1
|
Duz R, Cibuk S. Severity of Mitral Valve Stenosis - Possible Relationships With Blood Oxidant Markers and Antioxidants. Circ J 2024; 88:597-605. [PMID: 36858609 DOI: 10.1253/circj.cj-22-0750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
BACKGROUND This study examined whether the severity of mitral valve stenosis (MVS) is associated with oxidative stress (OS) markers in the blood, and other hematological and clinicodemographic parameters.Methods and Results: This prospective study was conducted between March and May 2022. Seventy-five patients with newly diagnosed MVS (25 mild, 25 moderate, 25 severe) were included. Mild, moderate, and severe MVS was defined as MV area >2, 1.5-2, and <1.5 cm2, respectively. Various OS markers and laboratory parameters were determined in venous blood samples. For predictive analyses, 2 different analyses were performed to detect patients with severe MVS and those with moderate or severe (moderate/severe) MVS. Age (P=0.388) and sex (P=0.372) distribution were similar in the 3 groups. Multiple logistic regression analysis revealed that a high white blood cell (WBC) count (P=0.023) and high malondialdehyde (P=0.010), superoxide dismutase (SOD; P=0.008), and advanced oxidation protein products (AOPP; P=0.007) levels were independently associated with severe MVS. A low platelet count (P=0.030) and high malondialdehyde (P=0.018), SOD (P=0.008), and AOPP (P=0.001) levels were independently associated with having moderate/severe MVS. The best discriminatory factors for severe MVS were SOD (cut-off >315.5 ng/mL) and glutathione (cut-off >4.7 μmol/L). CONCLUSIONS MVS severity seems to be affected by oxidant markers (malondialdehyde and AOPP), antioxidant enzymes (SOD), and inflammation-related cells (WBC and platelets). Future studies are needed to examine these relationships in larger populations.
Collapse
Affiliation(s)
- Ramazan Duz
- Department of Cardiology, Yuzuncu Yil University Faculty of Medicine
| | - Salih Cibuk
- Van Vocational Higher School of Healthcare Studies, Van Yuzuncu Yil University
| |
Collapse
|
2
|
Rumman RK, Verma S, Chan V, Mazer D, Quan A, Hibino M, De Varennes B, Chu MWA, Latter D, Teoh H, Yanagawa B, Leong-Poi H, Connelly KA. Predictors of mitral valve haemodynamics after mitral valve repair for degenerative mitral regurgitation. Heart 2023; 109:866-873. [PMID: 36750353 DOI: 10.1136/heartjnl-2022-321753] [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: 08/08/2022] [Accepted: 12/26/2022] [Indexed: 02/09/2023] Open
Abstract
OBJECTIVE Intraoperative predictors of functional mitral valve (MV) stenosis after surgical repair of mitral regurgitation (MR) caused by prolapse remain poorly characterised. This study evaluated the effect of annuloplasty size on postoperative MV haemodynamics during exercise and evaluated predictors of MV hemodynamics. METHODS 104 patients were randomly assigned to leaflet resection or preservation for surgical repair of MR in the Canadian Mitral Research Alliance CardioLink-2 study. In this post hoc analysis, we compared MV haemodynamics between the two surgical groups and examined the relationship between annuloplasty size and MV haemodynamics 1 year after repair in the combined groups. Echocardiograms were performed at baseline and intraoperatively. Exercise transthoracic echocardiography was performed 1 year postoperatively. Multivariable linear regression analysis was used to identify predictors of exercise MV gradients at follow-up. RESULTS Mean age of participants was 65±10 years, and 83% were male. Median annuloplasty size was 34 (IQR 32-36). Dividing by the median, 48 (46%) had annuloplasty size of <34 mm and 56 (54%) had ≥34 mm. Mean and peak exercise gradients at 1 year were 11±5 mm Hg and 22±9 mm Hg in <34, and 6±3 mm Hg and 14±5 mm Hg in ≥34 (p<0.001). Rate of residual MR was similar in both groups. In multivariable analyses, annuloplasty size of ≥34 mm was associated with lower mean and peak exercise gradients at 12 months, after adjustment for repair type, age, sex, heart rate and body surface area (β -4.1, 95% CI -6 to -3, p<0.001, and β -7 95% CI -10 to -4, p<0.001, respectively). Intraoperative mean and peak MV gradients by transesophageal echocardiography independently predicted mean and peak resting and exercise gradients at follow-up (p<0.001). Similar results were obtained in both leaflet resection and preservation. CONCLUSION Annuloplasty size of ≥34 mm is associated with a 4 and 7 mm Hg reduction in mean and peak exercise MV gradients, respectively, 1 year post MV repair regardless of the repair strategy used. Intraoperative TEE MV gradients predict exercise MV gradients 1 year post repair. TRIAL REGISTRATION NUMBER NCT02552771.
Collapse
Affiliation(s)
- Rawan K Rumman
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Cardiology, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada
| | - Subodh Verma
- Division of Cardiac Surgery, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Department of Pharmacology & Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Vincent Chan
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - David Mazer
- Department of Anesthesia, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Adrian Quan
- Division of Cardiac Surgery, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada
| | - Makoto Hibino
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Benoit De Varennes
- Division of Cardiac Surgery, Royal Victoria Hospital, McGill University Health Center, Montreal, Québec, Canada
| | - Michael W A Chu
- Division of Cardiac Surgery, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - David Latter
- Division of Cardiac Surgery, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Hwee Teoh
- Division of Cardiac Surgery, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada.,Division of Endocrinology and Metabolism, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada
| | - Bobby Yanagawa
- Division of Cardiac Surgery, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Department of Pharmacology & Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Howard Leong-Poi
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Cardiology, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada
| | - Kim A Connelly
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada .,Division of Cardiology, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada
| |
Collapse
|
3
|
MicroRNAs in Valvular Heart Diseases: Biological Regulators, Prognostic Markers and Therapeutical Targets. Int J Mol Sci 2021; 22:ijms222212132. [PMID: 34830016 PMCID: PMC8618095 DOI: 10.3390/ijms222212132] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 11/04/2021] [Accepted: 11/08/2021] [Indexed: 12/14/2022] Open
Abstract
miRNAs have recently attracted investigators’ interest as regulators of valvular diseases pathogenesis, diagnostic biomarkers, and therapeutical targets. Evidence from in-vivo and in-vitro studies demonstrated stimulatory or inhibitory roles in mitral valve prolapse development, aortic leaflet fusion, and calcification pathways, specifically osteoblastic differentiation and transcription factors modulation. Tissue expression assessment and comparison between physiological and pathological phenotypes of different disease entities, including mitral valve prolapse and mitral chordae tendineae rupture, emerged as the best strategies to address miRNAs over or under-representation and thus, their impact on pathogeneses. In this review, we discuss the fundamental intra- and intercellular signals regulated by miRNAs leading to defects in mitral and aortic valves, congenital heart diseases, and the possible therapeutic strategies targeting them. These miRNAs inhibitors are comprised of antisense oligonucleotides and sponge vectors. The miRNA mimics, miRNA expression vectors, and small molecules are instead possible practical strategies to increase specific miRNA activity. Advantages and technical limitations of these new drugs, including instability and complex pharmacokinetics, are also presented. Novel delivery strategies, such as nanoparticles and liposomes, are described to improve knowledge on future personalized treatment directions.
Collapse
|
4
|
Verma S, Latter DA, Bonow RO. Failed Mitral TEER: Are There Lessons for Decision Making? J Am Coll Cardiol 2021; 78:10-13. [PMID: 34059390 DOI: 10.1016/j.jacc.2021.04.086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 04/29/2021] [Indexed: 01/30/2023]
Affiliation(s)
- Subodh Verma
- Division of Cardiac Surgery, St. Michael's Hospital of Unity Health Toronto, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada.
| | - David A Latter
- Division of Cardiac Surgery, St. Michael's Hospital of Unity Health Toronto, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Robert O Bonow
- Division of Cardiology, Bluhm Cardiovascular Institute, Chicago, Illinois, USA; Department of Medicine, Northwestern University, Chicago, Illinois, USA
| |
Collapse
|
5
|
Abstract
PURPOSE OF REVIEW Mitral valve repair surgery has recently shifted from resection-based techniques to leaflet sparing approaches using synthetic neochordae. This has facilitated the growth of a new strategy of transapical off-pump mitral valve intervention with neochord implantation. RECENT FINDINGS Minimally invasive approaches for mitral valve repair with robotic or video-assisted mini-right anterolateral thoracotomy have been developed to mitigate the morbidity associated with conventional median sternotomy. Recently, an alternative, less invasive surgical strategy has emerged. This transapical off-pump technique employs the NeoChord DS1000 (NeoChord, Inc., Minneapolis, MN, USA) system to achieve repair with neochordae via a left minithoracotomy incision. With appropriate patient selection, advanced cardiac imaging, and training in device deployment are important for procedural success. SUMMARY Early results suggest that transapical off-pump mitral valve intervention with NeoChord implantation is a safe procedure with favorable outcomes for select patients with degenerative mitral regurgitation. Continued experience and clinical trials will assess the potential of this minimally invasive strategy, but this technique is likely to become part of the surgical repertoire for managing chronic degenerative mitral valve disease.
Collapse
|
6
|
Wazaren H, Bouhdadi H, El Boussaadani B, Rhissassi J, Sayah R, Laaroussi M. Use of neocords in the treatment of mitral valve prolapse: about 6 cases. Int J Surg Case Rep 2021; 80:105693. [PMID: 33667914 PMCID: PMC7933733 DOI: 10.1016/j.ijscr.2021.105693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 02/18/2021] [Accepted: 02/20/2021] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION AND IMPORTANCE Mitral insufficiency is a common valve disease with a prevalence of 2% and increases after the age of 65. This is the second valvulopathy operated after aortic stenosis. The surgical management of mitral insufficiency has been completely changed in recent years. The mitral valvular replacement with was the gold standard; is currently preceded by conservative surgery thanks to the emergence of reproducible and durable surgical techniques. The aim of our study is to highlight the place of Neogortex in the treatment of mitral valvular prolapse. METHODS This is a retrospective study that includes 6 adult patients operated on for mitral insufficiency by prolapse of the large valve between October 2016 and June 2018 in the Cardiovascular Surgery Department A of the Ibn Sina Hospital in Rabat, Morocco. RESULTS We collected 6 patients. The average age is 56 years. The clinical presentation was made of dyspnea in the 6 patients. On the echocardiographic level, all patients had mitral insufficiency due to prolapse of the large mitral valve in 2 patients and a restriction of the play of the valve by shortening of the ropes in 2 patients. The 6 patients were operated. The technique was the installation of a prosthetic ring with neogortex fixation between the free edge and the abutment and a tricuspid plasty type Devega. The operative sequences were simple. CONCLUSION Mitral valve repair gives satisfactory results in terms of survival and symptomatic improvement with a low operative risk.
Collapse
Affiliation(s)
- Hicham Wazaren
- Department of Cardiovascular Surgery A of Ibn Sina University Hospital Center, Mohammed V University of Rabat, Morocco.
| | - Hanae Bouhdadi
- Department of Cardiovascular Surgery A of Ibn Sina University Hospital Center, Mohammed V University of Rabat, Morocco.
| | - Badre El Boussaadani
- Department of Cardiology B of Ibn Sina University Hospital Center, Mohammed V University of Rabat, Morocco.
| | - Jaafar Rhissassi
- Cardiovascular Surgery A Department of Ibn Sina University Hospital Center, Mohammed V University of Rabat, Morocco.
| | - Rochde Sayah
- Cardiovascular Surgery A Department of Ibn Sina University Hospital Center, Mohammed V University of Rabat, Morocco.
| | - Mohammed Laaroussi
- Cardiovascular Surgery A Department of Ibn Sina University Hospital Center, Mohammed V University of Rabat, Morocco.
| |
Collapse
|
7
|
Chan V, Mazer CD, Ali FM, Quan A, Ruel M, de Varennes BE, Gregory AJ, Bouchard D, Whitlock RP, Chu MW, Dokollari A, Mesana T, Bhatt DL, Latter DA, Zuo F, Tsang W, Teoh H, Jüni P, Leong-Poi H, Verma S. Randomized, Controlled Trial Comparing Mitral Valve Repair With Leaflet Resection Versus Leaflet Preservation on Functional Mitral Stenosis. Circulation 2020; 142:1342-1350. [DOI: 10.1161/circulationaha.120.046853] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Equipoise exists between the use of leaflet resection and preservation for surgical repair of mitral regurgitation caused by prolapse. We therefore performed a randomized, controlled trial comparing these 2 techniques, particularly in regard to functional mitral stenosis.
Methods:
One hundred four patients with degenerative mitral regurgitation surgically amenable to either leaflet resection or preservation were randomized at 7 specialized cardiac surgical centers. Exclusion criteria included anterior leaflet or commissural prolapse, as well as a mixed cause for mitral valve disease. Using previous data, we determined that a sample size of 88 subjects would provide 90% power to detect a 5–mm Hg difference in mean mitral valve gradient at peak exercise, assuming an SD of 6.7 mm with a 2-sided test with α=5% and 10% patient attrition. The primary end point was the mean mitral gradient at peak exercise 12 months after repair.
Results:
Patient age, proportion who were female, and Society of Thoracic Surgeons risk score were 63.9±10.4 years, 19%, and 1.4±2.8% for those who were assigned to leaflet resection (n=54), and 66.3±10.8 years, 16%, and 1.9±2.6% for those who underwent leaflet preservation (n=50). There were no perioperative deaths or conversions to replacement. At 12 months, moderate mitral regurgitation was observed in 3 subjects in the leaflet resection group and 2 in the leaflet preservation group. The mean transmitral gradient at 12 months during peak exercise was 9.1±5.2 mm Hg after leaflet resection and 8.3±3.3 mm Hg after leaflet preservation (
P
=0.43). The participants had similar resting peak (8.3±4.4 mm Hg versus 8.4±2.6 mm Hg;
P
=0.96) and mean resting (3.2±1.9 mm Hg versus 3.1±1.1 mm Hg;
P
=0.67) mitral gradients after leaflet resection and leaflet preservation, respectively. The 6-minute walking distance was 451±147 m for those in the leaflet resection versus 481±95 m for the leaflet preservation group (
P
=0.27).
Conclusions:
In this adequately powered randomized trial, repair of mitral prolapse with either leaflet resection or leaflet preservation was associated with similar transmitral gradients at peak exercise at 12 months postoperatively. These data do not support the hypothesis that a strategy of leaflet resection (versus preservation) is associated with a risk of functional mitral stenosis.
Registration:
URL:
https://www.clinicaltrials.gov
; Unique identifier NCT02552771.
Collapse
Affiliation(s)
- Vincent Chan
- Division of Cardiac Surgery, University of Ottawa Heart Institute, ON, Canada (V.C., M.R., T.M.)
- School of Epidemiology, Public Health and Preventive Medicine (V.C.), University of Ottawa, ON, Canada
| | - C. David Mazer
- Department of Anesthesia (C.D.M.), Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine (C.D.M.), University of Toronto, ON, Canada
- Department of Physiology (C.D.M.), University of Toronto, ON, Canada
| | - Faeez Mohamad Ali
- Division of Cardiology (F.M.A., W.T., H.L.-P.), Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON, Canada
| | - Adrian Quan
- Division of Cardiac Surgery (A.Q., A.D., D.A.L., H.T., S.V.), Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON, Canada
| | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, ON, Canada (V.C., M.R., T.M.)
- Department of Cellular and Molecular Medicine (M.R.), University of Ottawa, ON, Canada
| | - Benoit E. de Varennes
- Division of Cardiac Surgery, Royal Victoria Hospital, McGill University Health Center, Montréal, QC, Canada (B.E.d.V.)
| | - Alexander J. Gregory
- Department of Anesthesiology, Perioperative and Pain Medicine, Cumming School of Medicine, University of Calgary, AB, Canada (A.J.G.)
- Department of Anesthesiology, Perioperative and Pain Medicine, Libin Cardiovascular Institute of Alberta, Calgary, Canada (A.J.G.)
| | - Denis Bouchard
- Department of Cardiac Surgery, Montreal Heart Institute and Université de Montréal, QC, Canada (D.B.)
| | - Richard P. Whitlock
- Division of Cardiac Surgery (R.P.W.), McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact (R.P.W.), McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada (R.P.W.)
| | - Michael W.A. Chu
- Division of Cardiac Surgery, London Health Sciences Center, University of Western Ontario, Canada (M.W.A.C.)
| | - Aleksander Dokollari
- Division of Cardiac Surgery (A.Q., A.D., D.A.L., H.T., S.V.), Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON, Canada
| | - Thierry Mesana
- Division of Cardiac Surgery, University of Ottawa Heart Institute, ON, Canada (V.C., M.R., T.M.)
| | - Deepak L. Bhatt
- Brigham and Women’s Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.)
| | - David A. Latter
- Division of Cardiac Surgery (A.Q., A.D., D.A.L., H.T., S.V.), Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON, Canada
- Department of Surgery (D.A.L., S.V.), University of Toronto, ON, Canada
| | - Fei Zuo
- Applied Health Research Centre (F.Z., P.J.), Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON, Canada
| | - Wendy Tsang
- Division of Cardiology (F.M.A., W.T., H.L.-P.), Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON, Canada
- Department of Medicine (W.T., P.J., H.L.-P.), University of Toronto, ON, Canada
| | - Hwee Teoh
- Division of Cardiac Surgery (A.Q., A.D., D.A.L., H.T., S.V.), Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON, Canada
- Division of Endocrinology and Metabolism (H.T.), Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON, Canada
| | - Peter Jüni
- Applied Health Research Centre (F.Z., P.J.), Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON, Canada
- Department of Medicine (W.T., P.J., H.L.-P.), University of Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (P.J.), University of Toronto, ON, Canada
| | - Howard Leong-Poi
- Division of Cardiology (F.M.A., W.T., H.L.-P.), Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON, Canada
- Department of Medicine (W.T., P.J., H.L.-P.), University of Toronto, ON, Canada
| | - Subodh Verma
- Division of Cardiac Surgery (A.Q., A.D., D.A.L., H.T., S.V.), Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON, Canada
- Department of Surgery (D.A.L., S.V.), University of Toronto, ON, Canada
- Department of Pharmacology and Toxicology (S.V.), University of Toronto, ON, Canada
| |
Collapse
|
8
|
Mao W, Caballero A, Hahn RT, Sun W. Comparative quantification of primary mitral regurgitation by computer modeling and simulated echocardiography. Am J Physiol Heart Circ Physiol 2020; 318:H547-H557. [PMID: 31922890 DOI: 10.1152/ajpheart.00367.2019] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Clinical investigations have demonstrated that mitral regurgitation (MR) quantification using echocardiography (echo) may significantly underestimate or overestimate the regurgitant volume, especially for two-dimensional (2D) echo. Computer modeling and simulated echo were conducted to evaluate the fundamental assumptions in the echo quantification of primary MR that is due to posterior mitral leaflet prolapse. The theoretical flaw of the proximal isovelocity surface area (PISA) method originates from the assumption that the MR flow rate is the product of the isovelocity surface area and aliasing velocity, which is only valid when the velocity vectors are perpendicular to the isovelocity surface. Other factors such as the Doppler angle effect, the view planes of 2D echo, and the single time instant of PISA were also analyzed. We find that the hemielliptic PISA method gives the smallest error for moderate and severe MR cases compared with other PISA methods. Compared with the PISA method, the volumetric technique (VT) is theoretically more robust. By considering correction factors that are caused by nonflat velocity profiles and the closing volume of the aortic valve, the accuracy of the VT method can be significantly improved. The corrected volumetric technique provides more accurate results compared with the PISA methods, especially for mild MR.NEW & NOTEWORTHY We evaluate the accuracy of common echocardiography techniques for the quantification of primary mitral regurgitations using computer modeling. The hemielliptic proximal isovelocity surface area (PISA) method gives the smallest error (within 15%) for moderate and severe mitral regurgitation cases compared with other PISA methods. The volumetric method is theoretically more robust than the PISA method. The accuracy of the volumetric method can be improved by a correction factor around 0.7 because of the nonflat velocity profiles and the closing volume of the aortic valve.
Collapse
Affiliation(s)
- Wenbin Mao
- Tissue Mechanics Laboratory, The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia
| | - Andrés Caballero
- Tissue Mechanics Laboratory, The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia
| | - Rebecca T Hahn
- Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Wei Sun
- Tissue Mechanics Laboratory, The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia
| |
Collapse
|
9
|
Abdouni AA, Brandão CM, Rochitte CE, Pomerantzeff PM, Veronese ET, Pacheco AB, Santis AS, Tarasoutchi F, Jatene FB. Cardiac Magnetic Resonance Analysis of Mitral Annular Dynamics after Mitral Valve Repair. Clinics (Sao Paulo) 2020; 75:e2428. [PMID: 33263628 PMCID: PMC7654962 DOI: 10.6061/clinics/2020/e2428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 09/24/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES The aim of this study was to analyze mitral annulus (MA) dynamics using cardiac magnetic resonance (CMR) in patients with degenerative mitral insufficiency who underwent mitral valve repair (MVR). METHODS Mitral valve imaging was performed by CMR in twenty-nine patients with degenerative mitral insufficiency who underwent MVR between July 2014 and August 2016, with quadrangular resection of the posterior leaflet without ring annuloplasty. They were prospectively followed up from the preoperative period up to 2 years postoperatively. RESULTS We observed a significant reduction in all measurements of the MA after surgery. The mean systolic circumference of the MA was reduced from 13.28±1.95 cm to 11.50±1.59 cm, and the diastolic circumference was reduced from 12.51±2.01 cm to 10.66±2.09 cm in the immediate postoperative period, measures that remained stable 2 years after MVR (p<0.001). The mean maximum area of the MA was significantly reduced from 14.34±4.03 to 10.45±3.17 cm2 when comparing the immediate postoperative period and the 2 year follow-up (p<0.001). The same occurred with the mean minimum area of the MA, which was reduced from 12.53±3.68 cm2 to 9.23±2.84 cm2 in the same period, and this reduction was greater in the antero-posterior diameter than in the mid-lateral diameter. The mobility of the MA was preserved after surgery, ranging between 19.6% and 25.7% at 2-year follow-up. CONCLUSION We observed a significant reduction in the MA size after MVR, with preservation of the MA mobility at the 2-year follow-up.
Collapse
Affiliation(s)
- Ahmad A. Abdouni
- Instituto do Coracao (InCor), Hospital das Cinicas (HCFMUSP), Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding Author. E-mail:
| | - Carlos M.A. Brandão
- Instituto do Coracao (InCor), Hospital das Cinicas (HCFMUSP), Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Carlos E. Rochitte
- Instituto do Coracao (InCor), Hospital das Cinicas (HCFMUSP), Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Pablo M.A. Pomerantzeff
- Instituto do Coracao (InCor), Hospital das Cinicas (HCFMUSP), Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Elinthon T. Veronese
- Instituto do Coracao (InCor), Hospital das Cinicas (HCFMUSP), Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Ariane B. Pacheco
- Instituto do Coracao (InCor), Hospital das Cinicas (HCFMUSP), Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Antonio S. Santis
- Instituto do Coracao (InCor), Hospital das Cinicas (HCFMUSP), Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Flávio Tarasoutchi
- Instituto do Coracao (InCor), Hospital das Cinicas (HCFMUSP), Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Fábio B. Jatene
- Instituto do Coracao (InCor), Hospital das Cinicas (HCFMUSP), Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| |
Collapse
|
10
|
Abstract
PURPOSE OF REVIEW In this review, we summarize the history of mitral valve repair, discuss the broad principles of neochord preparation and implantation, and highlight comparative outcomes between mitral valve repair strategies while focusing on the risk of neochordal rupture. RECENT FINDINGS There have been several recent studies comparing outcomes been leaflet-resection and nonresection, neochord-based mitral valve repair. Operative mortality was very low regardless of repair strategy; however, the rate of mitral valve reoperation is lower in those that undergo a neochord-based repair with overall lower mean mitral gradients postrepair. The introduction of minimally invasive approaches to mitral valve repair has preferentially favored an increase in neochord-based repair, given the technical simplicity compared with resection-based approaches. In very rare cases, neochord rupture can occur, likely secondary to a combination of chordal calcification and mechanical stress. SUMMARY The method of performing mitral valve repair with neochord implantation has demonstrated superior durability over leaflet resection approaches with equivalent operative outcomes. Although the risk of neochord rupture exists, it is exceedingly rare, and should not be considered a limitation to a neochord-based mitral valve repair. Recurrent mitral regurgitation secondary to neochord rupture is incredibly rare; however, regular echocardiographic evaluation of these patients appears warranted, especially when follow-up extends over 10 years.
Collapse
|
11
|
Tang GHL, Verma S, Bhatt DL. Two Randomized Clinical Trials on the Treatment of Secondary Mitral Regurgitation—Contradictory or Complementary? JAMA Cardiol 2019; 4:311-313. [DOI: 10.1001/jamacardio.2019.0204] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Gilbert H. L. Tang
- Department of Cardiovascular Surgery, Mount Sinai Health System, New York, New York
| | - Subodh Verma
- Division of Cardiac Surgery, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Deepak L. Bhatt
- Brigham and Women’s Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
12
|
Jain P, Fabbro M. ACC Expert Consensus Decision Pathway on the Management of Mitral Regurgitation: A Review of the 2017 Document for the Cardiac Anesthesiologist. J Cardiothorac Vasc Anesth 2019; 33:274-289. [DOI: 10.1053/j.jvca.2018.07.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Indexed: 12/12/2022]
|
13
|
Abstract
PURPOSE OF REVIEW This review summarizes the evidence describing functional mitral stenosis (MS) following surgical mitral valve repair. RECENT FINDINGS Functional MS is an evolving concept and has been implicated in the repair of functional and organic mitral regurgitation. Following repair of functional mitral regurgitation, an elevation in peak transmitral gradient and pulmonary artery pressure has been observed under physiologic stress. These changes have been associated with worse functional status early after restrictive annuloplasty. Following repair of organic mitral regurgitation, functional MS has also been observed and appears associated with worse functional status late after surgery. SUMMARY Because repair of functional mitral regurgitation commonly involves restrictive annuloplasty, the issue of functional MS must be weighed against the benefits and durability of repair. Functional MS following repair of degenerative mitral regurgitation, however, may be modifiable. Research evaluating various repair techniques and their impact on functional MS following repair of organic is ongoing.
Collapse
|
14
|
Jansen R, Urgel K, Cramer MJ, van Aarnhem EEHL, Zwetsloot PPM, Doevendans PA, Kluin J, Chamuleau SAJ. Reference Values for Physical Stress Echocardiography in Asymptomatic Patients after Mitral Valve Repair. Front Surg 2018. [PMID: 29516004 PMCID: PMC5826059 DOI: 10.3389/fsurg.2018.00006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Background Clinical decision-making in symptomatic patients after mitral valve (MV) repair remains challenging as echocardiographic reference values are lacking. In native MV disease intervention is recommended for mean transmitral pressure gradient (TPG) >15 mmHg or systolic pulmonary artery pressure (SPAP) >60 mmHg at peak exercise. Insight into standard stress echo parameters after MV repair may therefore aid to clinical decision-making during follow-up. Hypothesis Stress echocardiography derived parameters in asymptomatic patients after successful MV repair differ from current guidelines for native valves. Material and methods In 25 patients (NYHA I) after MV repair stress echocardiography was performed on a semi-supine bicycle. Doppler flow records and MV related hemodynamics at rest and peak were obtained. Linear regression analysis was performed for mean TPG and SPAP at peak, using predetermined variables and confounders. Results Mean TPG at rest (3.2 ± 1.4 mmHg) significantly increased at peak (15.0 ± 3.4 mmHg) but was always <25 mmHg. Mean SPAP at rest (21.4 ± 3.8 mmHg) significantly increased at peak (41.8 ± 8.9 mmHg) but was never >57 mmHg. Only the indexed MV ring diameter was inversely correlated to mean TPG at peak in a multivariable model. Conclusion In contrast to current recommendations in native MV disease, our data indicate that the standard value for mean TPG during stress echocardiography in asymptomatic patients after successful MV repair was above the guideline threshold of 15 mmHg in >50%, but always <25 mmHg. For SPAP, patients never reached the guideline cutoff (60 mmHg). Long-term follow-up data are needed to provide insight in clinical consequences. Baseline stress echocardiography may indicate individual reference values to compare with during follow-up. Clinical trial registration https://clinicaltrials.gov/ct2/show/NCT02371863?term=chamuleau+AND+Mitral&rank=1.
Collapse
Affiliation(s)
- Rosemarijn Jansen
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Kim Urgel
- Department of Cardiology, St Antonius Hospital Woerden, Woerden, Netherlands
| | - Maarten J Cramer
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | | | - Peter P M Zwetsloot
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Pieter A Doevendans
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Jolanda Kluin
- Department of Cardiothoracic Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | - Steven A J Chamuleau
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| |
Collapse
|
15
|
Neochordoplasty versus leaflet resection for ruptured mitral chordae treatment: Virtual mitral valve repair. Comput Biol Med 2017; 90:50-58. [DOI: 10.1016/j.compbiomed.2017.09.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Revised: 09/08/2017] [Accepted: 09/08/2017] [Indexed: 11/23/2022]
|
16
|
Mazine A, Friedrich JO, Nedadur R, Verma S, Ouzounian M, Jüni P, Puskas JD, Yanagawa B. Systematic review and meta-analysis of chordal replacement versus leaflet resection for posterior mitral leaflet prolapse. J Thorac Cardiovasc Surg 2017; 155:120-128.e10. [PMID: 28967416 DOI: 10.1016/j.jtcvs.2017.07.078] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 06/26/2017] [Accepted: 07/24/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVES To compare outcomes of chordal replacement versus leaflet resection techniques for repair of isolated posterior mitral leaflet prolapse. METHODS We searched MEDLINE and EMBASE databases for studies that compared chordal replacement ("neo-chord" group) versus leaflet resection ("resection" group) techniques for the treatment of posterior mitral leaflet prolapse. Data were extracted by 2 independent investigators and subjected to a meta-analysis using a random-effects model. RESULTS One randomized controlled trial (RCT), 1 propensity-matched study, and 6 unadjusted observational studies, with a total of 1926 patients, met our inclusion criteria. Two studies reported only perioperative outcomes; mean follow-up ranged from 1.0 to 5.9 years in the remaining studies. In pooled data from unadjusted observational studies, annuloplasty ring diameter was higher in the neo-chord group (+1.5 mm; P = .0003), but with high heterogeneity (I2 = 91%). Based on limited data, postprocedural left ventricular ejection fraction may be greater in the neo-chord group, but this difference reached statistical significance only in the RCT (+3.4%; P = .03), and not in 2 observational studies that reported this outcome (+2.7%; P = .10). There was no difference in recurrent mitral regurgitation at follow-up between the resection and neo-chord groups; however, patients in the neo-chord group had a lower rate of mitral valve reoperation at follow-up in the unadjusted observational studies (incidence rate ratio, 0.22; P = .0008 [I2 = 0%; 4 studies, 1331 patients]). CONCLUSIONS Chordal replacement may be associated with greater freedom from reoperation and may lead to improved postoperative left ventricular function compared with leaflet resection. However, these conclusions are supported primarily by data from unadjusted observational studies, and high-quality RCTs of chordal replacement versus leaflet resection are needed.
Collapse
Affiliation(s)
- Amine Mazine
- Division of Cardiac Surgery, Department of Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jan O Friedrich
- Department of Critical Care Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Rashmi Nedadur
- Division of Cardiac Surgery, Department of Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Subodh Verma
- Division of Cardiac Surgery, Department of Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiac Surgery, Department of Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Peter Jüni
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - John D Puskas
- Department of Cardiothoracic Surgery, Mount Sinai Saint Luke's, New York, NY
| | - Bobby Yanagawa
- Division of Cardiac Surgery, Department of Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
17
|
Chan V, Chu MWA, Leong-Poi H, Latter DA, Hall J, Thorpe KE, de Varennes BE, Quan A, Tsang W, Dhingra N, Yared K, Teoh H, Chu FV, Chan KL, Mesana TG, Connelly KA, Ruel M, Jüni P, Mazer CD, Verma S. Randomised trial of mitral valve repair with leaflet resection versus leaflet preservation on functional mitral stenosis (The CAMRA CardioLink-2 Trial). BMJ Open 2017; 7:e015032. [PMID: 28566364 PMCID: PMC5729977 DOI: 10.1136/bmjopen-2016-015032] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The gold-standard treatment of severe mitral regurgitation (MR) due to degenerative disease is valve repair, which is surgically performed with either a leaflet resection or leaflet preservation approach. Recent data suggest that functional mitral stenosis (MS) may occur following valve repair using a leaflet resection strategy, which adversely affects patient prognosis. A randomised comparison of these two approaches to mitral repair on functional MS has not been conducted. METHODS AND ANALYSIS This is a prospective, multicentre randomised controlled trial designed to test the hypothesis that leaflet preservation leads to better preservation of mitral valve geometry, and therefore, will be superior to leaflet resection for the primary outcome of functional MS as assessed by 12-month mean mitral valve gradient at peak exercise. Eighty-eight patients with posterior leaflet prolapse will be randomised intraoperatively once deemed by the operating surgeon to feasibly undergo mitral repair using either a leaflet resection or leaflet preservation approach. Secondary end points include comparison of repair strategies with regard to mitral valve orifice area, leaflet coaptation height, 6 min walk test and a composite major adverse event end point consisting of recurrent MR ≥2+, death or hospital readmission for congestive heart failure within 12 months of surgery. ETHICS AND DISSEMINATION Institutional ethics approval has been obtained from all enrolling sites. Overall, there remains clinical equipoise regarding the mitral valve repair strategy that is associated with the least likelihood of functional MS. This trial hopes to introduce high-quality evidence to help surgical decision making in this context. TRIAL REGISTRATION NUMBER NCT02552771.
Collapse
Affiliation(s)
- Vincent Chan
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Michael W A Chu
- Division of Cardiac Surgery, London Health Sciences Center, University of Western Ontario, London, Ontario, Canada
| | - Howard Leong-Poi
- Division of Cardiology, St Michael’s Hospital, Toronto, Ontario, Canada
- Keenan Research Centre for Biomedical Science, St Michael’s Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - David A Latter
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Judith Hall
- Applied Health Research Centre, St Michael's Hospital, Toronto, Ontario, Canada
| | - Kevin E Thorpe
- Applied Health Research Centre, St Michael's Hospital, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Benoit E de Varennes
- Division of Cardiac Surgery, Royal Victoria Hospital, McGill University Health Center, Montreal, Québec, Canada
| | - Adrian Quan
- Keenan Research Centre for Biomedical Science, St Michael’s Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Wendy Tsang
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiology, University Health Network, Toronto, Ontario, Canada
| | - Natasha Dhingra
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kibar Yared
- Division of Cardiology, The Scarborough Hospital, Toronto, Ontario, Canada
| | - Hwee Teoh
- Keenan Research Centre for Biomedical Science, St Michael’s Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
- Division of Endocrinology and Metabolism, St Michael's Hospital, Toronto, Ontario, Canada
| | - F Victor Chu
- Department of Cardiac Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Kwan-Leung Chan
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Thierry G Mesana
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Kim A Connelly
- Division of Cardiology, St Michael’s Hospital, Toronto, Ontario, Canada
- Keenan Research Centre for Biomedical Science, St Michael’s Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter Jüni
- Applied Health Research Centre, St Michael's Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - C David Mazer
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Subodh Verma
- Keenan Research Centre for Biomedical Science, St Michael’s Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
18
|
An Automated Expanded Polytetrafluoroethylene Suturing and Coaxial Fastener System for Mitral Chordae Replacement: Strength, Feasibility, and Healing. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2017; 11:400-406. [PMID: 27930604 DOI: 10.1097/imi.0000000000000316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Mitral valve (MV) chordae replacements can be technically challenging. Technology that remotely delivers and accurately secures artificial chordae may reduce the learning curve and improve the reliability of MV repairs. METHODS The technology involved two devices: a remote suturing device for delivery of expanded polytetrafluoroethylene (ePTFE) suture to the papillary muscle and a Coaxial titanium suture fastener (TF) device with integrated saline infusion for real-time determination of chordae length during fixation. A mechanical model simulating MV chordae tension in a beating heart quantified the durability of 120 coaxially fastened ePTFE sutures using TF over time. Investigation of the technology was performed in ex vivo porcine, ovine, and in situ cadaver hearts, whereas live-tissue testing was conducted in a survivor ovine model. Mitral valve repair procedures involved the iatrogenic induction of mitral regurgitation by the resection of one to two native MV chordae, followed by implantation of ePTFE suture using the technology. Epicardial echocardiography, saline infusion testing, and histologic analysis evaluated MV competence, repair integrity, and long-term healing. RESULTS Durability testing of ePTFE suture secured with TF demonstrated no degradation of TF pull-apart forces of for 440 million cycles. Mitral valve repairs using the technology were performed in eight sheep; four demonstrating proof of concept and four survived for an average of 6.5 months after completion of the procedure. At reoperation, echocardiography demonstrated trace to no mitral regurgitation with near complete endothelialization of the TF and artificial chordae. CONCLUSIONS This technology successfully enabled the implantation of artificial chordae while providing real-time adjustment of chordae length during MV repair. These results encourage further investigation of its use clinically.
Collapse
|
19
|
Sturla F, Onorati F, Puppini G, Pappalardo OA, Selmi M, Votta E, Faggian G, Redaelli A. Dynamic and quantitative evaluation of degenerative mitral valve disease: a dedicated framework based on cardiac magnetic resonance imaging. J Thorac Dis 2017; 9:S225-S238. [PMID: 28540065 DOI: 10.21037/jtd.2017.03.84] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Accurate quantification of mitral valve (MV) morphology and dynamic behavior over the cardiac cycle is crucial to understand the mechanisms of degenerative MV dysfunction and to guide the surgical intervention. Cardiac magnetic resonance (CMR) imaging has progressively been adopted to evaluate MV pathophysiology, although a dedicated framework is required to perform a quantitative assessment of the functional MV anatomy. METHODS We investigated MV dynamic behavior in subjects with normal MV anatomy (n=10) and patients referred to surgery due to degenerative MV prolapse, classified as fibro-elastic deficiency (FED, n=9) and Barlow's disease (BD, n=10). A CMR-dedicated framework was adopted to evaluate prolapse height and volume and quantitatively assess valvular morphology and papillary muscles (PAPs) function over the cardiac cycle. Multiple comparison was used to investigate the hallmarks associated to MV degenerative prolapse and evaluate the feasibility of anatomical and functional distinction between FED and BD phenotypes. RESULTS On average, annular dimensions were significantly (P<0.05) larger in BD than in FED and normal subjects while no significant differences were noticed between FED and normal. MV eccentricity progressively decreased passing from normal to FED and BD, with the latter exhibiting a rounder annulus shape. Over the cardiac cycle, we noticed significant differences for BD during systole with an abnormal annular enlargement between mid and late systole (LS) (P<0.001 vs. normal); the PAPs dynamics remained comparable in the three groups. Prolapse height and volume highlighted significant differences among normal, FED and BD valves. CONCLUSIONS Our CMR-dedicated framework allows for the quantitative and dynamic evaluation of MV apparatus, with quantifiable annular alterations representing the primary hallmark of severe MV degeneration. This may aid surgeons in the evaluation of the severity of MV dysfunction and the selection of the appropriate MV treatment.
Collapse
Affiliation(s)
- Francesco Sturla
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy
| | - Francesco Onorati
- Division of Cardiac Surgery, Department of Surgery, Università degli Studi di Verona, Verona, Italy
| | - Giovanni Puppini
- Department of Radiology, Università degli Studi di Verona, Verona, Italy
| | - Omar A Pappalardo
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy.,Division of Cardiac Surgery, Department of Surgery, Università degli Studi di Verona, Verona, Italy
| | - Matteo Selmi
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy.,Division of Cardiac Surgery, Department of Surgery, Università degli Studi di Verona, Verona, Italy
| | - Emiliano Votta
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy
| | - Giuseppe Faggian
- Division of Cardiac Surgery, Department of Surgery, Università degli Studi di Verona, Verona, Italy
| | - Alberto Redaelli
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy
| |
Collapse
|
20
|
Apostolidou E, Maslow AD, Poppas A. Primary mitral valve regurgitation: Update and review. Glob Cardiol Sci Pract 2017; 2017:e201703. [PMID: 31139637 PMCID: PMC6516795 DOI: 10.21542/gcsp.2017.3] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Mitral regurgitation is the second most common valvular disorder requiring surgical intervention worldwide. This review summarizes the current understanding of primary, degenerative mitral regurgitation with respect to etiology, comprehensive assessment, natural history and management. The new concept of staging of the valvular disorders, newer predictors of adverse and controversy of “watchful waiting” versus “early surgical intervention” for severe, asymptomatic, primary mitral regurgitation are addressed.
Collapse
Affiliation(s)
| | - Andrew D Maslow
- Section of Cardiac Anesthesia, Rhode Island and Miriam Hospital, Providence, RI, USA
| | | |
Collapse
|
21
|
Yanagawa B, Chan V, Verma S. The Dance of 2 Devils: Mitral Valve Repair and Functional Mitral Stenosis. Semin Thorac Cardiovasc Surg 2017; 29:33-34. [DOI: 10.1053/j.semtcvs.2017.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2017] [Indexed: 11/11/2022]
|
22
|
|
23
|
Kagiyama N, Toki M, Hayashida A, Ohara M, Hirohata A, Yamamoto K, Totsugawa T, Sakaguchi T, Yoshida K, Isobe M. Prolapse Volume to Prolapse Height Ratio for Differentiating Barlow’s Disease From Fibroelastic Deficiency. Circ J 2017; 81:1730-1735. [DOI: 10.1253/circj.cj-16-1291] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Nobuyuki Kagiyama
- Cardiovascular Medicine, The Sakakibara Heart Institute of Okayama
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | - Misako Toki
- Department of Clinical Laboratory, The Sakakibara Heart Institute of Okayama
| | | | - Minako Ohara
- Cardiovascular Medicine, The Sakakibara Heart Institute of Okayama
| | - Atsushi Hirohata
- Cardiovascular Medicine, The Sakakibara Heart Institute of Okayama
| | - Keizo Yamamoto
- Cardiovascular Medicine, The Sakakibara Heart Institute of Okayama
| | - Toshinori Totsugawa
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama
| | - Taichi Sakaguchi
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama
| | - Kiyoshi Yoshida
- Cardiovascular Medicine, The Sakakibara Heart Institute of Okayama
| | - Mitsuaki Isobe
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| |
Collapse
|
24
|
Khodaei S, Fatouraee N, Nabaei M. Numerical simulation of mitral valve prolapse considering the effect of left ventricle. Math Biosci 2016; 285:75-80. [PMID: 28038944 DOI: 10.1016/j.mbs.2016.12.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 09/07/2016] [Accepted: 12/20/2016] [Indexed: 11/15/2022]
Abstract
Heart failure is one of the most important issues that has been investigated in recent research studies. Variations that occur in apparatus of mitral valve, such as chordae tendineaea rupture, can affect the valve function during ventricular contraction and lead to regurgitation from the left ventricle into the left atrium. One method for understanding mitral valve function in such conditions is computational analysis. In this paper, we develop a finite element model of mitral valve prolapse, considering the direct effect of left ventricular motion on blood flow interacting with the mitral valve. Ventricular wall motion is used as a constraint for fluid domain. Arbitrary Lagrangian-Eulerian finite element method formulation is used for numerical solution of transient dynamic equations of the fluid domain. Leaflets' stresses and chordal forces during prolapse are determined and compared to previous healthy results, as well as flow characteristics in the computational domain. Results show considerable increases in the stress magnitudes of interior and posterior leaflets in prolapse condition in comparison with previous healthy studies. In addition, chordae tendineae forces are distributed non-uniformly with higher maximum value here, as a result of other chordae tendineae rupture.
Collapse
Affiliation(s)
- Seyedvahid Khodaei
- Biological Fluid Dynamics Laboratory, Biomedical Egngineering Faculty, Amirkabir University of Technology, Tehran, Iran
| | - Nasser Fatouraee
- Biological Fluid Dynamics Laboratory, Biomedical Egngineering Faculty, Amirkabir University of Technology, Tehran, Iran.
| | - Malikeh Nabaei
- Biological Fluid Dynamics Laboratory, Biomedical Egngineering Faculty, Amirkabir University of Technology, Tehran, Iran
| |
Collapse
|
25
|
Nielsen SL. Current status of transcatheter mitral valve repair therapies – From surgical concepts towards future directions. SCAND CARDIOVASC J 2016; 50:367-376. [DOI: 10.1080/14017431.2016.1248482] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Sten Lyager Nielsen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medine, Aarhus University Hospital, Aarhus, Denmark
| |
Collapse
|
26
|
Lee CY, Wong JK, Sauer JS, Gorea HR, Martellaro AJ, Sifain AR, Knight PA. An Automated Expanded Polytetrafluoroethylene Suturing and Coaxial Fastener System for Mitral Chordae Replacement: Strength, Feasibility, and Healing. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2016. [DOI: 10.1177/155698451601100606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Candice Y. Lee
- University of Rochester Medical Center, Rochester, NY USA
| | - Joshua K. Wong
- University of Rochester Medical Center, Rochester, NY USA
| | | | | | | | | | | |
Collapse
|
27
|
Morgan AE, Pantoja JL, Grossi EA, Ge L, Weinsaft JW, Ratcliffe MB. Neochord placement versus triangular resection in mitral valve repair: A finite element model. J Surg Res 2016; 206:98-105. [PMID: 27916382 DOI: 10.1016/j.jss.2016.07.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 05/23/2016] [Accepted: 07/07/2016] [Indexed: 01/27/2023]
Abstract
BACKGROUND Recurrent mitral regurgitation after mitral valve repair is common, occurring in nearly 50% of patients within 10 years of surgery. Durability of repair is partly related to stress distribution over the mitral leaflets. We hypothesized that repair with neochords (NCs) results in lower stress than leaflet resection (LR). MATERIALS AND METHODS Magnetic resonance imaging and 3D echocardiography were performed before surgical repair of P2 prolapse in a single patient. A finite element model of the left ventricle and mitral valve was created previously, and the modeling program LS-DYNA was used to calculate leaflet stress for the following repairs: Triangular LR; LR with ring annuloplasty (LR + RA); One NC; Two NCs; and 2NC + RA. RESULTS (1) NC placement resulted in stable posterior leaflet stress: Baseline versus 2 NC at end diastole (ED), 12.1 versus 12.0 kPa, at end systole (ES) 20.3 versus 21.7 kPa. (2) In contrast, LR increased posterior leaflet stress: Baseline versus LR at ED 12.1 versus 40.8 kPa, at ES 20.3 versus 46.1 kPa. (3) All repair types reduced anterior leaflet stress: Baseline versus 2 NC versus LR 34.2 versus 25.8 versus 20.6 kPa at ED and 80.8 versus 76.8 versus 67.8 kPa at ES. (4) The addition of RA reduced leaflet stress relative to repair without RA. CONCLUSIONS Neochord repair restored normal leaflet coaptation without creating excessive leaflet stress, whereas leaflet resection more than doubled stress across the posterior leaflet. The excess stress created by leaflet resection was partially, but not completely, mitigated by ring annuloplasty.
Collapse
Affiliation(s)
- Ashley E Morgan
- East Bay Surgical Residency, University of California, San Francisco, California
| | - Joe L Pantoja
- College of Medicine, University of California, San Francisco, California
| | - Eugene A Grossi
- Department of Cardiothoracic Surgery, New York University, New York, New York; Department of Cardiothoracic Surgery, New York Harbor Veterans Affairs Medical Center, New York, New York
| | - Liang Ge
- Department of Surgery, University of California, San Francisco, California; Department of Bioengineering, University of California, San Francisco, California; Department of Surgery, Veterans Affairs Medical Center, San Francisco, California
| | - Jonathan W Weinsaft
- Department of Medicine (Cardiology), Weill Cornell Medical College, New York, New York; Department of Radiology, Weill Cornell Medical College, New York, New York
| | - Mark B Ratcliffe
- Department of Surgery, University of California, San Francisco, California; Department of Bioengineering, University of California, San Francisco, California; Department of Surgery, Veterans Affairs Medical Center, San Francisco, California.
| |
Collapse
|
28
|
Popa MO, Irimia AM, Papagheorghe MN, Vasile EM, Tircol SA, Negulescu RA, Toader C, Adam R, Dorobantu L, Caldararu C, Alexandrescu M, Onciul S. The mechanisms, diagnosis and management of mitral regurgitation in mitral valve prolapse and hypertrophic cardiomyopathy. Discoveries (Craiova) 2016; 4:e61. [PMID: 32309580 PMCID: PMC7159827 DOI: 10.15190/d.2016.8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Valvular disease is a frequent cardiac pathology leading to heart failure and, ultimately, death. Mitral regurgitation, defined as the inability of the two mitral leaflets to coapt, is a common valvular disease and a self sustained pathology. A better understanding of the mitral valve histological layers provides a better understanding of the leaflet and chordae changes in mitral valve prolapse.
Mitral valve prolapse may occur in myxomatous degenerative abnormalities, connective tissue disorders or in sporadic isolated cases. It is the most common mitral abnormality of non-ischemic cause leading to severe surgery-requiring mitral regurgitation. In addition to standard echocardiographic investigations, newly implemented three-dimensional techniques are being used and they permit a better visualisation, from the so-called ‘surgical view’, and an improved evaluation of the mitral valve.
Hypertrophic cardiomyopathy is the most frequent inherited myocardial disease caused by mutations in various genes encoding proteins of the cardiac sarcomere, leading to a marked left ventricular hypertrophy unexplained by other comorbidities. The pathological echocardiographic hallmarks of hypertrophic cardiomyopathy are left ventricular hypertrophy, left ventricular outflow tract obstruction and systolic anterior motion of the mitral valve. The systolic anterior motion of the mitral valve contributes to the development of mitral regurgitation and further narrows the left ventricular outflow tract, leading to more severe symptomatology. Cardiac magnetic resonance imaging accurately measures the left ventricular mass, the degree of diastolic function and it may also be used to distinguish phenotypic variants.
The clinical outcome of patients with these pathologies is mostly determined by the selected option of treatment. The purpose of surgical correction regarding mitral valve involvement is to restore valvular competence. Surgery has proven to be the only useful treatment in preventing heart failure, improving symptomatology and reducing mortality. Our approach wishes to enhance the understanding of the mitral valve’s involvement in hypertrophic cardiomyopathy and mitral valve prolapse from genetic, haemodynamic and clinical perspectives, as well as to present novelties in the grand field of treatment.
Collapse
Affiliation(s)
| | - Ana Maria Irimia
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | | | | | | | | | - Catalina Toader
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Robert Adam
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Lucian Dorobantu
- Department of Cardiovascular Surgery, Monza Hospital, Bucharest, Romania
| | | | - Maria Alexandrescu
- Department of Radiology and Imaging Sciences, Monza Hospital, Bucharest, Romania
| | - Sebastian Onciul
- Department of Cardiology, Floreasca Clinical Emergency Hospital, Bucharest, Romania
| |
Collapse
|
29
|
Bonnet V, Boisselier C, Saplacan V, Belin A, Gérard JL, Fellahi JL, Hanouz JL, Fischer MO. The role of age and comorbidities in postoperative outcome of mitral valve repair: A propensity-matched study. Medicine (Baltimore) 2016; 95:e3938. [PMID: 27336886 PMCID: PMC4998324 DOI: 10.1097/md.0000000000003938] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
The average age of patients undergoing mitral valve repair is increasing each year. This retrospective study aimed to compare postoperative complications of mitral valve repair (known to be especially high-risk) between 2 age groups: under and over the age of 80.Patients who underwent mitral valve repair were divided into 2 groups: group 1 (<80 years old) and group 2 (≥80 years old). Baseline characteristics, pre- and postoperative hemodynamic data, surgical characteristics, and postoperative follow-up data until hospital discharge were collected.A total of 308 patients were included: 264 in group 1 (age 63 ± 13 years) and 44 in group 2 (age 83 ± 2 years). Older patients had more comorbidities (atrial fibrillation, history of cardiac decompensation, systemic hypertension, pulmonary hypertension, and chronic kidney disease) and they presented more postoperative complications (50.0% vs 33.7%; P = 0.043), with a longer hospital stay (8.9 ± 6.9 vs 6.6 ± 4.6 days; P = 0.005). To assess the burden of age, a propensity score was awarded to postoperative complications. Active smoking, chronic pulmonary disease, chronic kidney disease, associated ischemic heart disease, obesity, and cardio pulmonary by-pass duration were described as independent risk factors. When matched on this propensity score, there was no difference in morbidity or mortality between group 1 and group 2.Older patients suffered more postoperative complications, which were related to their comorbidities and not only to their age.
Collapse
Affiliation(s)
- Vincent Bonnet
- Pôle Réanimations Anesthésie SAMU/SMUR, CHU de Caen, Avenue de la Côte de Nacre
| | - Clément Boisselier
- Pôle Réanimations Anesthésie SAMU/SMUR, CHU de Caen, Avenue de la Côte de Nacre
| | | | - Annette Belin
- Department of Cardiology, University Hospital of Caen, Caen
| | - Jean-Louis Gérard
- Pôle Réanimations Anesthésie SAMU/SMUR, CHU de Caen, Avenue de la Côte de Nacre
| | - Jean-Luc Fellahi
- Department of Anaesthesiology and Critical Care, Hôpital Cardiologique Louis Pradel, Avenue du Doyen Lepine
- Faculty of Medicine, University of Lyon 1 Claude Bernard, Lyon
| | - Jean-Luc Hanouz
- Pôle Réanimations Anesthésie SAMU/SMUR, CHU de Caen, Avenue de la Côte de Nacre
- EA 4650, Université de Caen Basse-Normandie, Esplanade de la Paix, CS, Caen, France
| | - Marc-Olivier Fischer
- Pôle Réanimations Anesthésie SAMU/SMUR, CHU de Caen, Avenue de la Côte de Nacre
- EA 4650, Université de Caen Basse-Normandie, Esplanade de la Paix, CS, Caen, France
| |
Collapse
|
30
|
Sawazaki M, Tomari S, Zaikokuji K, Imaeda Y. Interrupted commissural band annuloplasty prevents mitral stenosis. Gen Thorac Cardiovasc Surg 2016; 64:524-8. [PMID: 27225485 DOI: 10.1007/s11748-016-0659-7] [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: 12/25/2015] [Accepted: 05/13/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Mitral annuloplasty is an important component of the treatment of degenerative mitral valve disease. However, postoperative echocardiography reveals elevated mitral gradients in some patients. We developed a technique that we termed interrupted commissural band annuloplasty (iCBA), which does not shorten either the anterior or posterior annulus and is not associated with the development of a mitral gradient. We compared the echocardiographic characteristics of patients treated using this method versus Cosgrove ring (COS) placement, both at rest and during exercise. METHODS ICBA features placement of three sutures in the commissures using two bands and shortens the commissural annular length by 60 %. We used this method to treat 63 patients and placed Cosgrove bands in 58. Of all patients, 48 who underwent iCBA and 34 with COSs passed the exercise echocardiographic test. RESULTS The maximal transmitral pressures at rest in the iCBA and Cosgrove groups were 8.04 ± 0.74 and 11.30 ± 0.88 mmHg (P = 0.0029), respectively, and the mean transmitral pressures at rest were 2.46 ± 0.74 and 3.61 ± 0.32 mmHg (P = 0.0037), respectively. The maximal transmitral pressures during exercise were 11.79 ± 0.97 and 18.37 ± 1.16 mmHg (P < 0.0001), and the mean transmitral pressures during exercise were 4.95 ± 0.45 and 7.76 ± 0.53 mmHg (P < 0.0001). CONCLUSIONS ICBA prevents postoperative mitral stenosis both at rest and importantly during exercise.
Collapse
Affiliation(s)
- Masaru Sawazaki
- Department of Cardiovascular Surgery, Heart Valve Center, Komaki City Hospital, 1-20 Jobushi, Komaki, Aichi, 485-8520, Japan.
| | - Shiro Tomari
- Department of Cardiovascular Surgery, Heart Valve Center, Komaki City Hospital, 1-20 Jobushi, Komaki, Aichi, 485-8520, Japan
| | - Kenta Zaikokuji
- Department of Cardiovascular Surgery, Heart Valve Center, Komaki City Hospital, 1-20 Jobushi, Komaki, Aichi, 485-8520, Japan
| | - Yusuke Imaeda
- Department of Cardiovascular Surgery, Heart Valve Center, Komaki City Hospital, 1-20 Jobushi, Komaki, Aichi, 485-8520, Japan
| |
Collapse
|
31
|
Greenhouse DG, Murphy A, Mignatti P, Zavadil J, Galloway AC, Balsam LB. Mitral valve prolapse is associated with altered extracellular matrix gene expression patterns. Gene 2016; 586:56-61. [PMID: 27063507 DOI: 10.1016/j.gene.2016.04.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 03/31/2016] [Accepted: 04/02/2016] [Indexed: 01/08/2023]
Abstract
Mitral valve prolapse (MVP) is the leading indication for isolated mitral valve surgery in the United States. Disorganization of collagens and glycosaminoglycans in the valvular extracellular matrix (ECM) are histological hallmarks of MVP. We performed a transcriptome analysis to study the alterations in ECM-related gene expression in humans with sporadic MVP. Mitral valve specimens were obtained from individuals undergoing valve repair for MVP (n=7 patients) and from non-beating heart-tissue donors (n=3 controls). Purified RNA was subjected to whole-transcriptome microarray analysis. Microarray results were validated by quantitative reverse transcription polymerase chain reaction (RT-qPCR). Gene ontology enrichment analysis was performed. 2046 unique genes showed significant differential expression (false discovery rate <0.5%). After demonstrating appropriate sample clustering, microarray results were globally validated using a subset of 22 differentially expressed genes by RT-qPCR (Pearson's correlation r=0.65, p=0.001). Gene ontology enrichment analyses performed with ErmineJ and DAVID Bioinformatics Database demonstrated overrepresentation of ECM components (p<0.05). Functional annotation clustering calculated enrichment of ECM-related ontology groups (enrichment score=4.1). ECM-related gene expression is significantly altered in MVP. Our study is consistent with the histologically observed alterations in collagen and mucopolysaccharide profiles of myxomatous mitral valves. Furthermore, whole-transcriptome analyses suggest dysregulation of multiple pathways, including TGF-beta signaling.
Collapse
Affiliation(s)
- David G Greenhouse
- Department of Cardiothoracic Surgery, NYU Langone Medical Center, New York, NY, United States
| | - Alison Murphy
- Department of Cardiothoracic Surgery, NYU Langone Medical Center, New York, NY, United States
| | - Paolo Mignatti
- Department of Cardiothoracic Surgery, NYU Langone Medical Center, New York, NY, United States; Department of Cell Biology, New York University School of Medicine, New York, NY, United States
| | - Jiri Zavadil
- Department of Pathology, New York University School of Medicine, New York, NY, United States; NYULMC Genome Technology Center, NYU Langone Medical Center, New York, NY, United States; Center for Health Informatics and Bioinformatics, NYU Langone Medical Center, New York, NY, United States
| | - Aubrey C Galloway
- Department of Cardiothoracic Surgery, NYU Langone Medical Center, New York, NY, United States
| | - Leora B Balsam
- Department of Cardiothoracic Surgery, NYU Langone Medical Center, New York, NY, United States.
| |
Collapse
|
32
|
Morgan AE, Pantoja JL, Weinsaft J, Grossi E, Guccione JM, Ge L, Ratcliffe M. Finite Element Modeling of Mitral Valve Repair. J Biomech Eng 2016; 138:021009. [PMID: 26632260 PMCID: PMC5101040 DOI: 10.1115/1.4032125] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Revised: 11/18/2015] [Indexed: 11/08/2022]
Abstract
The mitral valve is a complex structure regulating forward flow of blood between the left atrium and left ventricle (LV). Multiple disease processes can affect its proper function, and when these diseases cause severe mitral regurgitation (MR), optimal treatment is repair of the native valve. The mitral valve (MV) is a dynamic structure with multiple components that have complex interactions. Computational modeling through finite element (FE) analysis is a valuable tool to delineate the biomechanical properties of the mitral valve and understand its diseases and their repairs. In this review, we present an overview of relevant mitral valve diseases, and describe the evolution of FE models of surgical valve repair techniques.
Collapse
Affiliation(s)
- Ashley E. Morgan
- University of California,
San Francisco—East Bay Surgical Residency,
Oakland, CA 94602
e-mail:
| | - Joe Luis Pantoja
- School of Medicine,
University of California, San Francisco,
San Francisco, CA 94143
e-mail:
| | - Jonathan Weinsaft
- Department of Cardiology,
Cornell University School of Medicine,
New York, NY 10065
e-mail:
| | - Eugene Grossi
- Department of Cardiothoracic Surgery,
NYU School of Medicine,
New York, NY 10016
e-mail:
| | - Julius M. Guccione
- Department of Surgery and Bioengineering,
University of California, San Francisco,
San Francisco, CA 94143
e-mail:
| | - Liang Ge
- Department of Surgery and Bioengineering,
Veterans Affairs Medical Center,
University of California, San Francisco,
San Francisco, CA 94121
e-mail:
| | - Mark Ratcliffe
- Surgical Service (112)
Departments of Surgery and Bioengineering,
Veterans Affairs Medical Center,
University of California, San Francisco,
4150 Clement Street,
San Francisco, CA 94121
e-mail:
| |
Collapse
|
33
|
Year in review: mitral valve surgery. Curr Opin Cardiol 2016; 31:148-53. [PMID: 26814651 DOI: 10.1097/hco.0000000000000262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE OF REVIEW In the past year, there has been progress on several fronts in the field of mitral valve surgery and intervention. Here, we review key publications regarding the surgical and transcatheter management of mitral valve disease. RECENT FINDINGS This past year heralded the publication of the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) Guidelines for the Management of Patients With Valvular Heart Disease. Regarding degenerative mitral regurgitation, low risk of operative mortality and data demonstrating clinical benefit for early surgery are prompting renewed calls for early intervention before guideline-based triggers. For functional mitral regurgitation, the precise roles of chordal-sparing replacement versus repair and the optimal management of moderate disease at the time of surgical revascularization are unclear. Sternal-sparing minimally invasive mitral valve surgery has become a mature procedure in experienced centers and offers comparable surgical morbidity and mortality with superior cosmesis and faster return to baseline function. Transcatheter interventions for mitral regurgitation continue to undergo development and testing. Mounting experience and ongoing clinical trials with the MitraClip endovascular edge-to-edge repair device will provide important data on the optimal target population for this device. SUMMARY This past year has seen important advances in the surgical treatment of degenerative and functional mitral regurgitation as well as continued refinement of transcatheter interventions.
Collapse
|
34
|
Miceli A, Murzi M, Canarutto D, Gilmanov D, Ferrarini M, Farneti PA, Solinas M, Glauber M. Minimally invasive mitral valve repair through right minithoracotomy in the setting of degenerative mitral regurgitation: early outcomes and long-term follow-up. Ann Cardiothorac Surg 2015; 4:422-7. [PMID: 26539346 DOI: 10.3978/j.issn.2225-319x.2015.04.10] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Mitral valve (MV) repair is the gold standard for the treatment of degenerative MV regurgitation. Recently, minimally invasive mitral valve surgery (MIMVS) has shown excellent postoperative outcomes compared with conventional surgery. The aim of our study is to report early and long-term outcomes of patients undergoing MIMVS through right mini-thoracotomy (RT) over an eight year period. METHODS From September 2003 to December 2011, a total of 1,604 consecutive patients underwent MIMVS through RT. RESULTS The mean age was 62±13 years, 295 (42%) patients were female and 16 (2.3%) had previous cardiac operations. MV repair was successfully performed in 670 patients, with a rate of success of 95.3%. Repair techniques included annuloplasty (89%), leaflet resection (n=54.2%), neochordae implantation (12.1%), and sliding plasty (10.5%). Overall in-hospital mortality was 0.1%. Incidence of stroke was 1.3%. At eight-year follow-up, overall survival was 90.1%, freedom from reoperation 93%, and freedom from recurrent mitral regurgitation was 90%. CONCLUSIONS MIMV repair through right minithoracotomy is a safe and reproducible procedure associated with high rate of MV repair, and excellent early postoperative and long-term results.
Collapse
Affiliation(s)
- Antonio Miceli
- Fondazione Toscana G. Monasterio, Via Aurelia Sud, Massa, Italy
| | - Michele Murzi
- Fondazione Toscana G. Monasterio, Via Aurelia Sud, Massa, Italy
| | | | | | | | - Pier A Farneti
- Fondazione Toscana G. Monasterio, Via Aurelia Sud, Massa, Italy
| | - Marco Solinas
- Fondazione Toscana G. Monasterio, Via Aurelia Sud, Massa, Italy
| | - Mattia Glauber
- Fondazione Toscana G. Monasterio, Via Aurelia Sud, Massa, Italy
| |
Collapse
|
35
|
Chan V, Mesana TG. Functional mitral stenosis after mitral valve repair is a true anatomic problem that originates from the time of surgery. J Thorac Cardiovasc Surg 2015; 150:1091-2. [PMID: 26349594 DOI: 10.1016/j.jtcvs.2015.08.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Revised: 08/09/2015] [Accepted: 08/10/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Vincent Chan
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada; School of Epidemiology, Public Health, and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | |
Collapse
|
36
|
Al-Atassi T, Toeg HD, Jafar R, Sohmer B, Labrosse M, Boodhwani M. Impact of aortic annular geometry on aortic valve insufficiency: Insights from a preclinical, ex vivo, porcine model. J Thorac Cardiovasc Surg 2015. [PMID: 26215361 DOI: 10.1016/j.jtcvs.2015.06.060] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES We sought to create a model of aortic insufficiency in a left heart simulator combined with 3-dimensional echocardiography and finite element modeling of the aortic valve. We examined the effects of aortic root geometry alteration on aortic insufficiency. METHODS Porcine aortic roots were analyzed on a left heart simulator before (control, n = 8) and after intervention (n = 8). Intervention entailed 3 vertical incisions at the sinotubular junction with diamond-shaped patches incorporated into the defects to increase the sinotubular junction diameter. Hemodynamic parameters were assessed, including regurgitant volume and fraction. Video and echocardiography images evaluated aortic valve function, coaptation surface area, aortic insufficiency, and effective regurgitant orifice area. Finite element modeling corroborated relationships between root geometry and aortic insufficiency, and examined cusp stress. RESULTS The intervention resulted in a sinotubular junction diameter increase of 55% ± 4%. The sinotubular junction to ventriculo-aortic junction diameter ratio was significantly higher in the intervention group (1.89 ± 0.16 vs 1.47 ± 0.04, P = .02). Increased sinotubular junction diameter resulted in aortic insufficiency assessed by regurgitant volume (28 ± 7 mL vs 5 ± 2 mL, P = .004), regurgitant fraction (36% ± 5% vs 7% ± 1%, P < .001), and effective regurgitant orifice (15 ± 5 mm(2) vs 0 mm(2), P = .016). Intervention coaptation surface area was smaller (1.03 ± 0.11 cm(2) vs 1.80 ± 0.08 cm(2), P < .001). There was a linear correlation between increased sinotubular junction/ventriculo-aortic junction ratio and regurgitant fraction (R(2) = 0.65, P = .003). The finite element modeling demonstrated a similar relationship between increasing sinotubular junction diameter and aortic insufficiency severity, and between end-diastolic cusp stresses and sinotubular junction diameters (R(2) = 0.98, P < .001). CONCLUSIONS In this model, increasing sinotubular junction diameter is linearly related to reduced coaptation surface area and increasing aortic insufficiency severity. This model provides new insights into aortic insufficiency mechanisms and may be used to evaluate novel interventions for aortic valve repair.
Collapse
Affiliation(s)
- Talal Al-Atassi
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Canada
| | - Hadi Daood Toeg
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Canada
| | - Reza Jafar
- Department of Mechanical Engineering, University of Ottawa, Ottawa, Canada
| | - Benjamin Sohmer
- Department of Anesthesiology, University of Ottawa Heart Institute, Ottawa, Canada
| | - Michel Labrosse
- Department of Mechanical Engineering, University of Ottawa, Ottawa, Canada
| | - Munir Boodhwani
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Canada.
| |
Collapse
|
37
|
Rim Y, Choi A, McPherson DD, Kim H. Personalized Computational Modeling of Mitral Valve Prolapse: Virtual Leaflet Resection. PLoS One 2015; 10:e0130906. [PMID: 26103002 PMCID: PMC4477933 DOI: 10.1371/journal.pone.0130906] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 05/25/2015] [Indexed: 11/23/2022] Open
Abstract
Posterior leaflet prolapse following chordal elongation or rupture is one of the primary valvular diseases in patients with degenerative mitral valves (MVs). Quadrangular resection followed by ring annuloplasty is a reliable and reproducible surgical repair technique for treatment of posterior leaflet prolapse. Virtual MV repair simulation of leaflet resection in association with patient-specific 3D echocardiographic data can provide quantitative biomechanical and physiologic characteristics of pre- and post-resection MV function. We have developed a solid personalized computational simulation protocol to perform virtual MV repair using standard clinical guidelines of posterior leaflet resection with annuloplasty ring implantation. A virtual MV model was created using 3D echocardiographic data of a patient with posterior chordal rupture and severe mitral regurgitation. A quadrangle-shaped leaflet portion in the prolapsed posterior leaflet was removed, and virtual plication and suturing were performed. An annuloplasty ring of proper size was reconstructed and virtual ring annuloplasty was performed by superimposing the ring and the mitral annulus. Following the quadrangular resection and ring annuloplasty simulations, patient-specific annular motion and physiologic transvalvular pressure gradient were implemented and dynamic finite element simulation of MV function was performed. The pre-resection MV demonstrated a substantial lack of leaflet coaptation which directly correlated with the severe mitral regurgitation. Excessive stress concentration was found along the free marginal edge of the posterior leaflet involving the chordal rupture. Following the virtual resection and ring annuloplasty, the severity of the posterior leaflet prolapse markedly decreased. Excessive stress concentration disappeared over both anterior and posterior leaflets, and complete leaflet coaptation was effectively restored. This novel personalized virtual MV repair strategy has great potential to help with preoperative selection of the patient-specific optimal MV repair techniques, allow innovative surgical planning to expect improved efficacy of MV repair with more predictable outcomes, and ultimately provide more effective medical care for the patient.
Collapse
Affiliation(s)
- Yonghoon Rim
- Division of Cardiovascular Medicine, Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, United States of America
| | - Ahnryul Choi
- Division of Cardiovascular Medicine, Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, United States of America
| | - David D. McPherson
- Division of Cardiovascular Medicine, Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, United States of America
| | - Hyunggun Kim
- Division of Cardiovascular Medicine, Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, United States of America
| |
Collapse
|
38
|
BAIL DOROTHEEH. (Meta)-Analysis of Safety and Efficacy Following Edge-to-Edge Mitral Valve Repair Using the MitraClip System. J Interv Cardiol 2015; 28:69-75. [DOI: 10.1111/joic.12168] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- DOROTHEE H.L. BAIL
- Competence-Center Quality Assurance; Medical Service of Statutory Healthcare Insurance; Tuebingen and Stuttgart; Germany
| |
Collapse
|
39
|
Intraoperative Transesophageal Echocardiography for Surgical Repair of Mitral Regurgitation. J Am Soc Echocardiogr 2014; 27:345-66. [DOI: 10.1016/j.echo.2014.01.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Indexed: 12/14/2022]
|
40
|
Owais K, Kim H, Khabbaz KR, Bergman R, Matyal R, Gorman RC, Gorman JH, Hess PE, Mahmood F. In-vivo analysis of selectively flexible mitral annuloplasty rings using three-dimensional echocardiography. Ann Thorac Surg 2014; 97:2005-10. [PMID: 24612703 DOI: 10.1016/j.athoracsur.2014.01.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Revised: 12/30/2013] [Accepted: 01/06/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND Selectively flexible rings, Colvin-Galloway (CG) Future and Carpentier-Edwards (CE) Physio II, are used for annuloplasty during mitral valve repair to facilitate dynamic annular motion while preventing annular dilation. In this study, we assessed the extent and nature of the flexibility of these rings in vivo, which has not been objectively demonstrated. METHODS Three-dimensional transesophageal echocardiography was used intraoperatively to acquire data regarding dynamic motion of mitral annuli and annuloplasty rings in 33 patients undergoing mitral repair (15 CG Future and 18 CE Physio II) and in 15 control patients. Data were analyzed to assess the dynamic changes in annular geometry after implantation of selectively flexible rings. RESULTS After annuloplasty, there was an immediate and significant decrease in annular displacement (p < 0.001) and annular displacement velocity (p < 0.01). Dynamic change in multiple variables including anteroposterior diameter (p < 0.001) and annular area (p < 0.001) was also significantly depressed. In comparison with normal mitral valves, partially flexible rings allowed limited dynamic motion: percentage changes in anteroposterior diameter (p < 0.001), anterolateral posteromedial diameter (p < 0.001), and total circumference (p < 0.001) were significantly lower. Compared with each other, the two rings resulted in similar changes in anterior annulus length (p = 0.93), posterior annular length (p = 0.82), and annular area (p = 0.31). CONCLUSIONS Mitral annular dynamics were uniformly depressed after implantation of these rings. Selective flexibility could not be demonstrated in vivo using echocardiographic data.
Collapse
Affiliation(s)
- Khurram Owais
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Han Kim
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kamal R Khabbaz
- Division of Cardiothoracic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
| | - Remco Bergman
- Department of Anaesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Robina Matyal
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Robert C Gorman
- Division of Cardiovascular Surgery, Gorman Cardiovascular Research Group, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Joseph H Gorman
- Division of Cardiovascular Surgery, Gorman Cardiovascular Research Group, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Philip E Hess
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Feroze Mahmood
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
41
|
Mesana TG, Lam BK, Chan V, Chen K, Ruel M, Chan K. Clinical evaluation of functional mitral stenosis after mitral valve repair for degenerative disease: Potential affect on surgical strategy. J Thorac Cardiovasc Surg 2013; 146:1418-23; discussion 1423-5. [DOI: 10.1016/j.jtcvs.2013.08.011] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2013] [Revised: 07/21/2013] [Accepted: 08/01/2013] [Indexed: 11/29/2022]
|
42
|
Chan KL, Chen SY, Chan V, Hay K, Mesana T, Lam BK. Functional Significance of Elevated Mitral Gradients After Repair for Degenerative Mitral Regurgitation. Circ Cardiovasc Imaging 2013; 6:1041-7. [DOI: 10.1161/circimaging.112.000688] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Kwan Leung Chan
- From the University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Shin-Yee Chen
- From the University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Vincent Chan
- From the University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Karen Hay
- From the University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Thierry Mesana
- From the University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Buu Khanh Lam
- From the University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| |
Collapse
|
43
|
Mitral valve surgery in elderly patients with mitral regurgitation: repair or replacement with tissue valve? Curr Opin Cardiol 2013; 28:164-9. [PMID: 23314759 DOI: 10.1097/hco.0b013e32835da4f8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE OF REVIEW The fastest growing demographic in North America is the elderly. Significant mitral regurgitation is present in more than 10% of this population. There are sparse clinical data to inform decisions regarding the optimal timing of operation and the appropriate operative intervention for this large population of patients with severe mitral regurgitation. RECENT FINDINGS Mitral valve surgery can be safely performed in most elderly patients with severe mitral regurgitation. The best outcomes occur when operative intervention is performed early, before advanced symptoms of heart failure develop. In elderly patients with mitral regurgitation, mitral valve repair is associated with superior early and late results compared with replacement. Survival after mitral valve repair among elderly patients is equivalent to a normal age-matched population. SUMMARY Elderly patients with severe mitral regurgitation should be referred for operation before significant symptoms develop. Mitral valve repair is favoured over replacement whenever feasible and is associated with satisfactory early and long-term results. If repair is impossible or the likelihood of durable repair seems low, valve replacement with a bioprosthetic valve should be performed. Further prospective clinical trials are essential to define the role of screening for this prevalent condition and to identify which subgroups of elderly patients will benefit most from early surgical intervention.
Collapse
|
44
|
Izumo M, Shiota M, Kar S, Gurudevan SV, Tolstrup K, Siegel RJ, Shiota T. Comparison of real-time three-dimensional transesophageal echocardiography to two-dimensional transesophageal echocardiography for quantification of mitral valve prolapse in patients with severe mitral regurgitation. Am J Cardiol 2013. [PMID: 23206924 DOI: 10.1016/j.amjcard.2012.10.045] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Real-time 3-dimensional (3D) transesophageal echocardiography (TEE) provides more accurate geometric information on the mitral valve (MV) than 2-dimensional (2D) TEE. The aim of this study was to quantify MV prolapse using real-time 3D TEE in patients with severe mitral regurgitation. In 102 patients with severe mitral regurgitation due to MV prolapse and/or flail, 2D TEE quantified MV prolapse, including prolapse gap and width in the commissural view. Three-dimensional TEE also determined prolapse gap and width with the use of the 3D en face view. On the basis of the locations of MV prolapse, all patients were classified into group 1 (pure middle leaflet prolapse, n = 50) or group 2 (involvement of medial and/or lateral prolapse, n = 52). Prolapse gap and prolapse width determined by 3D TEE were significantly greater than those by 2D TEE (all p values <0.001). The differences in prolapse gap and prolapse width between 2D TEE and 3D TEE were significantly greater in group 2 than group 1 (Δ gap 1.3 ± 1.4 vs 2.4 ± 1.8 mm, Δ width 2.5 ± 3.0 vs 4.4 ± 5.1 mm, all p values <0.01). The differences in prolapse gap and width between 2D TEE and 3D TEE were best correlated with 3D TEE-derived prolapse width (r = 0.41 and r = 0.74, respectively). Two-dimensional TEE underestimated the width of MV prolapse and leaflet gap compared to 3D TEE. Two-dimensional TEE could not detect the largest prolapse gap and width, because of the complicated anatomy of the MV. In conclusion, 3D TEE provided more precise quantification of MV prolapse than 2D TEE.
Collapse
Affiliation(s)
- Masaki Izumo
- The Heart Institute at Cedars-Sinai Medical Center and UCLA, Los Angeles, California, USA
| | | | | | | | | | | | | |
Collapse
|
45
|
Sainger R, Grau JB, Branchetti E, Poggio P, Seefried WF, Field BC, Acker MA, Gorman RC, Gorman JH, Hargrove CW, Bavaria JE, Ferrari G. Human myxomatous mitral valve prolapse: role of bone morphogenetic protein 4 in valvular interstitial cell activation. J Cell Physiol 2012; 227:2595-604. [PMID: 22105615 DOI: 10.1002/jcp.22999] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Myxomatous mitral valve prolapse (MVP) is the most common cardiac valvular abnormality in industrialized countries and a leading cause of mitral valve surgery for isolated mitral regurgitation. The key role of valvular interstitial cells (VICs) during mitral valve development and homeostasis has been recently suggested, however little is known about the molecular pathways leading to MVP. We aim to characterize bone morphogenetic protein 4 (BMP4) as a cellular regulator of mitral VIC activation towards a pathologic synthetic phenotype and to analyze the cellular phenotypic changes and extracellular matrix (ECM) reorganization associated with the development of myxomatous MVP. Microarray analysis showed significant up regulation of BMP4-mediated signaling molecules in myxomatous MVP when compared to controls. Histological analysis and cellular characterization suggest that during myxomatous MVP development, healthy quiescent mitral VICs undergo a phenotypic activation via up regulation of BMP4-mediated pathway. In vitro hBMP4 treatment of isolated human mitral VICs mimics the cellular activation and ECM remodeling as seen in MVP tissues. The present study characterizes the cell biology of mitral VICs in physiological and pathological conditions and provides insights into the molecular and cellular mechanisms mediated by BMP4 during MVP. The ability to test and control the plasticity of VICs using different molecules may help in developing new diagnostic and therapeutic strategies for myxomatous MVP.
Collapse
Affiliation(s)
- Rachana Sainger
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA 19036, USA
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
46
|
Uechi M. Mitral valve repair in dogs. J Vet Cardiol 2012; 14:185-92. [PMID: 22366571 DOI: 10.1016/j.jvc.2012.01.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Revised: 12/01/2011] [Accepted: 01/12/2012] [Indexed: 11/17/2022]
Abstract
Prognosis for dogs with severe mitral regurgitation is poor with medical therapy alone. Open surgical mitral valve repair consisting of circumferential mitral annuloplasty and artificial chordal replacement confers durability and improved long-term clinical outcome without a need for long-term antithrombotic therapies. This approach has been successfully used in canine patients, including small-breed dogs. Methods for mitral valve repair applicable to small dogs are described.
Collapse
Affiliation(s)
- Masami Uechi
- Veterinary Cardiovascular Medicine and Surgery, Laboratory of Veterinary Internal Medicine, Department of Veterinary Medicine, College of Bioresource Sciences, Nihon University, 1866 Kameino, Fujisawa, Kanagawa 252-8510, Japan.
| |
Collapse
|
47
|
Bhattacharya S, He Z. Annulus tension of the prolapsed mitral valve corrected by edge-to-edge repair. J Biomech 2011; 45:562-8. [PMID: 22153221 DOI: 10.1016/j.jbiomech.2011.11.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2011] [Revised: 11/06/2011] [Accepted: 11/09/2011] [Indexed: 11/26/2022]
Abstract
BACKGROUND Mitral valve (MV) performance after edge-to-edge repair (ETER) without ring annuloplasty is suboptimal. ETER efficacy needs to be evaluated from annulus tension (AT) of a prolapsed MV corrected by ETER to understand annular dilatation. METHODS Ten porcine MVs were harvested and mounted on a MV closure test rig. The MV annulus tissue rested on top of a saddle-shaped plastic ring on which the annulus could slide freely. The annulus was held by strings in the periphery during MV closure under a hydrostatic trans-mitral pressure. String tensions were measured and further divided by string spacing to obtain AT. The MVs were then prolapsed by shifting split papillary muscles to simulate mono-leaflet prolapse due to elongation of chords, which insert into a single leaflet. Last, MV prolapse was corrected by ETER applied in the central leaflet region and AT was measured. RESULTS AT in both anterior and posterior leaflet prolapse corrected by ETER was less than that of normal MVs. AT in the anterior leaflet prolapse corrected by ETER was less than that in the posterior leaflet prolapse corrected by ETER. CONCLUSION ETER does not restore the normal AT and therefore leads potential of annular dilatation. The anterior leaflet prolapse has a greater potential of annular dilatation than the posterior leaflet prolapse after ETER. Annuloplasty is recommended to maintain long-term ETER efficacy.
Collapse
Affiliation(s)
- Shamik Bhattacharya
- Department of Mechanical Engineering, Texas Tech University, Lubbock, TX 79409, USA
| | | |
Collapse
|
48
|
Lau K, Díaz-Zuccarini V, Scambler P, Burriesci G. Fluid–structure interaction study of the edge-to-edge repair technique on the mitral valve. J Biomech 2011; 44:2409-17. [DOI: 10.1016/j.jbiomech.2011.06.030] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Revised: 06/02/2011] [Accepted: 06/26/2010] [Indexed: 10/17/2022]
|
49
|
A pulsatile simulator for the in vitro analysis of the mitral valve with tri-axial papillary muscle displacement. Int J Artif Organs 2011; 34:383-91. [PMID: 21534249 DOI: 10.5301/ijao.2011.7729] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2011] [Indexed: 11/20/2022]
Abstract
PURPOSE We developed a new pulsatile hydrodynamic simulator for the in vitro testing of mitral valve (MV) samples. The required specifications included a 3D positioning system for the papillary muscles (PMs) that is accurate and simple to manage; measurement of the force exerted by the chordae tendineae on the PMs; and the possibility to visually inspect the MV for kinematic analysis. METHODS An atrial/ventricular chamber system was developed. The ventricular chamber housed a tri-axial actuator system that was aligned to a morphometric Cartesian frame, allowing for PM positioning even while tests are running. Each PM holder had an embedded load cell for force measurement. The atrial chamber was designed so as to permit MV visual inspection, maintaining a non-disturbed flow at the sample inlet. The setup was subjected to trials with fresh porcine MVs. Flow and pressure difference across the MVs and PM forces were measured in different MV configurations, with different PM spatial dislocations. High speed video recordings were acquired. RESULTS The positioning accuracy was assessed. Tests with MVs showed good usability, even by the non-engineering personnel. The effects of PM displacement on valve function (valve competence and PM forces) was consistent with previously published data, thus confirming the general soundness of the design principles. CONCLUSIONS The developed simulator is a promising instrument for performing MV in vitro tests in a precise, well-repeatable manner. The ability to completely adjust the PM position while a test is running boosts the simulator's potential for detailed investigations of the pathological and surgically treated MV.
Collapse
|
50
|
Ghoreishi M, Dawood M, Stauffer CE, Gammie JS. Mitral regurgitation: current trends in diagnosis and management. Hosp Pract (1995) 2011; 39:181-92. [PMID: 21441774 DOI: 10.3810/hp.2011.02.389] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Mitral regurgitation is the most prevalent heart valve disorder in the United States. Individuals with mitral regurgitation may be asymptomatic or may present with dyspnea, orthopnea, fatigue, and/or heart rhythm disturbances. Long-standing mitral regurgitation causes chronic left ventricular volume overload, which leads to left ventricular dilation and contractile dysfunction. Without treatment, mitral regurgitation results in biventricular failure and death. Echocardiography is the preferred diagnostic test to assess the presence and severity of mitral regurgitation. Mitral valve surgery, the only effective treatment for patients with severe mitral regurgitation, is recommended early in the course of the disease to prevent the development of heart failure. Early recognition of mitral regurgitation and timely referral for mitral valve surgery significantly improve symptoms and long-term survival.
Collapse
Affiliation(s)
- Mehrdad Ghoreishi
- Division of Cardiac Surgery, University of Maryland Medical Center, Baltimore, MD 21201, USA
| | | | | | | |
Collapse
|