California 94143;
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Ghoreishi M, Evans CF, DeFilippi CR, Hobbs G, Young CA, Griffith BP, Gammie JS. Pulmonary hypertension adversely affects short- and long-term survival after mitral valve operation for mitral regurgitation: Implications for timing of surgery. J Thorac Cardiovasc Surg 2011; 142:1439-52. [DOI: 10.1016/j.jtcvs.2011.08.030] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2011] [Revised: 08/03/2011] [Accepted: 08/25/2011] [Indexed: 10/17/2022]
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Castillo JG, Solís J, González-Pinto Á, Adams DH. Ecocardiografía quirúrgica de la válvula mitral. Rev Esp Cardiol 2011; 64:1169-81. [DOI: 10.1016/j.recesp.2011.06.025] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2011] [Accepted: 06/30/2011] [Indexed: 11/24/2022]
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