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von Stein P, von Stein J, Hohmann C, Wienemann H, Guthoff H, Körber MI, Baldus S, Pfister R, Hahn RT, Iliadis C. Atrial Functional Mitral Regurgitation Subtypes Undergoing Transcatheter Edge-to-Edge Repair: Suboptimal Outcomes in Atriogenic Hamstringing. JACC Cardiovasc Imaging 2024:S1936-878X(24)00283-3. [PMID: 39207336 DOI: 10.1016/j.jcmg.2024.06.019] [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: 03/18/2024] [Revised: 06/04/2024] [Accepted: 06/28/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Two subtypes of atrial functional mitral regurgitation (AFMR) have been described, one is characterized by Carpentier type I and the other by Carpentier type IIIb leaflet motion. OBJECTIVES The authors sought to analyze echocardiographic characteristics and outcomes of AFMR subtypes undergoing mitral valve transcatheter edge-to-edge repair (M-TEER). METHODS Of 1,047 consecutive patients who underwent M-TEER, the authors identified those with isolated mitral annulus dilation (Carpentier I), termed AFMR-IAD, and those with atriogenic hamstringing characterized by restricted posterior mitral leaflet motion (Carpentier IIIb), termed AFMR-AH. Echocardiographic baseline characteristics and outcomes up to 1-year were analyzed. RESULTS A total of 128 patients (12.2%) met AFMR criteria; 75 (58.6%) were identified as AFMR-IAD and 53 (41.4%) as AFMR-AH. AFMR-AH displayed greater left atrial and left ventricular volumes, greater mitral annulus, shorter and steeper posterior mitral leaflet, and more pronounced MR (all P < 0.05). Technical success was achieved in 98.7% (AFMR-IAD) and 86.8% (AFMR-AH) of patients (P = 0.009). At discharge, device detachments were exclusively observed in AFMR-AH (10.0%). MR ≤II was achieved in 95.6% and 78.6% at 30 days (P = 0.009) and in 93.0% and 74.1% at 1 year (P = 0.038) in patients with AFMR-IAD and AFMR-AH, respectively. AFMR-AH was associated with procedural failure (OR: 1.17 [95% CI: 1.00-1.38]; P = 0.045) at 30 days (43.4% vs 24.0%; P = 0.023) and all-cause mortality (HR: 2.54 [95% CI: 1.09-5.91]; P = 0.031) at 1 year (77% vs 92%, Kaplan-Meier estimated 1-year survival; P = 0.017). CONCLUSIONS AFMR-AH shows worse procedural and clinical outcomes following M-TEER than AFMR-IAD. Thus, vigilance regarding this pathology is warranted and alternative mitral valve therapies might need to be considered.
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Affiliation(s)
- Philipp von Stein
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Cologne, Germany
| | - Jennifer von Stein
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Cologne, Germany
| | - Christopher Hohmann
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Cologne, Germany
| | - Hendrik Wienemann
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Cologne, Germany
| | - Henning Guthoff
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Cologne, Germany
| | - Maria I Körber
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Cologne, Germany
| | - Stephan Baldus
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Cologne, Germany
| | - Roman Pfister
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Cologne, Germany
| | - Rebecca T Hahn
- Department of Cardiology, Columbia University Irving Medical Center, New York, New York, USA; Cardiovascular Research Foundation, New York, New York, USA
| | - Christos Iliadis
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Cologne, Germany.
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Abraham B, Suppah M, Megaly M, Elbanna M, Kaldas S, Alsidawi S, David Fortuin F, Sweeney J, Ayoub C, Alkhouli M, Sell-Dottin K, Chao CJ, Arsanjani R. Impact of transcatheter edge to edge repair in functional mitral regurgitation and cardiac resynchronization-therapy nonresponders. Catheter Cardiovasc Interv 2024. [PMID: 39146522 DOI: 10.1002/ccd.31190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 07/02/2024] [Accepted: 08/07/2024] [Indexed: 08/17/2024]
Abstract
BACKGROUND Despite optimal medical therapy and cardiac resynchronization therapy (CRT), significant functional mitral regurgitation (MR) persisted in 30% of the patients and labeled as CRT nonresponders. AIMS We sought to study the impact of transcatheter edge-to-edge repair (TEER) in patients with symptomatic grade III and IV functional MR despite CRT. METHODS A retrospective analysis was conducted of all patients who had prior CRT for at least 6 months and underwent TEER for significant residual functional MR (grade ≥3) and symptomatic heart failure (HF) at our institution. The primary outcomes were the change in New York Heart Association classification (NYHA), MR grade, echo parameters, and NT-ProBNP from baseline to 1-year post-procedure. RESULTS A total of 28 patients were identified, mean age of 73 ± 6.7 years and 89% males. Procedure success was achieved in all patients. At 1-year follow-up, patients had lower MR grade (median 2, IQR 1 [1,2] vs. 4, IQR 1 [3,4]; p < 0.001), NYHA class (median 2, IQR 1 [2,3] vs. 3, IQR 1 [3,4]; p < 0.001), and NT-ProBNP (7658 ± 11322 vs. 3760 ± 4431; p = 0.035) compared to before the TEER procedure. The left ventricular end-diastolic volume (255 ± 59 vs. 244 ± 66 mm; p = 0.016) and the right ventricular systolic pressure (52 ± 14 mmHg vs. 37 ± 13 mmHg, <0.001) decreased. CONCLUSION Patients who remain symptomatic after CRT with severe functional MR had improved functional status and MR grade at 1-year following TEER. There was a signal toward reverse remodeling.
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Affiliation(s)
- Bishoy Abraham
- Division of Cardiovascular disease, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Mustafa Suppah
- Department of Medicine, Creighton University, Phoenix, Arizona, USA
| | - Michael Megaly
- Division of Cardiovascular disease, Willis-Knighton Medical Center, Shreveport, Louisiana, USA
| | - Mostafa Elbanna
- Department of Medicine, Rochester Regional Hospital, Rochester, New York, USA
| | - Sara Kaldas
- Division of Cardiovascular disease, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Said Alsidawi
- Division of Cardiovascular disease, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - F David Fortuin
- Division of Cardiovascular disease, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - John Sweeney
- Division of Cardiovascular disease, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Chadi Ayoub
- Division of Cardiovascular disease, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Mohamad Alkhouli
- Division of Cardiology, Mayo Clinic Hospital, Rochester, Minnesota, USA
| | - Kristen Sell-Dottin
- Department of Cardiovascular Surgery, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Chieh-Ju Chao
- Division of Cardiology, Mayo Clinic Hospital, Rochester, Minnesota, USA
| | - Reza Arsanjani
- Division of Cardiovascular disease, Mayo Clinic Hospital, Phoenix, Arizona, USA
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Barnes C, Sharma H, Gamble J, Dawkins S. Management of secondary mitral regurgitation: from drugs to devices. Heart 2024; 110:1099-1106. [PMID: 37607812 PMCID: PMC11347202 DOI: 10.1136/heartjnl-2022-322001] [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: 08/24/2023] Open
Abstract
Severe secondary mitral regurgitation carries a poor prognosis with one in five patients dying within 12 months of diagnosis. Fortunately, there are now a number of safe and effective therapies available to improve outcomes. Here, we summarise the most up-to-date treatments. Optimal guideline-directed medical therapy is the mainstay therapy and has been shown to reduce the severity of mitral regurgitation in 40-45% of patients. Rapid medication titration protocols reduce heart failure hospitalisation and facilitate earlier referral for device therapy. The pursuit of sinus rhythm in patients with atrial fibrillation has been shown to significantly reduce mitral regurgitation severity, as has the use of cardiac resynchronisation devices in patients who meet guideline-directed criteria. Finally, we highlight the key role of mitral valve intervention, particularly transcatheter edge-to-edge repair (TEER) for management of moderate-severe mitral regurgitation in carefully selected patients with poor left ventricular systolic function, with a number needed to treat of 3.1 to reduce heart failure hospitalisation and 5.9 to reduce all-cause death. To slow the rapid accumulation of morbidity and mortality, we advocate a proactive approach with accelerated medical optimisation, followed by management of atrial fibrillation and cardiac resynchronisation therapy if indicated, then, rapid referral to the Heart Team for consideration of mitral valve intervention in patients with ongoing symptoms and at least moderate-severe mitral regurgitation. Mitral TEER has been shown to be 'reasonably cost-effective' (but not cost-saving) in the UK in selected patients, although TEER remains underused with only 6.5 procedures per million population (pmp) compared with Germany (77 pmp), Switzerland (44 pmp) and the USA (32 pmp).
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Affiliation(s)
- Cara Barnes
- Oxford Heart Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Harish Sharma
- Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - James Gamble
- Oxford Heart Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sam Dawkins
- Oxford Heart Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Cameron JN, Kadhim KI, Kamsani SH, Han HC, Farouque O, Sanders P, Lim HS. Arrhythmogenic Mitral Valve Prolapse: Can We Risk Stratify and Prevent Sudden Cardiac Death? Arrhythm Electrophysiol Rev 2024; 13:e11. [PMID: 39145277 PMCID: PMC11322952 DOI: 10.15420/aer.2023.26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 01/10/2024] [Indexed: 08/16/2024] Open
Abstract
Ventricular arrhythmias associated with mitral valve prolapse (MVP) and the capacity to cause sudden cardiac death (SCD), referred to as 'malignant MVP', are an increasingly recognised, albeit rare, phenomenon. SCD can occur without significant mitral regurgitation, implying an interaction between mechanical derangements affecting the mitral valve apparatus and left ventricle. Risk stratification of these arrhythmias is an important clinical and public health issue to provide precise and targeted management. Evaluation requires patient and family history, physical examination and electrophysiological and imaging-based modalities. We provide a review of arrhythmogenic MVP, exploring its epidemiology, demographics, clinical presentation, mechanisms linking MVP to SCD, markers of disease severity, testing modalities and management, and discuss the importance of risk stratification. Even with recently improved understanding, it remains challenging how best to weight the prognostic importance of clinical, imaging and electrophysiological data to determine a clear high-risk arrhythmogenic profile in which an ICD should be used for the primary prevention of SCD.
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Affiliation(s)
- James N Cameron
- Department of Cardiology, Austin Health Melbourne, Australia
- Faculty of Medicine, Dentistry and Health Sciences University of Melbourne Melbourne, Australia
| | - Kadhim I Kadhim
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital Adelaide, Australia
| | - Suraya Hb Kamsani
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital Adelaide, Australia
| | - Hui-Chen Han
- Victorian Heart Institute, Monash University Melbourne, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health Melbourne, Australia
- Faculty of Medicine, Dentistry and Health Sciences University of Melbourne Melbourne, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital Adelaide, Australia
| | - Han S Lim
- Department of Cardiology, Austin Health Melbourne, Australia
- Faculty of Medicine, Dentistry and Health Sciences University of Melbourne Melbourne, Australia
- Department of Cardiology, Northern Health Melbourne, Australia
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Moriguchi S, Mukoyama Y, Takizawa F, Ogawa A, Ogawa T, Ito J, Yanagawa Y, Komiyama C, Niitsu R, Isojima T. Lifelong cardiovascular care in Turner syndrome: two cases with review of literature. Endocr J 2024; 71:713-719. [PMID: 38658359 DOI: 10.1507/endocrj.ej24-0038] [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: 04/26/2024] Open
Abstract
Cardiovascular disease is one of the most important complications in girls and women with Turner syndrome (TS). Although the latest international guideline provides useful suggestions for the management of cardiovascular diseases in TS, some unknown cardiac conditions warrant physicians' attention and awareness. Here, we have reported two adult cases wherein significant cardiovascular diseases were detected during the transition period. The first case patient was diagnosed with aortic crank deformity and left subclavian artery aneurysm at 14 years based on the report of cardiac catheterization, computed tomography angiography, and cardiac magnetic resonance imaging, which had remained undetected by annual evaluations using transthoracic echocardiography (TTE). This case emphasizes the importance of cardiac reevaluation during the transition period. The second case patient was diagnosed with moderate mitral valve regurgitation (MR) due to mitral valve prolapse at 18 years through TTE, although the first evaluation at 7 years by TTE detected slight MR without any clinical concerns. The condition however progressed to severe MR at 28 years, requiring mitral valvuloplasty. MR is the most common valve disease worldwide, which makes it challenging to comprehend whether the condition is a complication. However, the condition requiring surgery at this age is extremely rare, which implies the possibility of early progression. Because almost all literature on cardiovascular complications in TS is cross-sectional, further information about longitudinal cardiovascular conditions is vital for optimal care for girls and women with TS. The two cases reported in this article provide significant information for improving lifelong cardiovascular health issues in TS.
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Affiliation(s)
- Shun Moriguchi
- Department of Pediatrics, Toranomon Hospital, Tokyo 105-8470, Japan
| | - Yuri Mukoyama
- Department of Pediatrics, Toranomon Hospital, Tokyo 105-8470, Japan
| | | | - Atsushi Ogawa
- Department of Pediatrics, Toranomon Hospital, Tokyo 105-8470, Japan
| | - Tetsushi Ogawa
- Department of Pediatrics, Toranomon Hospital, Tokyo 105-8470, Japan
| | - Junko Ito
- Department of Pediatrics, Toranomon Hospital, Tokyo 105-8470, Japan
| | | | | | - Rieko Niitsu
- Department of Cardiology, Toranomon Hospital, Tokyo 105-8470, Japan
| | - Tsuyoshi Isojima
- Department of Pediatrics, Toranomon Hospital, Tokyo 105-8470, Japan
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Song K, Jang WS, Kim YS, Yoo J. Outcomes of maze procedure and mitral valve surgery in atrial functional mitral regurgitation: a retrospective study. J Cardiothorac Surg 2024; 19:433. [PMID: 38987787 PMCID: PMC11234554 DOI: 10.1186/s13019-024-02858-w] [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: 01/10/2024] [Accepted: 06/14/2024] [Indexed: 07/12/2024] Open
Abstract
BACKGROUND Atrial functional mitral regurgitation (AFMR) is a newly discovered condition associated with longstanding atrial fibrillation. This retrospective study aimed to analyze the outcomes of the maze procedure and mitral regurgitation (MR) surgery in AFMR and atrial fibrillation in comparison with those in degenerative MR (DMR). METHODS Patients who underwent mitral valve repair/replacement with a maze procedure at a hospital (July 2012-August 2021) were included. We excluded patients aged below 18 years undergoing concomitant coronary artery bypass grafting or atrial septal defect repair and those with MR etiology other than ARMR or DMR. RESULTS We included 35 patients with AFMR and 50 patients with DMR. Patient characteristics and postoperative outcomes were not significantly different between the two groups. Long-term outcomes revealed no significant differences in the ratio of cardiac mortality, stroke, or hospital readmission. However, after the maze procedure, the sinus rhythm restoration rate was significantly lower (62% vs. 28.5%, p < 0.001), a junctional rhythm state (p < 0.001) and permanent pacemaker insertion for sick sinus syndrome (SSS) (p = 0.03) were significantly more common in AFMR than DMR. On postoperative transthoracic echocardiography (TTE), the pulmonary artery systolic pressure was significantly less decreased in the AFMR group than in the DMR group compared with that on preoperative TTE (p = 0.04). CONCLUSIONS AFMR showed excellent mitral valve surgery outcomes, similar to DMR, but had a significantly higher risk of pacemaker insertion for SSS after the maze procedure.
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Affiliation(s)
- Kyungsub Song
- Department of Thoracic and Cardiovascular Surgery, Keimyung University Dongsan Medical Center, Keimyung University College of Medicine, 1035, Dalgubeol-daero, Dalseo-gu, Daegu, 42601, Republic of Korea.
| | - Woo Sung Jang
- Department of Thoracic and Cardiovascular Surgery, Keimyung University Dongsan Medical Center, Keimyung University College of Medicine, 1035, Dalgubeol-daero, Dalseo-gu, Daegu, 42601, Republic of Korea
| | - Yun Seok Kim
- Department of Thoracic and Cardiovascular Surgery, Keimyung University Dongsan Medical Center, Keimyung University College of Medicine, 1035, Dalgubeol-daero, Dalseo-gu, Daegu, 42601, Republic of Korea
| | - Jonghoon Yoo
- Department of Emergency Medicine, Keimyung University Dongsan Medical Center, Keimyung University College of Medicine, 1035, Dalgubeol-daero, Dalseo-gu, Daegu, 42601, Republic of Korea
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Avierinos JF, Tribouilloy C, Bursi F, Grigioni F, Vanoverschelde JL, Resseguier N, Théron A, Pasquet A, Pradier J, Biagini E, Barbieri A, Michelena H, Benfari G, Rusinaru D, Zaffran S, Vancraeynest D, Collart F, Bohbot Y, Essayagh B, Enriquez-Sarano M. Degenerative mitral regurgitation due to flail leaflet: sex-related differences in presentation, management, and outcomes. Eur Heart J 2024; 45:2306-2316. [PMID: 38751052 DOI: 10.1093/eurheartj/ehae265] [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] [Received: 07/21/2023] [Revised: 02/26/2024] [Accepted: 04/15/2024] [Indexed: 07/10/2024] Open
Abstract
BACKGROUND AND AIMS Presentation, outcome, and management of females with degenerative mitral regurgitation (DMR) are undefined. We analysed sex-specific baseline clinical and echocardiographic characteristics at referral for DMR due to flail leaflets and subsequent management and outcomes. METHODS In the Mitral Regurgitation International Database (MIDA) international registry, females were compared with males regarding presentation at referral, management, and outcome (survival/heart failure), under medical treatment, post-operatively, and encompassing all follow-up. RESULTS At referral, females (n = 650) vs. males (n = 1660) were older with more severe symptoms and higher MIDA score. Smaller cavity diameters belied higher cardiac dimension indexed to body surface area. Under conservative management, excess mortality vs. expected was observed in males [standardized mortality ratio (SMR) 1.45 (1.27-1.65), P < .001] but was higher in females [SMR 2.00 (1.67-2.38), P < .001]. Female sex was independently associated with mortality [adjusted hazard ratio (HR) 1.29 (1.04-1.61), P = .02], cardiovascular mortality [adjusted HR 1.58 (1.14-2.18), P = .007], and heart failure [adjusted HR 1.36 (1.02-1.81), P = .04] under medical management. Females vs. males were less offered surgical correction (72% vs. 80%, P < .001); however, surgical outcome, adjusted for more severe presentation in females, was similar (P ≥ .09). Ultimately, overall outcome throughout follow-up was worse in females who displayed persistent excess mortality vs. expected [SMR 1.31 (1.16-1.47), P < .001], whereas males enjoyed normal life expectancy restoration [SMR 0.92 (0.85-0.99), P = .036]. CONCLUSIONS Females with severe DMR were referred to tertiary centers at a more advanced stage, incurred higher mortality and morbidity under conservative management, and were offered surgery less and later after referral. Ultimately, these sex-related differences yielded persistent excess mortality despite surgery in females with DMR, while males enjoyed restoration of life expectancy, warranting imperative re-evaluation of sex-specific DMR management.
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Affiliation(s)
- Jean-Fançois Avierinos
- Département de Cardiologie, Centre Hospitalier Universitaire Timone, Assistance Publique Hôpitaux de Marseille, Aix-Marseille Université, 264 rue Saint-Pierre, 13005 Marseille, France
- U1251 INSERM, Marseille Medical Genetics, Aix-Marseille Université, 27 Bd Jean Moulin, 13385 Marseille, France
| | - Christophe Tribouilloy
- Département de Cardiologie, Centre Hospitalier Universitaire d'Amiens, Amiens, France
- EA 7517, Jules Verne University of Picardie, Amiens, France
| | - Francesca Bursi
- Department of Health Sciences, University of Milan, Milano, Italy
| | - Francesco Grigioni
- Research Unit of Cardiovascular Science, Università e Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
| | - Jean-Louis Vanoverschelde
- Service de Cardiologie, Clinique Universitaire Saint-Luc, Brussels, Belgium
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Noémie Resseguier
- Methodological Support Unit for Clinical and Epidemiological Research, University Hospital of Marseille (APHM), Marseille, France
- CEReSS-Health Services and Quality of Life Research, Aix Marseille Université, Marseille, France
| | - Alexis Théron
- U1251 INSERM, Marseille Medical Genetics, Aix-Marseille Université, 27 Bd Jean Moulin, 13385 Marseille, France
- Service de Chirurgie Cardiaque, Centre Hospitalier Universitaire Timone, Assistance Publique Hôpitaux de Marseille, Aix-Marseille Université, Marseille, France
| | - Agnes Pasquet
- Service de Cardiologie, Clinique Universitaire Saint-Luc, Brussels, Belgium
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Julie Pradier
- Département de Cardiologie, Centre Hospitalier Universitaire Timone, Assistance Publique Hôpitaux de Marseille, Aix-Marseille Université, 264 rue Saint-Pierre, 13005 Marseille, France
| | - Elena Biagini
- Cardiology Unit, St Orsola Hospital, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andrea Barbieri
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Hector Michelena
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Giovanni Benfari
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Dan Rusinaru
- Département de Cardiologie, Centre Hospitalier Universitaire d'Amiens, Amiens, France
- EA 7517, Jules Verne University of Picardie, Amiens, France
| | - Stéphane Zaffran
- U1251 INSERM, Marseille Medical Genetics, Aix-Marseille Université, 27 Bd Jean Moulin, 13385 Marseille, France
| | - David Vancraeynest
- Service de Cardiologie, Clinique Universitaire Saint-Luc, Brussels, Belgium
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Fréderic Collart
- Service de Chirurgie Cardiaque, Centre Hospitalier Universitaire Timone, Assistance Publique Hôpitaux de Marseille, Aix-Marseille Université, Marseille, France
| | - Yohann Bohbot
- Département de Cardiologie, Centre Hospitalier Universitaire d'Amiens, Amiens, France
- EA 7517, Jules Verne University of Picardie, Amiens, France
| | - Benjamin Essayagh
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
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Li Z, Cheng S, Guo B, Ding L, Liang Y, Shen Y, Li J, Hu Y, Long T, Guo X, Ge J, Gao R, Pibarot P, Zhang B, Xu H, Clavel MA, Wu Y. Wearable device-measured moderate to vigorous physical activity and risk of degenerative aortic valve stenosis. Eur Heart J 2024:ehae406. [PMID: 38953786 DOI: 10.1093/eurheartj/ehae406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 04/04/2024] [Accepted: 06/17/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND AND AIMS Physical activity has proven effective in preventing atherosclerotic cardiovascular disease, but its role in preventing degenerative valvular heart disease (VHD) remains uncertain. This study aimed to explore the dose-response association between moderate to vigorous physical activity (MVPA) volume and the risk of degenerative VHD among middle-aged adults. METHODS A full week of accelerometer-derived MVPA data from 87 248 UK Biobank participants (median age 63.3, female: 56.9%) between 2013 and 2015 were used for primary analysis. Questionnaire-derived MVPA data from 361 681 UK Biobank participants (median age 57.7, female: 52.7%) between 2006 and 2010 were used for secondary analysis. The primary outcome was the diagnosis of incident degenerative VHD, including aortic valve stenosis (AS), aortic valve regurgitation (AR), and mitral valve regurgitation (MR). The secondary outcome was VHD-related intervention or mortality. RESULTS In the accelerometer-derived MVPA cohort, 555 incident AS, 201 incident AR, and 655 incident MR occurred during a median follow-up of 8.11 years. Increased MVPA volume showed a steady decline in AS risk and subsequent AS-related intervention or mortality risk, levelling off beyond approximately 300 min/week. In contrast, its association with AR or MR incidence was less apparent. The adjusted rates of AS incidence (95% confidence interval) across MVPA quartiles (Q1-Q4) were 11.60 (10.20, 13.20), 7.82 (6.63, 9.23), 5.74 (4.67, 7.08), and 5.91 (4.73, 7.39) per 10 000 person-years. The corresponding adjusted rates of AS-related intervention or mortality were 4.37 (3.52, 5.43), 2.81 (2.13, 3.71), 1.93 (1.36, 2.75), and 2.14 (1.50, 3.06) per 10 000 person-years, respectively. Aortic valve stenosis risk reduction was also observed with questionnaire-based MVPA data [adjusted absolute difference Q4 vs. Q1: AS incidence, -1.41 (-.67, -2.14) per 10 000 person-years; AS-related intervention or mortality, -.38 (-.04, -.88) per 10 000 person-years]. The beneficial association remained consistent in high-risk populations for AS, including patients with hypertension, obesity, dyslipidaemia, and chronic kidney disease. CONCLUSIONS Higher MVPA volume was associated with a lower risk of developing AS and subsequent AS-related intervention or mortality. Future research needs to validate these findings in diverse populations with longer durations and repeated periods of activity monitoring.
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Affiliation(s)
- Ziang Li
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science, Peking Union Medical College, Beijing, China
- Research Center, Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), Université Laval, 2725 Chemin Sainte-Foy, Québec City, Québec, Canada G1V-4G5
| | - Sijing Cheng
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science, Peking Union Medical College, Beijing, China
| | - Bo Guo
- Department of Medicine for Sports and Performing Arts, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Lu Ding
- Institute for Molecular Bioscience, The University of Queensland, St Lucia, QLD, Australia
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yu Liang
- Department of Mathematical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Yinghan Shen
- Institute of Computing Technology, Chinese Academy of Sciences, Beijing, China
| | - Jinyue Li
- Key Laboratory of Cardiovascular Epidemiology, Department of Epidemiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Yiqing Hu
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China
| | - Tianxin Long
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science, Peking Union Medical College, Beijing, China
| | - Xinli Guo
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science, Peking Union Medical College, Beijing, China
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China
| | - Runlin Gao
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science, Peking Union Medical College, No.167 Beilishi Road, Beijing 100037, China
| | - Philippe Pibarot
- Research Center, Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), Université Laval, 2725 Chemin Sainte-Foy, Québec City, Québec, Canada G1V-4G5
| | - Bin Zhang
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science, Peking Union Medical College, Beijing, China
- Research Center, Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), Université Laval, 2725 Chemin Sainte-Foy, Québec City, Québec, Canada G1V-4G5
| | - Haiyan Xu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science, Peking Union Medical College, No.167 Beilishi Road, Beijing 100037, China
| | - Marie-Annick Clavel
- Research Center, Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), Université Laval, 2725 Chemin Sainte-Foy, Québec City, Québec, Canada G1V-4G5
| | - Yongjian Wu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science, Peking Union Medical College, No.167 Beilishi Road, Beijing 100037, China
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9
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Silva Ferreira MV, Soares CSP, Araujo-Filho JDAB, Dantas RN, Torres RVA, Morais TC, Avila LFR, Ishikawa W, Nomura CH, Rajiah PS, Parga Filho J. Mitral Annular Disease at Cardiac MRI: What to Know and Look For. Radiographics 2024; 44:e230156. [PMID: 38870043 DOI: 10.1148/rg.230156] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
Accurate evaluation of the mitral valve (MV) apparatus is essential for understanding the mechanisms of MV disease across various clinical scenarios. The mitral annulus (MA) is a complex and crucial structure that supports MV function; however, conventional imaging techniques have limitations in fully capturing the entirety of the MA. Moreover, recognizing annular changes might aid in identifying patients who may benefit from advanced cardiac imaging and interventions. Multimodality cardiovascular imaging plays a major role in the diagnosis, prognosis, and management of MV disease. Transthoracic echocardiography is the first-line modality for evaluation of the MA, but it has limitations. Cardiac MRI (CMR) has emerged as a robust imaging modality for assessing annular changes, with distinct advantages over other imaging techniques, including accurate flow and volumetric quantification and assessment of variations in the measurements and shape of the MA during the cardiac cycle. Mitral annular disjunction (MAD) is defined as atrial displacement of the hinge point of the MV annulus away from the ventricular myocardium, a condition that is now more frequently diagnosed and studied owing to recent technical advances in cardiac imaging. However, several unresolved issues regarding MAD, such as the functional significance of pathologic disjunction and how this disjunction advances in the clinical course, require further investigation. The authors review the role of CMR in the assessment of MA disease, with a focus on MAD and its functional implications in MV prolapse and mitral regurgitation. ©RSNA, 2024 Supplemental material is available for this article. See the invited commentary by Stojanovska and Fujikura in this issue.
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Affiliation(s)
- Marcus Vinicius Silva Ferreira
- From the Department of Radiology, Hospital Sirio-Libanes, Rua Adma Jafet, 91, Sao Paulo, SP 01308-050, Brazil (M.V.S.F., C.S.P.S., J.dA.B.A.F., R.N.D., R.V.A.T., T.C.M., L.F.R.A., C.H.N., J.P.F.); Department of Radiology, Hospital Israelita Albert Einstein, Sao Paulo, SP 05652-900, Brazil (W.I.); and Department of Radiology, Mayo Clinic, Rochester, MN 55905 (P.S.R.)
| | - Clarice Santos Parreira Soares
- From the Department of Radiology, Hospital Sirio-Libanes, Rua Adma Jafet, 91, Sao Paulo, SP 01308-050, Brazil (M.V.S.F., C.S.P.S., J.dA.B.A.F., R.N.D., R.V.A.T., T.C.M., L.F.R.A., C.H.N., J.P.F.); Department of Radiology, Hospital Israelita Albert Einstein, Sao Paulo, SP 05652-900, Brazil (W.I.); and Department of Radiology, Mayo Clinic, Rochester, MN 55905 (P.S.R.)
| | - Jose de Arimateia Batista Araujo-Filho
- From the Department of Radiology, Hospital Sirio-Libanes, Rua Adma Jafet, 91, Sao Paulo, SP 01308-050, Brazil (M.V.S.F., C.S.P.S., J.dA.B.A.F., R.N.D., R.V.A.T., T.C.M., L.F.R.A., C.H.N., J.P.F.); Department of Radiology, Hospital Israelita Albert Einstein, Sao Paulo, SP 05652-900, Brazil (W.I.); and Department of Radiology, Mayo Clinic, Rochester, MN 55905 (P.S.R.)
| | - Roberto Nery Dantas
- From the Department of Radiology, Hospital Sirio-Libanes, Rua Adma Jafet, 91, Sao Paulo, SP 01308-050, Brazil (M.V.S.F., C.S.P.S., J.dA.B.A.F., R.N.D., R.V.A.T., T.C.M., L.F.R.A., C.H.N., J.P.F.); Department of Radiology, Hospital Israelita Albert Einstein, Sao Paulo, SP 05652-900, Brazil (W.I.); and Department of Radiology, Mayo Clinic, Rochester, MN 55905 (P.S.R.)
| | - Roberto Vitor Almeida Torres
- From the Department of Radiology, Hospital Sirio-Libanes, Rua Adma Jafet, 91, Sao Paulo, SP 01308-050, Brazil (M.V.S.F., C.S.P.S., J.dA.B.A.F., R.N.D., R.V.A.T., T.C.M., L.F.R.A., C.H.N., J.P.F.); Department of Radiology, Hospital Israelita Albert Einstein, Sao Paulo, SP 05652-900, Brazil (W.I.); and Department of Radiology, Mayo Clinic, Rochester, MN 55905 (P.S.R.)
| | - Thamara Carvalho Morais
- From the Department of Radiology, Hospital Sirio-Libanes, Rua Adma Jafet, 91, Sao Paulo, SP 01308-050, Brazil (M.V.S.F., C.S.P.S., J.dA.B.A.F., R.N.D., R.V.A.T., T.C.M., L.F.R.A., C.H.N., J.P.F.); Department of Radiology, Hospital Israelita Albert Einstein, Sao Paulo, SP 05652-900, Brazil (W.I.); and Department of Radiology, Mayo Clinic, Rochester, MN 55905 (P.S.R.)
| | - Luis Francisco Rodrigues Avila
- From the Department of Radiology, Hospital Sirio-Libanes, Rua Adma Jafet, 91, Sao Paulo, SP 01308-050, Brazil (M.V.S.F., C.S.P.S., J.dA.B.A.F., R.N.D., R.V.A.T., T.C.M., L.F.R.A., C.H.N., J.P.F.); Department of Radiology, Hospital Israelita Albert Einstein, Sao Paulo, SP 05652-900, Brazil (W.I.); and Department of Radiology, Mayo Clinic, Rochester, MN 55905 (P.S.R.)
| | - Walther Ishikawa
- From the Department of Radiology, Hospital Sirio-Libanes, Rua Adma Jafet, 91, Sao Paulo, SP 01308-050, Brazil (M.V.S.F., C.S.P.S., J.dA.B.A.F., R.N.D., R.V.A.T., T.C.M., L.F.R.A., C.H.N., J.P.F.); Department of Radiology, Hospital Israelita Albert Einstein, Sao Paulo, SP 05652-900, Brazil (W.I.); and Department of Radiology, Mayo Clinic, Rochester, MN 55905 (P.S.R.)
| | - Cesar Higa Nomura
- From the Department of Radiology, Hospital Sirio-Libanes, Rua Adma Jafet, 91, Sao Paulo, SP 01308-050, Brazil (M.V.S.F., C.S.P.S., J.dA.B.A.F., R.N.D., R.V.A.T., T.C.M., L.F.R.A., C.H.N., J.P.F.); Department of Radiology, Hospital Israelita Albert Einstein, Sao Paulo, SP 05652-900, Brazil (W.I.); and Department of Radiology, Mayo Clinic, Rochester, MN 55905 (P.S.R.)
| | - Prabhakar Shantha Rajiah
- From the Department of Radiology, Hospital Sirio-Libanes, Rua Adma Jafet, 91, Sao Paulo, SP 01308-050, Brazil (M.V.S.F., C.S.P.S., J.dA.B.A.F., R.N.D., R.V.A.T., T.C.M., L.F.R.A., C.H.N., J.P.F.); Department of Radiology, Hospital Israelita Albert Einstein, Sao Paulo, SP 05652-900, Brazil (W.I.); and Department of Radiology, Mayo Clinic, Rochester, MN 55905 (P.S.R.)
| | - Jose Parga Filho
- From the Department of Radiology, Hospital Sirio-Libanes, Rua Adma Jafet, 91, Sao Paulo, SP 01308-050, Brazil (M.V.S.F., C.S.P.S., J.dA.B.A.F., R.N.D., R.V.A.T., T.C.M., L.F.R.A., C.H.N., J.P.F.); Department of Radiology, Hospital Israelita Albert Einstein, Sao Paulo, SP 05652-900, Brazil (W.I.); and Department of Radiology, Mayo Clinic, Rochester, MN 55905 (P.S.R.)
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10
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Milojevic M, Nikolic A, Bakaeen FG, Myers PO. Clinical practice guidelines: ensuring quality through international collaboration. Eur J Cardiothorac Surg 2024; 66:ezae237. [PMID: 38958045 DOI: 10.1093/ejcts/ezae237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Accepted: 06/15/2024] [Indexed: 07/04/2024] Open
Affiliation(s)
- Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Aleksandar Nikolic
- Department of Cardiac Surgery, Acibadem Sistina Hospital, Skopje, North Macedonia
| | - Faisal G Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Patrick O Myers
- Division of Cardiac Surgery, CHUV-Lausanne University Hospital, Lausanne, Switzerland
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11
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Essayagh B, Benfari G, Antoine C, Grigioni F, Le Tourneau T, Roussel JC, Bax JJ, Ajmone Marsan N, Butcher SC, Tribouilloy C, Rusinaru D, Hochstadt A, Topilsky Y, El-Am E, Thapa P, Michelena HI, Enriquez-Sarano M. Reappraisal of the Concept and Implications of Pulmonary Hypertension in Degenerative Mitral Regurgitation. JACC Cardiovasc Imaging 2024:S1936-878X(24)00195-5. [PMID: 38934979 DOI: 10.1016/j.jcmg.2024.05.006] [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: 02/14/2024] [Revised: 04/18/2024] [Accepted: 05/07/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND European and U.S. clinical guidelines diverge regarding pulmonary hypertension (PHTN) in degenerative mitral regurgitation (DMR). Gaps in knowledge underpinning these divergences affect risk assessment and management recommendations attached to systolic pulmonary pressure (SPAP) in DMR. OBJECTIVES This study sought to define PHTN links to DMR severity, prognostic thresholds, and independent outcome impact in a large quantitative DMR registry. METHODS This study gathered a large multicentric registry of consecutive patients with isolated moderate-to-severe DMR, with DMR and SPAP quantified prospectively at diagnosis. RESULTS In 3,712 patients (67 ± 15 years, 36% women) with ≥ moderate-to-severe DMR, effective regurgitant orifice (ERO) was 0.42 ± 0.19 cm2, regurgitant volume 66 ± 327 mL/beat and SPAP 41 ± 16 mm Hg. Spline-curve analysis showed excess mortality under medical management emerging around SPAP 35 mm Hg and doubling around SPAP 50 mm Hg. Accordingly, severe pulmonary hypertension (sPHTN) (SPAP ≥50 mm Hg) was detected in 916 patients, moderate pulmonary hypertension (mPHTN) (SPAP 35-49 mm Hg) in 1,128, and no-PHTN (SPAP <35 mm Hg) in 1,668. Whereas SPAP was strongly associated with DMR-ERO, nevertheless excess mortality with sPHTN (adjusted HR: 1.65; 95% CI: 1.24-2.20) and mPHTN (adjusted HR: 1.44; 95% CI: 1.11-1.85; both P ≤ 0.005) was observed independently of ERO and all baseline characteristics and in all patient subsets. Nested models demonstrated incremental prognostic value of mPHTN and sPHTN (all P < 0.0001). Despite higher operative risk with mPHTN and sPHTN, DMR surgical correction was followed by higher survival in all PHTN ranges with strong survival benefit of early surgery (<3 months). Postoperatively, excess mortality was abolished (P ≥ 0.30) in mPHTN, but only abated in sPHTN. CONCLUSIONS This large international registry, with prospectively quantified DMR and SPAP, demonstrates a Doppler-defined PHTN impact on mortality, independent of DMR severity. Crucially, it defines objectively the new and frequent mPHTN range, independently linked to excess mortality under medical management, which is abolished by DMR correction. Thus, at DMR diagnosis, Doppler-SPAP measurement defining these new PHTN ranges, is crucial to guiding DMR management.
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Affiliation(s)
- Benjamin Essayagh
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA; Department of Echocardiography, Cardio X Clinic, Cannes, France
| | - Giovanni Benfari
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Clemence Antoine
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | | | - Jeroen J Bax
- Leiden University Medical Center, Department of Cardiology, Leiden, the Netherlands
| | - Nina Ajmone Marsan
- Leiden University Medical Center, Department of Cardiology, Leiden, the Netherlands
| | - Steele C Butcher
- Leiden University Medical Center, Department of Cardiology, Leiden, the Netherlands; Department of Cardiology. Royal Perth Hospital, Perth, Western Australia, Australia
| | | | - Dan Rusinaru
- University of Amiens, Department of Cardiology, Amiens, France
| | - Aviram Hochstadt
- Tel Aviv Medical Center and Sackler Faculty of Medicine, Department of Cardiology, Tel Aviv, Israel
| | - Yan Topilsky
- Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Edward El-Am
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Prabin Thapa
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Hector I Michelena
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Maurice Enriquez-Sarano
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA; Abbott Northwestern Hospital, Minneapolis, Minnesota, USA.
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12
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Song K, Lee JH, Woo HT, Kim YS, Jang WS, Chung S, Cho YH, Kim WS, Sung K. Surgical outcome of mitral valve surgery in atrial functional mitral regurgitation compared with degenerative etiology. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00515-4. [PMID: 38879118 DOI: 10.1016/j.jtcvs.2024.06.002] [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: 02/19/2024] [Revised: 05/06/2024] [Accepted: 06/02/2024] [Indexed: 07/07/2024]
Abstract
OBJECTIVE To analyze and compare the outcomes of mitral valve surgery for atrial functional mitral regurgitation (AFMR) and for degenerative mitral regurgitation (DMR). METHODS Patients with AFMR or DMR who underwent mitral valve repair/replacement at 2 institutions between January 2012 and December 2022 were included. Patients <18 years of age and patients undergoing concomitant cardiac surgery (except for the maze procedure or tricuspid annuloplasty) were excluded. Propensity score analysis was used to adjust for baseline differences. RESULTS A total of 642 patients were enrolled. After propensity score analysis, 164 patients were classified into the DMR group, and 82 patients were classified into the AFMR group. All matched patients in both groups had atrial fibrillation. In DMR and AFMR, the 5-year freedom from readmission for heart failure and cardiac death was 96.3% in the DMR group versus 88.6% in the AFMR group (P = .045) and freedom from readmission for cardiac death in the 2 groups was 100% and 90.0%, respectively (P = .002). The recurrence rate of significant mitral regurgitation (MR) after mitral valve repair was not significantly different between the 2 groups (P = .699, log-rank test), and the 5-year freedom from MR recurrence (moderate or greater) was 89.8% and 93.0%, respectively. After the maze procedure, significantly more patients in the AFMR group than the DMR group were in junctional rhythm (49.1% vs 3.3%; P < .001) and required permanent pacemaker insertion during the follow-up period (11.4% vs 1.5% after 5 years; P = .041, log-rank test). CONCLUSIONS AFMR was associated with acceptable outcomes of mitral valve surgery, and mitral valve repair is a good treatment option. However, significantly more patients were in junctional rhythm after the maze procedure, needing more permanent pacemaker insertion.
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Affiliation(s)
- Kyungsub Song
- Department of Thoracic and Cardiovascular Surgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Jun Ho Lee
- Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Hyeong Taek Woo
- Department of Preventive Medicine, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Yun Seok Kim
- Department of Thoracic and Cardiovascular Surgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Woo Sung Jang
- Department of Thoracic and Cardiovascular Surgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Suryeun Chung
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yang Hyun Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Wook Sung Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kiick Sung
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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13
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Akashi J, Otsuji Y, Nishimura Y, Levine RA, Kataoka M. Updated pathophysiological overview of functional MR (ventricular and atrial). Gen Thorac Cardiovasc Surg 2024:10.1007/s11748-024-02047-5. [PMID: 38858323 DOI: 10.1007/s11748-024-02047-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 05/22/2024] [Indexed: 06/12/2024]
Abstract
Basic mechanism of ventricular functional mitral regurgitation (FMR) is subvalvular tethering. Left ventricular (LV) dilatation, in association with mitral valve (MV) annular dilatation, causes outward displacement of papillary muscles (PMs), which abnormally pulls or tethers MV leaflets, resulting in MV tenting, reduction in leaflets coaptation and MR. Because surgical annuloplasty does shorten distance between anterior and posterior MV annuli to improve coaptation but does not address this subvalvular tethering, ventricular FMR frequently persists or recurs in the chronic stage after surgical annuloplasty. This high incidence of persistent/recurrent MR requires additional procedures to reduce subvalvular tethering. Although patients occasionally show marked improvements after annuloplasty with surgical tethering reduction procedures such as PM approximation, evidence to support benefits of such surgery is limited, requiring further trials. Recently, MV adaptation or MV leaflets tissue growth associated with LV dilatation attracts attention. Patients with larger MV leaflets with significant LV dilatation/dysfunction show less MV tethering and MR compared to those with smaller MV leaflets but with similar LV remodeling, suggesting the protective or beneficial role of MV leaflets tissue growth against LV remodeling. The MV leaflets tissue growth has the potential to lead to novel strategies of treatment for ventricular FMR. It is well known that atrial FMR is frequent in patients with left atrial dilatation, typically in those with isolated atrial fibrillation. The degree of atrial FMR is usually mild, even when it is present, and occasionally moderate, and severe atrial FMR is really rare. It is known that only severe regurgitation causes heart failure in primary MR, resulting in description on indications of surgery or intervention for only severe MR in current guidelines. Therefore, this atrial FMR up to moderate degree did not attract attention for a long time. However, recent studies have shown that patients with only moderate atrial FMR develop severe heart failure, suggesting more aggressive indication of MV surgery or intervention for "moderate" regurgitation in patients with atrial FMR. Therefore, atrial FMR is now recognized highly important. The unveiled malignant nature of atrial FMR arises many questions, including (1) why patients with only moderate atrial FMR develop heart failure? (2) do patients with mild atrial FMR develop heart failure or not?, and many others. Atrial FMR seems even more mysterious after the unveiling of its significance.
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Affiliation(s)
- Jun Akashi
- Second Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yutaka Otsuji
- Department of Cardiovascular Medicine, Hagiwara Central Hospital, 1-10-1 Hagiwara, Yahatanishiku, Kitakyushu, 806-0059, Japan.
| | - Yosuke Nishimura
- Department of Cardiovascular Surgery, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Robert A Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Boston, MA, USA
| | - Masaharu Kataoka
- Second Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
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14
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Pölzl L, Gollmann-Tepeköylü C, Nägele F, Cetin K, Spilka J, Holfeld J, Oezpeker UC, Stastny L, Graber M, Hirsch J, Engler C, Dumfarth J, Ruttmann-Ulmer E, Hangler H, Grimm M, Müller L, Höfer D, Bonaros N. Five-year outcomes of different techniques for minimally invasive mitral valve repair in Barlow's disease. Eur J Cardiothorac Surg 2024; 65:ezae213. [PMID: 38781502 PMCID: PMC11150856 DOI: 10.1093/ejcts/ezae213] [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] [Received: 02/21/2024] [Revised: 04/12/2024] [Accepted: 05/22/2024] [Indexed: 05/25/2024] Open
Abstract
OBJECTIVES Barlow's disease is a specific sub-form of mitral valve (MV) disease, characterized by diffuse excessive tissue and multi segment prolapse. The anterolateral mini-thoracotomy represents the standard access for MV regurgitation in many centres. It still remains unclear which surgical technique provides the best results. Therefore, the aim of this study was to compare operative safety and mid-term outcomes after (i) isolated annuloplasty, (ii) use of additional artificial chordae or (iii) leaflet resection in patients suffering from Barlow's disease undergoing minimally invasive MV repair. METHODS A consecutive series of patients suffering from Barlow's disease undergoing minimally invasive MV surgery between 2001 and 2020 were analysed (n = 246). Patients were grouped and analysed according to the used surgical technique. The primary outcome was a modified Mitral Valve Academic Research Consortium combined end-point of mortality, reoperation due to repair failure or reoccurrence of severe mitral regurgitation within 5 years. The secondary outcome included operative success and safety up to 30 days. RESULTS No significant difference was found between the 3 surgical techniques with regard to operative safety (P = 0.774). The primary outcome did not differ between groups (P = 0.244). Operative success was achieved in 93.5% and was lowest in the isolated annuloplasty group (77.1%). Conversion to MV replacement was increased in patients undergoing isolated annuloplasty (P < 0.001). CONCLUSIONS Isolated annuloplasty, use of additional artificial chordae and leaflet resection represent feasible techniques in Barlow patients undergoing minimally invasive MV surgery with comparable 5-year results. In view of the increased conversion rate in the annuloplasty group, the pathology should not be oversimplified.
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Affiliation(s)
- Leo Pölzl
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Felix Nägele
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Kardelen Cetin
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Johannes Spilka
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Johannes Holfeld
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Ulvi C Oezpeker
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Luka Stastny
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Graber
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Jakob Hirsch
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Clemens Engler
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Julia Dumfarth
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Herbert Hangler
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Grimm
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Ludwig Müller
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Daniel Höfer
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Nikolaos Bonaros
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
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15
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Hamid N, Bursi F, Benfari G, Vanoverschelde JL, Tribouilloy C, Biagini E, Avierinos JF, Barbieri A, Fan Y, Guerra F, Leng CY, Essayagh B, Pasquet A, Szymansky C, Théron A, Michelena HI, Nkomo VT, Vancraeynest D, Rusinaru D, Grigioni F, Enriquez-Sarano ML, Pin DZ, Pui-Wai Lee A. Degenerative Mitral Regurgitation Outcomes in Asian Compared With European-American Institutions. JACC. ASIA 2024; 4:468-480. [PMID: 39100700 PMCID: PMC11291393 DOI: 10.1016/j.jacasi.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 03/14/2024] [Accepted: 03/16/2024] [Indexed: 08/06/2024]
Abstract
Background Clinical outcome and interventional thresholds for degenerative mitral regurgitation (DMR) were developed in studies of patients at European and American institutions (EAIs), but little is known about patients at Asian institutions (AsIs). Objectives This study sought to contrast DMR presentation/management/outcomes of AsI patients vs EAI patients. Methods Patients with DMR due to flail leaflet from Hong Kong and Singapore (AsI cohort, n = 737) were compared with EAI patients (n = 682) enrolled in the MIDA (Mitral regurgitation International Database) registry with similar eligibility criteria. Results AsI patients presented similar DMR lesion/consequences vs EAI patients, but they were younger, with fewer symptoms (74% vs 44% Class I), more sinus rhythm (83% vs 69%), and lower EuroSCORE II (European System for Cardiac Operative Risk Evaluation II) (0.9 ± 0.5 vs 1.4 ± 1.5; all P < 0.0001). Imaging showed smaller absolute left atrial/ventricular dimensions in AsI patients, belying cardiac dilatation with larger body surface area-indexed diameters (all P < 0.01). Surgical/interventional mitral repair was similarly predominant (90% vs 91%; P = 0.47), and early repair was similarly beneficial (for AsI patients, adjusted HR: 0.28; 95% CI: 0.16-0.49; for EAI patients, HR: 0.32; 95% CI: 0.20-0.49; both P < 0.0001). However, AsI patients underwent fewer interventions (55% ± 2% vs 77% ± 2% at 1 year; P < 0.0001) and incurred excess mortality (adjusted HR: 1.60 [95% CI: 1.13-2.27] vs EAI patients; P = 0.008) at long-term postdiagnosis. Propensity score matching (434 patient pairs), which balanced all clinical characteristics, confirmed that there was undertreatment and excess mortality in the long term in AsI patients with DMR (P < 0.0001). Conclusions Imaging may underestimate volume overload in AsI patients due to smaller cardiac cavities related to smaller body size compared with EAI patients with similar mitral lesions and DMR severity. AsI patients enjoy similar mitral repair predominance and early intervention benefits but undergo fewer mitral interventions than EAI patients and incur subsequent excess mortality, suggesting the need to account for imaging and cultural specificity to improve DMR outcomes worldwide.
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Affiliation(s)
- Nadira Hamid
- National Heart Centre Singapore, Singapore
- New York Presbyterian Hospital, Columbia University Medical Center, New York, New York
| | - Francesca Bursi
- University of Milan, Department of Health Sciences, Division of Cardiology, San Paolo Hospital, ASST Santi Paolo e Carlo, Milan, Italy
| | - Giovanni Benfari
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester Minnesota, USA
- University of Verona, Department of Medicine, Section of cardiology, Verona, Italy
| | - Jean-Louis Vanoverschelde
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain and Divisions of Cardiology and Cardiothoracic Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Christophe Tribouilloy
- Department of Cardiology, Amiens University Hospital, Amiens, France, and EA 7517 MP3CV Université de Picardie Jules Verne University Hospital, Amiens, France
| | - Elena Biagini
- Cardiovascular Department, University Hospital S. Orsola-Malpighi, Bologna, Italy
| | | | - Andrea Barbieri
- Divison of Cardiology, Department of Diagnostics, Clinical and Health Public, University of Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Yiting Fan
- Shanghai Chest Hospital, Shanghai, P.R. China
| | - Federico Guerra
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital "Umberto I - Lancisi - Salesi", Ancona, Italy
| | | | - Benjamin Essayagh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester Minnesota, USA
| | - Agnés Pasquet
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain and Divisions of Cardiology and Cardiothoracic Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Catherine Szymansky
- Department of Cardiology, Amiens University Hospital, Amiens, France, and EA 7517 MP3CV Université de Picardie Jules Verne University Hospital, Amiens, France
| | - Alexis Théron
- Cardiovascular Division, Aix-Marseille Université, INSERM MMG U1251, Marseille, France
| | - Hector I. Michelena
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester Minnesota, USA
| | - Vuyisile T. Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester Minnesota, USA
| | - David Vancraeynest
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain and Divisions of Cardiology and Cardiothoracic Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Dan Rusinaru
- Department of Cardiology, Amiens University Hospital, Amiens, France, and EA 7517 MP3CV Université de Picardie Jules Verne University Hospital, Amiens, France
| | | | - Maurice L. Enriquez-Sarano
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester Minnesota, USA
- Minneapolis Heart Institute, Minneapolis, Minnesota, USA
| | | | - Alex Pui-Wai Lee
- Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Sha Tin, Hong Kong, P.R. China
| | - the MIDA Investigators
- National Heart Centre Singapore, Singapore
- New York Presbyterian Hospital, Columbia University Medical Center, New York, New York
- University of Milan, Department of Health Sciences, Division of Cardiology, San Paolo Hospital, ASST Santi Paolo e Carlo, Milan, Italy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester Minnesota, USA
- University of Verona, Department of Medicine, Section of cardiology, Verona, Italy
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain and Divisions of Cardiology and Cardiothoracic Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
- Department of Cardiology, Amiens University Hospital, Amiens, France, and EA 7517 MP3CV Université de Picardie Jules Verne University Hospital, Amiens, France
- Cardiovascular Department, University Hospital S. Orsola-Malpighi, Bologna, Italy
- Cardiovascular Division, Aix-Marseille Université, INSERM MMG U1251, Marseille, France
- Divison of Cardiology, Department of Diagnostics, Clinical and Health Public, University of Modena, University of Modena and Reggio Emilia, Modena, Italy
- Shanghai Chest Hospital, Shanghai, P.R. China
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital "Umberto I - Lancisi - Salesi", Ancona, Italy
- Cardiovascular Department, University Campus Bio-Medico, Rome, Italy
- Minneapolis Heart Institute, Minneapolis, Minnesota, USA
- Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Sha Tin, Hong Kong, P.R. China
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16
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Fiore G, Ingallina G, Ancona F, Gaspardone C, Biondi F, Margonato D, Morosato M, Belli M, Tavernese A, Stella S, Agricola E. Quantification of Mitral Regurgitation in Mitral Valve Prolapse by Three-Dimensional Vena Contracta Area: Derived Cutoff Values and Comparison With Two-Dimensional Multiparametric Approach. J Am Soc Echocardiogr 2024; 37:591-598. [PMID: 38522488 DOI: 10.1016/j.echo.2024.03.009] [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] [Received: 01/10/2024] [Revised: 03/06/2024] [Accepted: 03/08/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND Echocardiographic grading of mitral regurgitation (MR) in mitral valve prolapse (MVP) is challenging. Three-dimensional (3D) vena contracta area (VCA) has been proposed as a valuable method. However, data defining the cutoff values of severity and validation in the subset of patients with MVP are scarce. The aim of this study was to validate the 3D VCA by 3D color-Doppler transesophageal echocardiography (TEE) in patients with MVP and to define the cutoff values of severity grading. The secondary aim was to compare 3D VCA to the effective regurgitant orifice area estimation by proximal isovelocity surface area (EROA-PISA) method. METHODS A total of 1,138 patients with at least moderate MR who underwent TEE were included. Three-dimensional VCA was measured, and the cutoff value and area under the curve (AUC) for the prediction of severe MR were estimated by receiver operating characteristic curve using a guideline-suggested multiparametric approach as the reference standard. In a subgroup of patients, 3D regurgitant volume (RV) and 3D fraction were calculated from mitral and left ventricular outflow tract stroke volumes to further validate 3D VCA against a 3D volumetric reference standard. RESULTS The optimal 3D VCA cutoff value for predicting severe MR was 0.45 cm2 (specificity, 0.87; sensitivity, 0.90) with an AUC of 0.95 using a multiparametric approach as reference. Three-dimensional VCA had a good linear correlation with EROA-PISA (r = 0.62, P < .05) with larger values compared to EROA-PISA (0.63 cm2 vs 0.44 cm2, P < .05). A cutoff of 0.50 cm2 (AUC of 0.84; sensitivity, 0.78; specificity, 0.78) predicts an EROA-PISA of 0.40 cm2. Three-dimensional VCA had a good linear correlation with 3D RV (r = 0.56, P < .01), with an AUC of 0.86 to predict a 3D fraction >50%. CONCLUSIONS The present study suggests 0.45 cm2 as the best cutoff value of 3D VCA to define severe MR in patients with MVP, showing an optimal agreement with the reference standard multiparametric approach and 3D RV.
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Affiliation(s)
- Giorgio Fiore
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giacomo Ingallina
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Ancona
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Carlo Gaspardone
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Federico Biondi
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Davide Margonato
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Michele Morosato
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Martina Belli
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Annamaria Tavernese
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Stella
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Eustachio Agricola
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy.
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17
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Koukos M, Dimitroglou Y, Tsartsalis D, Beneki E, Tolis E, Patsourakos D, Kalompatsou A, Aggeli C, Tsioufis K. Left Atrium: A New Prognostic Marker and Therapeutic Target in Secondary Mitral Regurgitation? Eur Cardiol 2024; 19:e04. [PMID: 38807855 PMCID: PMC11131153 DOI: 10.15420/ecr.2023.47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 03/13/2024] [Indexed: 05/30/2024] Open
Abstract
Mitral regurgitation (MR) is one of the most common valvular abnormalities worldwide and can be subdivided into primary and secondary causes. Atrial MR consists of a novel type of secondary MR (SMR), most often observed in patients with AF and heart failure with preserved ejection fraction. The main pathophysiological mechanism of atrial MR is mitral valve annular dilatation. Recently published studies have highlighted the clinical significance of left atrium (LA) evaluation in the early diagnosis and prognosis of patients with primary MR. However, there are little data regarding the role of the LA in SMR. The present literature review aims to elucidate the use of the echocardiographic parameters regarding LA evaluation in the prognosis prediction and therapeutic strategy of patients with SMR.
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Affiliation(s)
- Markos Koukos
- 1st Department of Cardiology, Hippokration Hospital of Athens, University of Athens Athens, Greece
| | - Yannis Dimitroglou
- 1st Department of Cardiology, Hippokration Hospital of Athens, University of Athens Athens, Greece
| | - Dimitrios Tsartsalis
- 1st Department of Cardiology, Hippokration Hospital of Athens, University of Athens Athens, Greece
| | - Eirini Beneki
- 1st Department of Cardiology, Hippokration Hospital of Athens, University of Athens Athens, Greece
| | - Elias Tolis
- 1st Department of Cardiology, Hippokration Hospital of Athens, University of Athens Athens, Greece
| | - Dimitrios Patsourakos
- 1st Department of Cardiology, Hippokration Hospital of Athens, University of Athens Athens, Greece
| | - Argyro Kalompatsou
- 1st Department of Cardiology, Hippokration Hospital of Athens, University of Athens Athens, Greece
| | - Constantina Aggeli
- 1st Department of Cardiology, Hippokration Hospital of Athens, University of Athens Athens, Greece
| | - Konstantinos Tsioufis
- 1st Department of Cardiology, Hippokration Hospital of Athens, University of Athens Athens, Greece
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18
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Spieker M, Sidabras J, Lagarden H, Christian L, Angendohr S, Zweck E, Bejinariu A, Veulemanns V, Schulze C, Polzin A, Rana O, Westenfeld R, Kelm M, Horn P. Prevalence and prognostic impact of dynamic atrial functional mitral regurgitation assessed by isometric handgrip exercise. Eur Heart J Cardiovasc Imaging 2024; 25:589-598. [PMID: 38066677 DOI: 10.1093/ehjci/jead336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 11/17/2023] [Accepted: 12/02/2023] [Indexed: 01/10/2024] Open
Abstract
AIMS In atrial functional mitral regurgitation (aFMR), a considerable proportion of patients displays a discrepancy between symptoms and echocardiographic findings at rest. Exercise testing plays a substantial role in assessing the haemodynamic relevance of mitral regurgitation (MR) and is recommended by current guidelines. Here, we aimed to assess the prevalence, extent, and prognostic impact of exercise-induced changes in patients with aFMR. METHODS AND RESULTS Patients with at least mild MR who underwent handgrip exercise echocardiography at the University Hospital Duesseldorf between January 2019 and September 2021 were enrolled. Patients were followed up for 1 year to assess clinical outcomes. Eighty patients with aFMR were included [median age: 80 (77-83) years; 53.8% female]. The median N-terminal pro-brain natriuretic peptide level was 1756 (1034-3340) ng/L. At rest, half of the patients (53.8%) had mild MR, 20 patients (25.0%) had moderate MR, and 17 patients (21.2%) had severe MR. In approximately every fifth patient (17.5%) with non-severe MR at rest, the MR became severe during exercise. Handgrip exercise led to a reclassification of MR severity in 28 patients (35.0%). At 1-year follow-up, adverse events occurred more often in patients with severe MR at rest (76.5%) and exercise-induced dynamic severe MR (66.7%) than in those with non-severe MR (28.6%; P < 0.001). CONCLUSION Handgrip exercise during echocardiography revealed exercise-induced changes in aFMR in every third patient. These data may have implications for therapeutic decision-making in symptomatic patients with non-severe aFMR at rest.
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Affiliation(s)
- Maximilian Spieker
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Jonas Sidabras
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Hannah Lagarden
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Lucas Christian
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Stephan Angendohr
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Elric Zweck
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Alexandru Bejinariu
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Verena Veulemanns
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Christian Schulze
- Division of Cardiology, Intensive Care Medicine and Vascular Medicine, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Amin Polzin
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Obaida Rana
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Ralf Westenfeld
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
- Cardiovascular Research Institute Duesseldorf, Medical Faculty, Heinrich-Heine University, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Patrick Horn
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
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19
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Naser JA, Alexandrino FB, Harada T, Michelena HI, Borlaug BA, Eleid MF, Lin G, Scott C, Kennedy AM, Pellikka PA, Nkomo VT, Pislaru SV. The Natural History of Atrial Functional Mitral Regurgitation. J Am Coll Cardiol 2024; 83:1495-1507. [PMID: 38530687 DOI: 10.1016/j.jacc.2024.02.026] [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] [Received: 01/25/2024] [Accepted: 02/20/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND The natural history of moderate/severe atrial functional mitral regurgitation (AFMR) is unknown. OBJECTIVES The authors sought to study the incidence of left ventricular (LV) systolic dysfunction (LVSD), progression or regression of ≥mild-moderate AFMR, and impact on mortality. METHODS Adults with left atrial (LA) volume index ≥40 mL/m2, ≥mild-moderate AFMR, and follow-up echocardiogram were followed for incident LVSD (ejection fraction <50% and ≥10% lower than baseline), progression of mild-moderate/moderate AFMR to severe, and persistent regression of AFMR to no/trivial. Relation of AFMR progression or regression as time-dependent covariates with all-cause mortality was studied. Incidence of LVSD was compared with patients with no/mild AFMR matched on age, sex, comorbidities and ejection fraction. Patients were followed until mitral intervention, myocardial infarction, or last follow-up. RESULTS A total of 635 patients (median age 75 years, 51% female, 96% mild-moderate/moderate AFMR, 4% severe AFMR) were included. Over a median 2.2 years (Q1-Q3: 1.0-4.3 years), incidence rates per 100 person-years were 3.2 for LVSD (P = 0.52 vs patients with no/mild AFMR), 1.9 for progression of AFMR, and 3.9 for regression. Female sex and larger LA volume index were independently associated with progression, whereas younger age, male sex, absent atrial fibrillation, and higher LA emptying fraction were independently associated with regression. Neither AFMR progression nor regression was independently associated with mortality. Instead, independent risk factors for mortality included older age, concentric LV geometry, and higher estimated LV filling and pulmonary pressures. CONCLUSIONS In patients with predominantly mild-moderate/moderate AFMR, regression of MR was more common than progression, but neither was associated with mortality. Instead, diastolic function abnormalities were more important. Over a median 2-year follow-up, LVSD risk was not increased.
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Affiliation(s)
- Jwan A Naser
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | | | - Tomonari Harada
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Hector I Michelena
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Grace Lin
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Christopher Scott
- Department of Biostatistics and Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Austin M Kennedy
- Department of Biostatistics and Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Patricia A Pellikka
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
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20
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Vandervoort PM, Deferm S. The Course of Atrial Functional Mitral Regurgitation: The Atrium Dictates the Path. J Am Coll Cardiol 2024; 83:1508-1510. [PMID: 38631770 DOI: 10.1016/j.jacc.2024.03.357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 03/06/2024] [Indexed: 04/19/2024]
Affiliation(s)
| | - Sébastien Deferm
- Department of Cardiology, Ziekenhuis Oost-Limburg Genk, Limburg, Belgium; Department of Cardiology, Inselspital Bern, Bern, Switzerland. https://twitter.com/S_Deferm
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21
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Dhont S, van den Acker G, van Loon T, Verbrugge FH, Verwerft J, Deferm S, Churchill TW, Mullens W, Lumens J, Bertrand PB. Mitral regurgitation in heart failure with preserved ejection fraction: The interplay of valve, ventricle, and atrium. Eur J Heart Fail 2024; 26:974-983. [PMID: 38629747 PMCID: PMC11184410 DOI: 10.1002/ejhf.3231] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/22/2024] [Accepted: 03/26/2024] [Indexed: 05/31/2024] Open
Abstract
Mitral regurgitation (MR) is highly prevalent among patients with heart failure and preserved ejection fraction (HFpEF). Despite this combination being closely associated with unfavourable outcomes, it remains relatively understudied. This is partly due to the inherent heterogeneity of patients with HFpEF. To address this gap, dissecting HFpEF into mechanism-based phenotypes may offer a promising avenue for advancing our comprehension of these complex intertwined conditions. This review employs the validated CircAdapt model to explore the haemodynamic implications of moderate to severe MR across a well-defined spectrum of myocardial disease, characterized by impaired relaxation and reduced myocardial compliance. Both heart failure and mitral valve disease share overlapping symptomatology, primarily attributed to elevated pulmonary pressures. The intricate mechanisms contributing to these elevated pressures are multifaceted, potentially influenced by diastolic dysfunction, left atrial myopathy, and MR. Accurate evaluation of the haemodynamic and clinical impact of MR necessitates a comprehensive approach, taking into account the characteristics of both the left atrium and left ventricle, as well as their intricate interactions, which may currently be underemphasized in diagnostic practice. This holistic assessment is imperative for enhancing our understanding and refining therapeutic strategies within this patient cohort.
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Affiliation(s)
- Sebastiaan Dhont
- Faculty of Medicine and Life Sciences, LCRC, Hasselt University, Diepenbeek, Belgium
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Department of Future Health, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Gitte van den Acker
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Tim van Loon
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Frederik H. Verbrugge
- Center for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Jan Verwerft
- Faculty of Medicine and Life Sciences, LCRC, Hasselt University, Diepenbeek, Belgium
- Department of Cardiology, Jessa Hospital, Hasselt, Belgium
| | - Sébastien Deferm
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Department of Cardiology, Inselspital Bern, Bern, Switzerland
| | | | - Wilfried Mullens
- Faculty of Medicine and Life Sciences, LCRC, Hasselt University, Diepenbeek, Belgium
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Department of Future Health, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Joost Lumens
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Philippe B. Bertrand
- Faculty of Medicine and Life Sciences, LCRC, Hasselt University, Diepenbeek, Belgium
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Department of Future Health, Ziekenhuis Oost-Limburg, Genk, Belgium
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22
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Minga I, Kwak E, Hussain K, Wathen L, Gaznabi S, Singh L, Macrinici V, Wang CH, Singulane C, Addetia K, Sarswat N, Slivnick J, Pursnani A. Prevalence of valvular heart disease in cardiac amyloidosis and impact on survival. Curr Probl Cardiol 2024; 49:102417. [PMID: 38280494 DOI: 10.1016/j.cpcardiol.2024.102417] [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: 01/16/2024] [Accepted: 01/18/2024] [Indexed: 01/29/2024]
Abstract
BACKGROUND Limited data exists on the prognostic impact of valvular heart disease in cardiac amyloidosis (CA). We therefore sought to define the prevalence of valvular disease in patients with CA and assess the effects of significant valve disease on survival. METHODS This multi-center retrospective cohort study included consecutive patients with confirmed transthyretin (TTR) or light chain (AL) amyloidosis. Echocardiographic data closest to the date of amyloid diagnosis was reviewed, and severity was graded according to ASE guidelines. Kaplan-Meier survival analysis was performed to compare survival between patients with moderate or greater valve disease against those with mild or less disease. RESULTS We included 345 patients (median age 76 years; 73 % men; 110 AL, 235TTR). The median survival for the total patient cohort with cardiac amyloidosis was 2.92 years, with 30 % of patients surviving at five years after their diagnosis. Median survival comparing AL vs ATTR was 2.58 years vs 2.82 years (p = 0.67) The most common valvular abnormalities in the total cohort were mitral (62 %) and tricuspid (66 %).regurgitation There was a statistically significant difference in median survival between patients with no or mild MR compared to those with moderate or severe MR (2.92 years vs 3.35 years, p = 0.0047) (Fig. 5). There was a statistically significant difference in median survival in patients with no or mild TR compared to those with moderate or severe TR (3.35 years vs 2.3 years, p = 0.015). CONCLUSION Our study demonstrates a significant prevalence of mitral and tricuspid regurgitation in CA, with patients with moderate to severe MR and TR having a poorer prognosis.
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Affiliation(s)
- Iva Minga
- University of Chicago Medical Center, Chicago, IL, United States.
| | - Esther Kwak
- Medical College of Milwaukee Medical Center, Milwaukee, IL, United States
| | - Kifah Hussain
- Northshore University HealthSystem, Evanston, IL, United States
| | - Lucas Wathen
- Northshore University HealthSystem, Evanston, IL, United States
| | | | - Lavisha Singh
- Northshore University HealthSystem, Evanston, IL, United States
| | | | - Chi-Hsiung Wang
- Northshore University HealthSystem, Evanston, IL, United States
| | | | - Karima Addetia
- University of Chicago Medical Center, Chicago, IL, United States
| | - Nitasha Sarswat
- University of Chicago Medical Center, Chicago, IL, United States
| | - Jeremy Slivnick
- University of Chicago Medical Center, Chicago, IL, United States
| | - Amit Pursnani
- Northshore University HealthSystem, Evanston, IL, United States
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Mori M, Waldron C, Ragnarsson S, Krane M, Geirsson A. The high-risk features among patients undergoing mitral valve operation for ischemic mitral regurgitation: The 3-strike score. JTCVS OPEN 2024; 18:52-63. [PMID: 38690412 PMCID: PMC11056490 DOI: 10.1016/j.xjon.2024.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 01/26/2024] [Accepted: 02/19/2024] [Indexed: 05/02/2024]
Abstract
Objective Ischemic mitral regurgitation is prevalent and associated with high surgical risk. With the less-invasive option of transcatheter edge-to-edge repair, the optimal patient selection for mitral valve operation for ischemic mitral regurgitation remains unclear. We sought to identify high-risk features in this group to guide patient selection. Methods Using the Cardiothoracic Surgery Trial Network's severe ischemic mitral regurgitation trial data, we identified patient and echocardiographic characteristics associated with an increased risk of 2-year mortality using the support vector classifier and Cox proportional hazards model. We identified 6 high-risk features associated with 2-year survival. Patients were categorized into 3 groups, each having 1 or less, 2, or 3 or more of the 6 identified high-risk features. Results Among the 251 patients, the median age was 69 (Q1 62, Q3 75) years, and 96 (38%) were female. Two-year mortality was 21% (n = 53). We identified 6 high-risk preoperative features: age 75 years or more (n = 69, 28%), prior sternotomy (n = 49, 20%), renal insufficiency (n = 69, 28%), gastrointestinal bleeding (n = 15, 6%), left ventricular ejection fraction less than 40% (n = 131, 52%), and ventricular end-systolic volume index less than 50 mL/m2 (n = 93, 37%). In patients who had 1 or less, 2, and 3 or more high-risk features, 90-day mortality was 4.2% (n = 5), 9.9% (n = 4), and 20.0% (n = 10), respectively (P = .006), and 2-year mortality was 10% (n = 12), 22% (n = 18), and 46% (n = 23) (P < .001), respectively. Conclusions We developed the 3-strike score by identifying high-risk preoperative features for mitral valve surgery for ischemic mitral regurgitation. Patients having 3 or more of such high-risk features should undergo careful evaluation for surgical candidacy given the high early and late mortality after mitral valve operations.
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Affiliation(s)
- Makoto Mori
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Conn
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Conn
| | - Christina Waldron
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Conn
| | | | - Markus Krane
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Conn
| | - Arnar Geirsson
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Conn
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Zhang L, Cheng Z, Xu D, Wang Z, Cai S, Hu N, Ma J, Mei X. Developing an AI-assisted digital auscultation tool for automatic assessment of the severity of mitral regurgitation: protocol for a cross-sectional, non-interventional study. BMJ Open 2024; 14:e074288. [PMID: 38553085 PMCID: PMC10982737 DOI: 10.1136/bmjopen-2023-074288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 03/11/2024] [Indexed: 04/02/2024] Open
Abstract
INTRODUCTION Mitral regurgitation (MR) is the most common valvular heart disorder, with a morbidity rate of 2.5%. While echocardiography is commonly used in assessing MR, it has many limitations, especially for large-scale MR screening. Cardiac auscultation with electronic stethoscope and artificial intelligence (AI) can be a fast and economical modality for assessing MR severity. Our objectives are (1) to establish a deep neural network (DNN)-based cardiac auscultation method for assessing the severity of MR; and (2) to quantitatively measure the performance of the developed AI-based MR assessment method by virtual clinical trial. METHODS AND ANALYSIS In a cross-sectional design, phonocardiogram will be recorded at the mitral valve auscultation area of outpatients. The enrolled patients will be checked by echocardiography to confirm the diagnosis of MR or no MR. Echocardiographic parameters will be used as gold standard to assess the severity of MR, classified into four levels: none, mild, moderate and severe. The study consists of two stages. First, an MR-related cardiac sound database will be created on which a DNN-based MR severity classifier will be trained. The automatic MR severity classifier will be integrated with the Smartho-D2 electronic stethoscope. Second, the performance of the developed smart device will be assessed in an independent clinical validation data set. Sensitivity, specificity, precision, accuracy and F1 score of the developed smart MR assessment device will be evaluated. Agreement on the performance of the smart device between cardiologist users and patient users will be inspected. The interpretability of the developed model will also be studied with statistical comparisons of occlusion map-guided variables among the four severity groups. ETHICS AND DISSEMINATION The study protocol was approved by the Medical Ethics Committee of Huzhou Central Hospital, China (registration number: 202302009-01). Informed consent is required from all participants. Dissemination will be through conference presentations and peer-reviewed journals. TRIAL REGISTRATION NUMBER ChiCTR2300069496.
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Affiliation(s)
- Li Zhang
- Department of Cardiology, Huzhou Central Hospital, The Fifth School of Clinical Medicine of Zhejiang Chinese Medical University, The Affiliated Central Hospital of Huzhou University, Huzhou, Zhejiang, China
| | - Zhenfeng Cheng
- Department of Cardiology, Huzhou Central Hospital, The Fifth School of Clinical Medicine of Zhejiang Chinese Medical University, The Affiliated Central Hospital of Huzhou University, Huzhou, Zhejiang, China
| | - Dongyang Xu
- Center for Intelligent Acoustics and Signal Processing, Huzhou Institute of Zhejiang University, Huzhou, Zhejiang, China
| | - Zhi Wang
- Center for Intelligent Acoustics and Signal Processing, Huzhou Institute of Zhejiang University, Huzhou, Zhejiang, China
- State Key Laboratory of Industrial Control Technology, Zhejiang University, Hangzhou, Zhejiang, China
| | - Shengsheng Cai
- Center for Intelligent Acoustics and Signal Processing, Huzhou Institute of Zhejiang University, Huzhou, Zhejiang, China
- Suzhou Melodicare Medical Technology Co., Ltd, Suzhou, Jiangsu, China
| | - Nan Hu
- School of Electronics and Information Engineering, Soochow University, Suzhou, Jiangsu, China
| | - Jianming Ma
- Administration Office, Huzhou Central Hospital, The Fifth School of Clinical Medicine of Zhejiang Chinese Medical University, The Affiliated Central Hospital of Huzhou University, Huzhou, Zhejiang, China
| | - Xueqin Mei
- Department of Medical Engineering, Huzhou Central Hospital, The Fifth School of Clinical Medicine of Zhejiang Chinese Medical University, The Affiliated Central Hospital of Huzhou University, Huzhou, Zhejiang, China
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Papadopoulos K, Ikonomidis I, Vannan MA. The added value of three-dimensional transthoracic echocardiography in mitral annular disjunction: a case report. Front Cardiovasc Med 2024; 11:1366444. [PMID: 38601046 PMCID: PMC11004239 DOI: 10.3389/fcvm.2024.1366444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 03/13/2024] [Indexed: 04/12/2024] Open
Abstract
Background Mitral annular disjunction (MAD) refers to the arrhythmic mitral valve prolapse (MVP) syndrome associated with ventricular arrhythmias and sudden cardiac death. Although the pathophysiology of this disease is still under investigation, specific imaging criteria that establish the diagnosis have been recognized. In this article, we demonstrate most of these criteria using three-dimensional transthoracic echocardiography (3D-TTE) and provide added value in the management of MAD syndrome. Case presentation A 50-year-old male patient with recent syncope and a history of mitral regurgitation (MR) and MAD was admitted to our clinic for further investigation. According to our protocol, the patient underwent a complete 3D-TTE, laboratory blood exams, and 24 h ambulatory electrocardiogram (ECG). Our investigation confirmed the presence of MAD syndrome with bileaflet prolapse, severe MR, and non-sustained ventricular tachycardia, necessitating an implantable cardioverter defibrillator (ICD) and surgical mitral valve repair. The 3D-TTE analysis of the mitral valve demonstrated mitral annular systolic expansion and systolic flattening of the saddle-shaped annulus and quantified the extent of the disjunction arc. Additionally, four-dimensional (4D) strain analysis of the left ventricle revealed the presence of fibrosis of the posteromedial papillary muscle and basal inferolateral wall, which are variables that are required for the diagnosis and therapeutic management of MAD syndrome. Conclusions 3D-TTE and 4D strain offer valuable insights for diagnosing and managing patients with MAD syndrome. This method seems to correlate well with the other imaging modalities and could be included in the management protocol of MAD syndrome.
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Affiliation(s)
| | - Ignatios Ikonomidis
- Echocardiography Laboratory, 2nd Cardiology Department, Medical School, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Mani A. Vannan
- Structural and Valvular Center of Excellence, Marcus Heart Valve Center, Piedmont Heart Institute, Atlanta, GA, United States
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26
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Naser JA, Michelena HI, Pellikka PA, Scott CG, Kennedy AM, Lin G, Nkomo VT, Pislaru SV. Prevalence and Incidence of Atrial Functional Mitral Regurgitation and its Association With Mortality. JACC Cardiovasc Imaging 2024; 17:333-335. [PMID: 37921721 DOI: 10.1016/j.jcmg.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/14/2023] [Indexed: 11/04/2023]
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27
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Akashi J, Iwataki M, Nabeshima Y, Onoue T, Hayashi A, Tanaga T, Nishino S, Kimura T, Yano M, Watanabe N, Tsuda Y, Araki M, Shibata Y, Nishimura Y, Otsuji Y, Kataoka M. Potential Effects of Mild Atrial Secondary Mitral Regurgitation in Patients With Isolated Atrial Fibrillation. Circ Cardiovasc Imaging 2024; 17:e016239. [PMID: 38415386 DOI: 10.1161/circimaging.123.016239] [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] [Received: 10/18/2023] [Accepted: 01/17/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND Patients with only moderate atrial secondary mitral regurgitation (asMR) frequently develop heart failure (HF). Mechanisms of HF with moderate asMR and the impact of mild asMR remain unclarified. Although mild/moderate primary mitral regurgitation is compensated by left ventricular (LV) dilatation, the LV is not dilated in asMR. We hypothesized that patients with mild asMR without LV dilatation may have impaired hemodynamics and higher risks of subsequent symptomatic HF deterioration. METHODS Stroke volume, cardiac output, and systolic pulmonary artery pressure were measured by echocardiography in 142 patients with isolated atrial fibrillation and 30 healthy controls. The prognosis of patients with isolated atrial fibrillation was followed up. RESULTS In the 142 patients with isolated atrial fibrillation, asMR was no/trivial in 55, mild in 83, moderate in 4, while none had severe asMR. Compared with controls and patients with no/trivial asMR, LV end-diastolic volume index was not increased and hemodynamic parameters were abnormal in patients with mild asMR (LV end-diastolic volume index, 65±6 versus 58±8 versus 60±8 mL/m²; stroke volume index, 42±4 versus 35±4 versus 29±6 mL/m²; P<0.001 versus other 2 groups; cardiac output index, 2.8±0.4 versus 2.8±0.5 versus 2.3±0.6 L/min per m²; P<0.001; systolic pulmonary artery pressure, 21±3 versus 26±5 versus 37±9 mm Hg; P<0.001). Although the event-free rate of HF symptomatic deterioration or hospitalization in patients with no/trivial asMR during a median 13.9 months follow-up was 86.9% and 100%, the rate in mild asMR was 59.4% and 85.0% (P<0.001 or P=0.032), respectively. CONCLUSIONS In the presence of isolated AF and no compensatory LV dilatation, impaired hemodynamics and higher risks of symptomatic HF deterioration were associated with mild asMR, requiring further studies of causalities.
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Affiliation(s)
- Jun Akashi
- Second Department of Internal Medicine (J.A., M.I., Y. Nabeshima, T.O., Y.T., M.A., Y.O., M.K.)
| | - Mai Iwataki
- Second Department of Internal Medicine (J.A., M.I., Y. Nabeshima, T.O., Y.T., M.A., Y.O., M.K.)
| | - Yosuke Nabeshima
- Second Department of Internal Medicine (J.A., M.I., Y. Nabeshima, T.O., Y.T., M.A., Y.O., M.K.)
| | - Takeshi Onoue
- Second Department of Internal Medicine (J.A., M.I., Y. Nabeshima, T.O., Y.T., M.A., Y.O., M.K.)
| | - Atsushi Hayashi
- Division of Cardiovascular Medicine, Shiga University of Medical Science, Japan (A.H.)
| | - Tetsuo Tanaga
- Departments of Clinical Laboratory (T.T.), Miyazaki Medical Association Hospital Cardiovascular Center, Japan
| | - Shun Nishino
- Cardiology (S.N., T.K., Y.S.), Miyazaki Medical Association Hospital Cardiovascular Center, Japan
| | - Toshiyuki Kimura
- Cardiology (S.N., T.K., Y.S.), Miyazaki Medical Association Hospital Cardiovascular Center, Japan
| | - Mitsuhiro Yano
- Cardiovascular Surgery (M.Y.), Miyazaki Medical Association Hospital Cardiovascular Center, Japan
| | - Nozomi Watanabe
- Cardiovascular Physiology, Faculty of Medicine, University of Miyazaki, Japan (N.W.)
| | - Yuki Tsuda
- Second Department of Internal Medicine (J.A., M.I., Y. Nabeshima, T.O., Y.T., M.A., Y.O., M.K.)
| | - Masaru Araki
- Second Department of Internal Medicine (J.A., M.I., Y. Nabeshima, T.O., Y.T., M.A., Y.O., M.K.)
| | - Yoshisato Shibata
- Cardiology (S.N., T.K., Y.S.), Miyazaki Medical Association Hospital Cardiovascular Center, Japan
| | - Yosuke Nishimura
- Department of Cardiovascular Surgery, University of Occupational and Environmental Health, Kitakyushu, Japan (Y. Nishimura)
| | - Yutaka Otsuji
- Second Department of Internal Medicine (J.A., M.I., Y. Nabeshima, T.O., Y.T., M.A., Y.O., M.K.)
| | - Masaharu Kataoka
- Second Department of Internal Medicine (J.A., M.I., Y. Nabeshima, T.O., Y.T., M.A., Y.O., M.K.)
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Tanaka T, Sugiura A, Vogelhuber J, Öztürk C, Böhm L, Wilde N, Zimmer S, Nickenig G, Weber M. Outcomes of transcatheter edge-to-edge repair for atrial functional mitral regurgitation. EUROINTERVENTION 2024; 20:e250-e260. [PMID: 38389471 PMCID: PMC10870009 DOI: 10.4244/eij-d-23-00819] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 11/08/2023] [Indexed: 02/24/2024]
Abstract
BACKGROUND The prognostic benefits of transcatheter edge-to-edge repair (TEER) remain unclear in patients with atrial functional mitral regurgitation (AFMR). AIMS We aimed to investigate the clinical outcomes of TEER for patients with AFMR. METHODS We retrospectively classified functional mitral regurgitation (FMR) patients undergoing TEER into those with AFMR or ventricular FMR (VFMR). A residual MR ≤1+ at discharge was considered optimal mitral regurgitation (MR) reduction, and an elevated mean mitral valve pressure gradient (MPG) was defined as an MPG ≥5 mmHg at discharge. The primary outcome was a composite of all-cause mortality and hospitalisation due to heart failure within one year. RESULTS Of 441 FMR patients, 125 patients were considered as having AFMR. Residual MR ≤1+ was associated with a lower risk of the composite outcome in both AFMR and VFMR patients, while an MPG ≥5 mmHg was associated with a higher risk of the composite outcome in patients with AFMR but not with VFMR. AFMR patients with residual MR ≤1+ and an MPG ≥5 mmHg, as well as those with residual MR >1+, had a higher incidence of the composite outcome than those with residual MR ≤1+ and an MPG <5 mmHg (50.7%, 41.8%, and 14.3%, respectively; p<0.001). This association was consistent after adjustment for clinical and echocardiographic characteristics. CONCLUSIONS An MR reduction to ≤1+ following TEER was associated with a lower risk of clinical outcomes in patients with AFMR, while an MPG ≥5 mmHg was related to a higher risk of clinical outcomes. Optimal MR reduction by TEER may have potential benefits on the prognosis of patients with AFMR, although the prognostic benefit may be attenuated by an elevated MPG.
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Affiliation(s)
- Tetsu Tanaka
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Atsushi Sugiura
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Johanna Vogelhuber
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Can Öztürk
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Lukas Böhm
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Nihal Wilde
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Sebastian Zimmer
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Georg Nickenig
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Marcel Weber
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
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Luis SA, Michelena HI, Nkomo VT. Navigating the Complex Landscape of Atrial Functional Mitral Regurgitation: Insights, Challenges, and Emerging Interventions. Am J Cardiol 2024; 213:170-172. [PMID: 38103768 DOI: 10.1016/j.amjcard.2023.11.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 11/29/2023] [Indexed: 12/19/2023]
Affiliation(s)
- Sushil Allen Luis
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Hector I Michelena
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Vuyisile T Nkomo
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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30
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Bursi F, Enriquez-Sarano M. The Left Atrium: Passive Receptacle or Active Contributor to Mitral Regurgitation Severity and Outcome. JACC Case Rep 2024; 29:102195. [PMID: 38361572 PMCID: PMC10865207 DOI: 10.1016/j.jaccas.2023.102195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Affiliation(s)
- Francesca Bursi
- University of Milan, Department of Health Sciences, Division of Cardiology, San Paolo Hospital, Milan, Italy
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31
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Gedela M, Cangut B, Safi L, Krishnamoorthy P, Pandis D, El-Eshmawi A, Tang GHL. Mitral Valve Intervention in Elderly or High-Risk Patients: A Review of Current Surgical and Interventional Management. Can J Cardiol 2024; 40:250-262. [PMID: 38042339 DOI: 10.1016/j.cjca.2023.11.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 11/25/2023] [Accepted: 11/26/2023] [Indexed: 12/04/2023] Open
Abstract
Mitral regurgitation is a prevalent valvular disease, and its management has gained increasing importance because of the aging population. Although traditional surgery remains the gold standard, the field of transcatheter therapies, including transcatheter edge-to-edge repair and, more recently transcatheter mitral valve replacement are advancing and are being explored as viable alternatives, particularly for patients at high surgical risk. It is essential to emphasize the necessity of a multidisciplinary team approach, involving specialized valve teams, imaging experts, cardiac anaesthesiologists, and other relevant specialists, is crucial in achieving optimal outcomes. Furthermore, proper execution of procedures, postprocedural care, and diligent follow-up for these patients are essential components for successful results. It is essential to underscore that traditional mitral valve surgery continues to play a significant role. Simultaneously, it is important to acknowledge the expanding array of transcatheter interventions available for this specific patient population.
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Affiliation(s)
- Maheedhar Gedela
- Heartland Cardiology, Wesley Medical Center, Wichita, Kansas, USA
| | - Busra Cangut
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lucy Safi
- Division of Cardiology, Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Parasuram Krishnamoorthy
- Division of Cardiology, Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Dimosthenis Pandis
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ahmed El-Eshmawi
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Gilbert H L Tang
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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Toader DM. Echocardiographic quantification of mitral apparatus morphology and dynamics in patients with dilated cardiomyopathy. J Int Med Res 2024; 52:3000605231209830. [PMID: 38318649 PMCID: PMC10846232 DOI: 10.1177/03000605231209830] [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: 06/22/2023] [Accepted: 10/09/2023] [Indexed: 02/07/2024] Open
Abstract
Mitral regurgitation is among the most common valvular heart diseases. Mitral regurgitation in patients with dilated cardiomyopathy is a complex pathology involving annular dilatation, papillary muscle displacement, systolic leaflet tethering, and left ventricular remodeling. Quantification of mitral apparatus damage in these patients is essential for successful interventional and surgical therapy. Mitral regurgitation in the presence of dilated cardiomyopathy is classified as Carpentier type IIIB, with restricted leaflet mobility as a standard feature. Echocardiography allows accurate evaluation of the complex anatomy and function of the mitral apparatus. Updated guidelines recommend two-dimensional followed by systematic three-dimensional echocardiographic evaluation in patients with mitral regurgitation. New three-dimensional echocardiographic software packages provide many parameters that help identify the precise morphology and function of the various components of the mitral apparatus, helping to determine the etiology of mitral regurgitation and evaluate disease severity. This review provides the first point-by-point approach to the assessment of all old and new echocardiographic methods, from the simplest to the most complex, used to examine the components of the mitral valve apparatus in patients with dilated cardiomyopathy. Although these parameters are still under research, this information will be helpful for establishing therapeutic procedures in a disease with a poor prognosis.
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Affiliation(s)
- Despina-Manuela Toader
- EuroEchoLab Craiova Cardiology Center, Emergency Hospital Craiova, Romania, Str Tabaci nr 1, Craiova, Romania
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33
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Masiero G, Montonati C, Rubbio AP, Adamo M, Grasso C, Denti P, Giordano A, Godino C, Bartorelli AL, De Felice F, Mongiardo A, Monteforte I, Villa E, Giannini C, Tamburino C, Petroni AS, Montorfano M, Giulia L, Dario G, Bedogni F, Giuseppe T. Impact of Transcatheter Edge-to-Edge Mitral Valve Repair on Atrial Functional Mitral Regurgitation from the GIOTTO Registry. Am J Cardiol 2024; 211:219-227. [PMID: 37944779 DOI: 10.1016/j.amjcard.2023.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 10/23/2023] [Accepted: 11/04/2023] [Indexed: 11/12/2023]
Abstract
Atrial functional mitral regurgitation (aFMR) has a peculiar pathophysiology that may have distinctive outcomes. We investigated the impact of transcatheter edge-to-edge repair in aFMR compared with other FMR etiologies. The GIOTTO (GIse registry Of Transcatheter treatment of MR) is a multicenter, prospective study enrolling patients with symptomatic MR treated with MitraClip up to 2020. We categorized patients with FMR as aFMR, ischemic FMR (iFMR), and nonischemic ventricular FMR (niFMR). The clinical end points were defined according to the Mitral Valve Academic Research Consortium. Of 1,153 patients, 6% had aFMR, 47% iFMR, and 47% niFMR. Patients with aFMR were older, mostly women, and had a higher atrial fibrillation rate. They had better left ventricular ejection fraction and smaller left ventricular volumes, with no difference in mitral effective regurgitant orifice area. The acute device and procedural success rates were similar among the groups. At the longest available follow-up (median 478 days, interquartile range 91 to 741 days), the rate of MR ≥2+ was similar among the groups. Patients with aFMR had a lower rate of cardiovascular death and heart failure than patients with iFMR (hazard ratio [HR] 0.43, p = 0.02) and niFMR (HR 0.45, p = 0.03). The aFMR etiology remained independently associated with the composite outcome, together with postprocedural MR ≤1+ (HR 0.63, p <0.01) and peripheral arteriopathy (HR 1.82, p = 0.003). The results of this GIOTTO subanalysis suggested that aFMR is less prevalent and associated with better outcomes compared with other causes of FMR treated by transcatheter edge-to-edge repair. Postprocedural MR >1+, peripheral vasculopathy, non-aFMR were independent predictors of worse outcomes.
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Affiliation(s)
- Giulia Masiero
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Carolina Montonati
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Antonio Popolo Rubbio
- Department of Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Marianna Adamo
- Cardiology and Cardiac Catheterization Laboratory, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Carmelo Grasso
- Division of Cardiology, Centro Alte Specialità e Trapianti (CAST), Azienda Ospedaliero-universitaria Policlinico-Vittorio Emanuele, University of Catania, Catania, Italy
| | - Paolo Denti
- Cardiac Surgery Department, San Raffaele University Hospital, Milan, Italy
| | - Arturo Giordano
- Invasive Cardiology Unit, Pineta Grande Hospital, Castel Volturno, Caserta, Italy
| | - Cosmo Godino
- Cardio-Thoracic-Vascular Department, San Raffaele University Hospital, Milan, Italy
| | | | - Francesco De Felice
- Division of Interventional Cardiology, Azienda Ospedaliera S. Camillo Forlanini, Rome, Italy
| | | | - Ida Monteforte
- AORN Ospedali dei Colli, Monaldi Hospital, Naples, Italy
| | - Emmanuel Villa
- Cardiac Surgery Unit, Poliambulanza Hospital, Fondazione Poliambulanza, Brescia, Italy
| | - Cristina Giannini
- Cardiac Catheterization Laboratory, Cardiothoracic and Vascular Department, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Corrado Tamburino
- Division of Cardiology, Centro Alte Specialità e Trapianti (CAST), Azienda Ospedaliero-universitaria Policlinico-Vittorio Emanuele, University of Catania, Catania, Italy
| | - Anna Sonia Petroni
- Cardiac Catheterization Laboratory, Cardiothoracic and Vascular Department, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Matteo Montorfano
- Cardio-Thoracic-Vascular Department, San Raffaele University Hospital, Milan, Italy
| | - Lorenzoni Giulia
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Gregori Dario
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Francesco Bedogni
- Department of Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Tarantini Giuseppe
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy.
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Bai W, Chen Y, Zhong Y, Deng L, Li D, Zhu W, Rao L. Assessment of mitral valve geometry in nonvalvular atrial fibrillation patients with or without ventricular dysfunction: insights from high volume rate three-dimensional transesophageal echocardiography. Int J Cardiovasc Imaging 2023; 39:2427-2436. [PMID: 37665486 PMCID: PMC10691988 DOI: 10.1007/s10554-023-02940-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 08/18/2023] [Indexed: 09/05/2023]
Abstract
Meticulous understanding of the mechanisms underpinning mitral regurgitation in atrial fibrillation (AF) patients is crucial to optimize therapeutic strategies. The morphologic characteristics of mitral valves in atrial functional mitral regurgitation (FMR) patients with and without left ventricular (LV) dysfunction were evaluated by high volume rate (HVR) three-dimensional transesophageal echocardiography (3D-TEE). In our study, 68 of 265 AF patients who underwent 3D-TEE were selected, including 36 patients with AF, FMR, and preserved LV function (AFMR group) and 32 patients with AF, FMR, and LV dysfunction (VFMR group). In addition, 36 fever patients without heart disease were included in the control group. Group comparisons were performed by one-way analysis of variance for continuous variables. The left atrium (LA) was enlarged in the AFMR and VFMR groups compared with the control group. The mitral annulus (MA) in the AFMR group was enlarged and flattened compared with the control group and was smaller than in the VFMR group. The annulus area fraction was significantly diminished in the AFMR and VFMR groups, indicative of reduced MA contractility. The posterior mitral leaflet (PML) angle was smallest in the AFMR group and largest in the control group, whereas the distal anterior mitral leaflet angle did not significantly differ among the three groups. LA remodeling causes expansion of the MA and reduced MA contractility, disruption of the annular saddle shape, and atriogenic PML tethering. Comparison of atrial FMR patients with and without LV dysfunction indicates that atriogenic PML tethering is an important factor that aggravates FMR. HVR 3D-TEE improves the 3D temporal resolution greatly.
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Affiliation(s)
- Wenjuan Bai
- Department of Cardiology, West China Hospital of Sichuan University, 37 Guo Xue Xiang, Chengdu, Sichuan, 610041, China
| | - Ying Chen
- Department of Cardiology, West China Hospital of Sichuan University, 37 Guo Xue Xiang, Chengdu, Sichuan, 610041, China
| | - Yue Zhong
- Department of Cardiology, West China Hospital of Sichuan University, 37 Guo Xue Xiang, Chengdu, Sichuan, 610041, China
| | - Ling Deng
- Department of Cardiology, West China Hospital of Sichuan University, 37 Guo Xue Xiang, Chengdu, Sichuan, 610041, China
| | - Dayan Li
- Department of Cardiology, West China Hospital of Sichuan University, 37 Guo Xue Xiang, Chengdu, Sichuan, 610041, China
| | - Wei Zhu
- Department of Cardiology, West China Hospital of Sichuan University, 37 Guo Xue Xiang, Chengdu, Sichuan, 610041, China
| | - Li Rao
- Department of Cardiology, West China Hospital of Sichuan University, 37 Guo Xue Xiang, Chengdu, Sichuan, 610041, China.
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Hasegawa H, Kuwajima K, Kagawa S, Yamane T, Rader F, Siegel RJ, Shiota T. Impact of eccentric jet on outcomes in patients with atrial functional mitral regurgitation: An echocardiographic study. Int J Cardiol 2023; 391:131342. [PMID: 37678430 DOI: 10.1016/j.ijcard.2023.131342] [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] [Received: 07/06/2023] [Revised: 08/17/2023] [Accepted: 09/03/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Previous studies have reported the mechanisms underlying atrial functional mitral regurgitation (A-FMR). Recently, A-FMR subtypes based on mitral regurgitation (MR) mechanisms were proposed: "central jet" due to insufficient leaflet remodeling and "eccentric jet" due to atriogenic tethering. However, their prognostic value remains unclear. Therefore, this study investigated the impact of A-FMR subtypes on clinical outcomes. METHODS Outpatients with significant A-FMR between January 2013 and December 2016 were retrospectively reviewed. They were classified into two subtypes according to the MR jet's direction. All-cause mortality, heart failure hospitalization, and any mitral valve interventions were the primary composite endpoint. RESULTS Among 101 patients with significant A-FMR, 32% had eccentric jet. The primary endpoint was observed in 56 patients during the follow-up period (median 0.7 years, range 0.1-4.2 years). Kaplan-Meier curves demonstrated that the composite endpoint was higher among patients with eccentric jet than those with central jet (log-rank p < 0.001). Eccentric jet (hazard ratio [HR] 2.46, 95% confidence interval [CI] 1.28-4.73; p = 0.007), age (HR 1.06, 95% CI 1.02-1.11; p = 0.002), symptoms (HR 6.22, 95% CI 2.18-17.8; p < 0.001), severe MR (HR 3.97, 95% CI 1.92-8.18; p < 0.001), and significant tricuspid regurgitation (TR; HR 2.00, 95% CI 1.01-3.97; p = 0.047) were independent predictors of the composite endpoint. CONCLUSIONS Patients with eccentric jet had poorer outcomes than those with central jet. Eccentric jet, age, symptoms, severe MR, and significant TR were independently associated with poor outcomes.
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Affiliation(s)
- Hiroko Hasegawa
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Ken Kuwajima
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Shunsuke Kagawa
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Takafumi Yamane
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Florian Rader
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Robert J Siegel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Takahiro Shiota
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Naser JA, Michelena HI, Lin G, Scott CG, Lee E, Kennedy AM, Noseworthy PA, Pellikka PA, Nkomo VT, Pislaru SV. Incidence, risk factors, and outcomes of atrial functional mitral regurgitation in patients with atrial fibrillation or sinus rhythm. Eur Heart J Cardiovasc Imaging 2023; 24:1450-1457. [PMID: 37556366 DOI: 10.1093/ehjci/jead199] [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] [Received: 04/14/2023] [Revised: 07/17/2023] [Accepted: 07/28/2023] [Indexed: 08/11/2023] Open
Abstract
AIMS Atrial functional mitral regurgitation (AFMR) has been associated with atrial fibrillation (AF) and heart failure with preserved ejection fraction. However, data on incident AFMR are scarce. We aimed to study the incidence, risk factors, and clinical significance of AFMR in AF or sinus rhythm (SR). METHODS AND RESULTS Adults with new diagnosis of AF and adults in SR were identified. Patients with >mild MR at baseline, primary mitral disease, cardiomyopathy, left-sided valve disease, previous cardiac surgery, or with no follow-up echocardiogram were excluded. Diastolic dysfunction (DD) was indicated by ≥2/4 abnormal diastolic function parameters [mitral medial e', mitral medial E/e', tricuspid regurgitation velocity, left atrial volume index (LAVI)]. Overall, 1747 patients with AF and 29 623 in SR were included. Incidence rate of >mild AFMR was 2.6 per 100 person-year in new-onset AF and 0.7 per 100 person-year in SR, P < 0.001. AF remained associated with AFMR in a propensity score-matched analysis based on age, sex, and comorbidities between AF and SR [hazard ratio: 3.80 (95% confidence interval 3.04-4.76)]. Independent risk factors associated with incident AFMR were age ≥65 years, female sex, LAVI, and DD in both AF and SR, in addition to rate (vs. rhythm) control in AF. Incident AFMR was independently associated with all-cause death in both groups (both P < 0.001). CONCLUSIONS AF conferred a three-fold increase in the risk of incident AFMR. DD, older age, left atrial size, and female sex were independent risk factors in both SR and AF, while rhythm control was protective. AFMR was universally associated with worse mortality.
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Affiliation(s)
- Jwan A Naser
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Hector I Michelena
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Grace Lin
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | | | - Eunjung Lee
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Austin M Kennedy
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Peter A Noseworthy
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Patricia A Pellikka
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
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Qiu W, Cai A, Xiao X, Gao Z, Feng Y, Li L. Association of Functional Tricuspid Regurgitation and All-Cause Mortality in Ischemic Heart Failure Varies by Left Atrial Size: A Prospective Cohort Study. Am J Cardiol 2023; 205:50-57. [PMID: 37586121 DOI: 10.1016/j.amjcard.2023.06.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/12/2023] [Accepted: 06/16/2023] [Indexed: 08/18/2023]
Abstract
This study aimed to evaluate whether the mortality risk of tricuspid regurgitation (TR) varies by left atrial (LA) size in patients with heart failure (HF). In total, 2,234 patients with ischemic HF were included. Participants were categorized as normal LA group and LA enlargement group based on the guideline recommendations, and in each group, patients were further classified as non/mild TR group and moderate/severe TR group according to echocardiographic examination. All-cause mortality was used as the only end point, and comparisons were conducted between the TR degree groups stratified by LA size status. Propensity-matched analyses and restricted cubic splines were performed to verify the robustness of the results. Of 2,234 patients with ischemic HF participants, 1,002 (44.9%) had LA enlargement and 294 (13.2%) had moderate/severe TR. After a median follow-up of 3.02 years (7,140 person-years), 453 patients (20.3%) died. After adjusting for the covariates, the higher mortality risk of moderate/severe TR was only observed in the normal LA diameter group (hazard ratio 1.64, 95% confidence interval 1.02 to 2.65) rather than the LA enlargement group (hazard ratio 0.96, 95% confidence interval 0.69 to 1.34). A significant interaction of TR degree was observed between the normal LA size group and the LA enlargement group. The relation was consistent in the propensity-matching cohort and in the restricted cubic splines analysis. In conclusion, mortality rate and prevalence of moderate/severe TR were high in patients with ischemic HF. Moderate/severe TR is significantly associated with all-cause mortality in those with normal LA diameter. The mechanisms underlying these observations merit further investigation.
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Affiliation(s)
- Weida Qiu
- Department of Cardiology, Hypertension Research Laboratory, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences; Department of the Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Anping Cai
- Department of the Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Xiaoju Xiao
- Department of Cardiology, Hypertension Research Laboratory, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences; Department of the Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Zhiping Gao
- Department of the Concord Medical Center, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yingqing Feng
- Department of Cardiology, Hypertension Research Laboratory, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences; Department of the Second School of Clinical Medicine, Southern Medical University, Guangzhou, China.
| | - Liwen Li
- Department of Cardiology, Hypertension Research Laboratory, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences; Department of the Second School of Clinical Medicine, Southern Medical University, Guangzhou, China.
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38
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Shechter A, Koren O, Skaf S, Makar M, Chakravarty T, Koseki K, Kaewkes D, Solanki A, Patel V, Makkar RR, Siegel RJ. Transcatheter edge-to-edge repair for chronic functional mitral regurgitation in patients with very severe left ventricular dysfunction. Am Heart J 2023; 264:59-71. [PMID: 37276912 DOI: 10.1016/j.ahj.2023.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 05/05/2023] [Accepted: 05/27/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND There is scarce data on transcatheter edge-to-edge repair (TEER) for chronic functional mitral regurgitation (FMR) in the setting of very severe left ventricular dysfunction (LVD), defined by a left ventricular ejection fraction (LVEF) of <20%. METHODS We retrospectively explored periprocedural characteristics and one-year clinical and echocardiographic outcomes of consecutive patients with chronic FMR and very severe LVD who underwent an isolated, first-time TEER. The composite of all-cause mortality or heart failure hospitalizations constituted the primary outcome. RESULTS Ninety-six patients (median age 69 [IQR, 55-76] years, 64 (66.7%) males, median LVEF 15 [IQR, 12-17] %) were included. In 47 (49.0%), TEER was performed urgently or in the setting of hemodynamic instability. Almost all procedures (98.0%) were technically successful, leading to ≤moderate MR in 94.7% and 90.7% of cases by 1-month and 1-year, respectively. New York Heart Association class ≤II was maintained in 60.0% of patients. One-year survival and freedom from the primary outcome were 74.0% and 50.0%, respectively. Functional and echocardiographic improvement compared to baseline was independent of procedural urgency, hemodynamic stability, and downstream left ventricular assist device implantation / heart transplantation (n = 12). Mortality was not predicted by COAPT exclusion criteria, nor was the primary outcome discriminated by published risk models. CONCLUSION TEER for chronic FMR is feasible, safe, and efficacious in selected patients with very severe LVD. Preprocedural risk stratification in this population may be optimized.
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Affiliation(s)
- Alon Shechter
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA; Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel; Department of Cardiology, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ofir Koren
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA; Department of Cardiology, Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Sabah Skaf
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Moody Makar
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Tarun Chakravarty
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Keita Koseki
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA; Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
| | - Danon Kaewkes
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA; Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Aum Solanki
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Vivek Patel
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Raj R Makkar
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Robert J Siegel
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA; Division of Cardiology, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA.
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Hamada S, Ueyama H, Aikawa T, Kampaktsis PN, Misumida N, Takagi H, Kuno T, Latib A. Outcomes of transcatheter edge-to-edge repair for atrial functional mitral regurgitation: A meta-analysis of observational studies. Catheter Cardiovasc Interv 2023; 102:751-760. [PMID: 37579199 DOI: 10.1002/ccd.30806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 07/28/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND Transcatheter edge-to-edge repair (TEER) may have potential benefits in the treatment of atrial functional mitral regurgitation (AFMR), but robust evidence is currently lacking. We conducted a systematic review and meta-analysis to investigate the clinical outcomes of TEER for AFMR, including comparisons to ventricular functional MR (VFMR). METHODS MEDLINE and EMBASE were searched through January 2023 to identify studies eligible for analysis. The primary outcome was postprocedural MR severity. Postprocedural New York Heart Association (NYHA) functional class classification and all-cause mortality were also evaluated. Outcomes were stratified into short term (postprocedure to 6 months) and long term (6 months to 2 years). RESULTS A total of eight observational studies met the inclusion criteria, enrolling 539 AFMR and 3486 VFMR patients. Postprocedural MR grade ≤2 in the AFMR group was observed in 93.7% (454/491 patients; 95% confidence interval (CI), 91.1%-96.2%, I2 = 24.3%) and 97.1% (89/93 patients; 95% CI, 92.9%-100%, I2 = 26.4%) in short- and long-term follow-up, respectively. There was no difference in the rates of postprocedural MR grade ≤2 between AFMR and VFMR either in short-term (risk ratio [RR], 1.00 [95% CI, 0.95-1.06]; p = 0.90; I2 = 53%) or long-term follow-up (RR, 1.08 [95% CI, 0.89-1.32]; p = 0.44; I2 = 22%). Similarly, no difference was observed between AFMR and VFMR in the rates of postprocedural NYHA class ≤2 or all-cause mortality. CONCLUSION TEER provides similar clinical outcomes for AFMR and VFMR. A high rate of MR grade ≤2 was observed in patients at both short- and long-term follow-ups. Further prospective studies with TEER versus medical therapy and/or rhythm control for AFMR are warranted.
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Affiliation(s)
- Seiji Hamada
- Imperial College London, School of Public Health, London, UK
| | - Hiroki Ueyama
- Division of Cardiology, Emory University School of Medicine, Georgia, Atlanta, USA
| | - Tadao Aikawa
- Department of Cardiology, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Polydoros N Kampaktsis
- Division of Cardiology, Columbia University Irving Medical Center, New York City, New York, USA
| | - Naoki Misumida
- Division of Cardiovascular Medicine, Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky, USA
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Toshiki Kuno
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York City, New York, USA
- Department of Cardiology, Jacobi Medical Center, Albert Einstein College of Medicine, New York, USA
| | - Azeem Latib
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York City, New York, USA
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40
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Naser JA, Lee E, Michelena HI, Lin G, Pellikka PA, Nkomo VT, Noseworthy PA, Friedman PA, Attia ZI, Pislaru SV. Artificial Intelligence-Enabled Electrocardiogram in the Detection of Patients at Risk of Atrial Secondary Mitral Regurgitation. Circ Arrhythm Electrophysiol 2023; 16:e012033. [PMID: 37565338 DOI: 10.1161/circep.123.012033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Affiliation(s)
- Jwan A Naser
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Eunjung Lee
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | - Grace Lin
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | - Paul A Friedman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Zachi I Attia
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
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41
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Ong G, Leong-Poi H. Coaptation Angle: Linking Atrial Functional and Ventricular Functional Mitral Regurgitation. Am J Cardiol 2023; 200:239-240. [PMID: 37357038 DOI: 10.1016/j.amjcard.2023.05.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 05/31/2023] [Indexed: 06/27/2023]
Affiliation(s)
- Geraldine Ong
- The Division of Cardiology, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Howard Leong-Poi
- The Division of Cardiology, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada.
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Romano LR, Scalzi G, Malizia B, Aquila I, Polimeni A, Indolfi C, Curcio A. Impact of Percutaneous Mitral Valve Repair on Left Atrial Strain and Atrial Fibrillation Progression. J Cardiovasc Dev Dis 2023; 10:320. [PMID: 37623333 PMCID: PMC10456079 DOI: 10.3390/jcdd10080320] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/19/2023] [Accepted: 07/26/2023] [Indexed: 08/26/2023] Open
Abstract
Transcatheter edge-to-edge repair (TEER) currently represents a valuable therapeutic option for patients with severe mitral regurgitation (MR) considered at high surgical risk. Besides symptoms and left ventricular (LV) echocardiographic improvements upon TEER, it has been postulated that left atrial (LA) function plays a prognostic role. The aims of our study were to evaluate LA changes after TEER, measured by two-dimensional speckle-tracking echocardiography analysis (2D-STE), their association with atrial fibrillation (AF) occurrence, and relative arrhythmic burden. We considered in a single-center study 109 patients affected by symptomatic severe MR undergoing TEER from February 2015 to April 2022. By 2D-STE, LA reservoir (R_s), conduct (D_s), and contractile (C_s) strains were assessed along with four-chamber emptying fraction (LAEF-4CH) before, 1, 6, and 12 months following TEER. Statistical analysis for comparison among baseline, and follow-ups after TEER was carried out by ANOVA, MANOVA, and linear regression. Successful TEER significantly improved LV dimensions and LA performances, as indicated by all strain components, and LAEF-4CH after 1 year. Strikingly, a significant reduction in arrhythmic burden was observed, since only one case of subclinical AF detected by a previously implanted cardiac electronic device was found in the cohort of sinus rhythm patients (n = 48) undergone TEER; in addition, ventricular rate was reduced in the AF cohort (n = 61) compared to baseline, together with few episodes of nonsustained ventricular tachycardias (5/61, 8.2%) after MR improvement. Overall, TEER was associated with improved cardiac performance, LA function amelioration, and reduced arrhythmic burden.
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Affiliation(s)
- Letizia Rosa Romano
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, 88100 Catanzaro, Italy
| | - Giuseppe Scalzi
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, 88100 Catanzaro, Italy
| | - Biagio Malizia
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, 88100 Catanzaro, Italy
| | - Iolanda Aquila
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, 88100 Catanzaro, Italy
| | - Alberto Polimeni
- Division of Cardiology, Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, 87100 Cosenza, Italy
| | - Ciro Indolfi
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, 88100 Catanzaro, Italy
| | - Antonio Curcio
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, 88100 Catanzaro, Italy
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43
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Apostolou F, Ioannides M, Mitsis A, Koutsofti C, Deltas C, Avraamides P. Case report: Aborted sudden cardiac death as a first presentation of severe mitral annulus disjunction-a case series and review of the literature. Front Cardiovasc Med 2023; 10:1171226. [PMID: 37547253 PMCID: PMC10400284 DOI: 10.3389/fcvm.2023.1171226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 07/03/2023] [Indexed: 08/08/2023] Open
Abstract
Mitral annulus disjunction (MAD) is defined as a systolic displacement between the ventricular myocardium and the posterior mitral annulus supporting the posterior mitral leaflet. This structural abnormality is associated with the loss of mechanical annular function manifested as an abnormal systolic excursion of the leaflet hinge point into the left atrium but with maintained electrical function, separating the left atrium and ventricle electrophysiologically. The mitro-aortic fibrous continuity limits MAD anteriorly, between the aortic cusps and the anterior leaflet of the mitral valve. Consequently, MAD has been observed only at the insertion of the posterior leaflet. It can extend preferentially at the central posterior scallop. The first diagnostic modality aiding the diagnosis is transthoracic echocardiography (TTE), although in some cases adjunctive cardiac imaging modality might be suggested. MAD carries a strong association with malignant ventricular arrhythmogenesis and a profound predisposition for sudden cardiac death (SCD). In this context, a thorough investigation of this morphological and functional abnormality is vital in estimating the risk assessment and stratification for optimal management and elimination of the risk of the patient for SCD. Based on the current scientific data and literature, we will discuss the diagnosis, clinical implications, risk stratification, and therapeutic management of MAD.
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Affiliation(s)
- Fay Apostolou
- Department of Cardiology, Nicosia General Hospital,Strovolos, Cyprus
| | - Marios Ioannides
- Department of Cardiology, Nicosia General Hospital,Strovolos, Cyprus
| | - Andreas Mitsis
- Department of Cardiology, Nicosia General Hospital,Strovolos, Cyprus
| | - Constantina Koutsofti
- Biobank.cy Center of Excellence in Biobanking and Biomedical Research, University of Cyprus,Nicosia, Cyprus
| | - Constantinos Deltas
- Biobank.cy Center of Excellence in Biobanking and Biomedical Research, University of Cyprus,Nicosia, Cyprus
- School of Medicine, University of Cyprus, Nicosia, Cyprus
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44
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Deferm S, Bertrand PB, Dhont S, von Bardeleben RS, Vandervoort PM. Arrythmia-Mediated Valvular Heart Disease. Heart Fail Clin 2023; 19:357-377. [PMID: 37230650 DOI: 10.1016/j.hfc.2023.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The aging population is rising at record pace worldwide. Along with it, a steep increase in the prevalence of atrial fibrillation and heart failure with preserved ejection fraction is to be expected. Similarly, both atrial functional mitral and tricuspid regurgitation (AFMR and AFTR) are increasingly observed in daily clinical practice. This article summarizes all current evidence regarding the epidemiology, prognosis, pathophysiology, and therapeutic options. Specific attention is addressed to discern AFMR and AFTR from their ventricular counterparts, given their different pathophysiology and therapeutic needs.
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Affiliation(s)
- Sébastien Deferm
- Hasselt University, Agoralaan Building D, 3590 Diepenbeek, Belgium; Department of Cardiology, Mainz University Hospital, Langenbeckstraße 1, Mainz, Germany. https://twitter.com/S_Deferm
| | - Philippe B Bertrand
- Hasselt University, Agoralaan Building D, 3590 Diepenbeek, Belgium; Department of Cardiology, Hospital Oost-Limburg Genk, Schiepse Bos 6, 3600 Genk, Belgium. https://twitter.com/Ph_Bertrand
| | - Sebastiaan Dhont
- Hasselt University, Agoralaan Building D, 3590 Diepenbeek, Belgium; Department of Cardiology, Hospital Oost-Limburg Genk, Schiepse Bos 6, 3600 Genk, Belgium. https://twitter.com/S_Dhont
| | - Ralph S von Bardeleben
- Department of Cardiology, Mainz University Hospital, Langenbeckstraße 1, Mainz, Germany. https://twitter.com/vonbardelebenRS
| | - Pieter M Vandervoort
- Hasselt University, Agoralaan Building D, 3590 Diepenbeek, Belgium; Department of Cardiology, Hospital Oost-Limburg Genk, Schiepse Bos 6, 3600 Genk, Belgium.
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Oguz D, Huntley GD, El-Am EA, Scott CG, Thaden JJ, Pislaru SV, Fabre KL, Singh M, Greason KL, Crestanello JA, Pellikka PA, Oh JK, Nkomo VT. Impact of atrial fibrillation on outcomes in asymptomatic severe aortic stenosis: a propensity-matched analysis. Front Cardiovasc Med 2023; 10:1195123. [PMID: 37408654 PMCID: PMC10318187 DOI: 10.3389/fcvm.2023.1195123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 06/05/2023] [Indexed: 07/07/2023] Open
Abstract
Background Atrial fibrillation (AF) portends poor prognosis in patients with aortic stenosis (AS). Objectives This study aimed to study the association of AF vs. sinus rhythm (SR) with outcomes in asymptomatic severe AS during routine clinical practice. Methods We identified 909 asymptomatic patients from 3,208 consecutive patients with aortic valve area ≤1.0 cm2 and left ventricular ejection fraction ≥50% at a tertiary academic center. Patients were grouped by rhythm at the time of transthoracic echocardiogram [SR: 820/909 (90%) and AF: 89/909 (10%)]. Propensity-matched analyses (2 SR:1 AF) matching 174 SR to 89 AF patients by age, sex, and clinical comorbidities were used to compare outcomes. Results In the propensity-matched cohort, median age (82 ± 8 vs. 81 ± 9 years, p = 0.31), sex distribution (male 58% vs. 52%, p = 0.30), and Charlson comorbidity index (4.0 vs. 3.0, p = 0.26) were not different in AF vs. SR. Median follow-up duration was 2.6 (IQR: 1.0-4.4) years. The 1-year rate of aortic valve replacement (AVR) was not different (AF: 32% vs. SR: 37%, p = 0.31). All-cause mortality was higher in AF [hazard ratio (HR): 1.68 (1.13-2.50), p = 0.009]. Independent predictors of mortality were age [HR: 1.92 (1.40-2.62), p < 0.001], Charlson comorbidity index [1.09 (1.03-1.15), p = 0.002], aortic valve peak velocity [HR: 1.87 (1.20-2.94), p = 0.006], stroke volume index [HR: 0.75 (0.60-0.93), p = 0.01], moderate or more mitral regurgitation [HR: 2.97 (1.43-6.19), p = 0.004], right ventricular systolic dysfunction [HR: 2.39 (1.29-4.43), p = 0.006], and time-dependent AVR [HR: 0.36 (0.19-0.65), p = 0.0008]. There was no significant interaction of AVR and rhythm (p = 0.57). Conclusions Lower forward flow, right ventricular systolic dysfunction, and mitral regurgitation identified increased risk of subsequent mortality in asymptomatic patients with AF and AS. Additional studies of risk stratification of asymptomatic AS in AF vs. SR are needed.
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Affiliation(s)
- Didem Oguz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Geoffrey D. Huntley
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Edward A. El-Am
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Christopher G. Scott
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, United States
| | - Jeremy J. Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Sorin V. Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Katarina L. Fabre
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States
| | - Mandeep Singh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Kevin L. Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, United States
| | - Juan A. Crestanello
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, United States
| | - Patricia A. Pellikka
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Jae K. Oh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Vuyisile T. Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
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46
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Enriquez-Sarano M. Valve Repair for Degenerative Mitral Regurgitation. JAMA 2023; 329:1922-1923. [PMID: 37314285 DOI: 10.1001/jama.2023.9668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
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47
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Dreyfus GD, Essayagh B. Can Transcatheter Edge-to-Edge Mitral Repair Be Considered as Efficient as Surgical Mitral Valve Repair? JACC Cardiovasc Interv 2023; 16:1189-1191. [PMID: 37225289 DOI: 10.1016/j.jcin.2023.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 04/18/2023] [Indexed: 05/26/2023]
Affiliation(s)
- Gilles D Dreyfus
- Department of Cardiac Surgery, Hôpital Européen Georges Pompidou, Paris, France.
| | - Benjamin Essayagh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; Department of Echocardiography, Cardio X Clinic, Cannes, France. https://twitter.com/EssayaghBen
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48
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Spargias K, Lim DS, Makkar R, Kar S, Kipperman RM, O Neill WW, Ng MKC, Smith RL, Fam NP, Rinaldi MJ, Raffel CO, Walters DL, Levisay J, Montorfano M, Latib A, Carroll JD, Nickenig G, Windecker S, Marcoff L, Cohen GN, Schäfer U, Webb JG, Szerlip M. Three-year outcomes for transcatheter repair in patients with mitral regurgitation from the CLASP study. Catheter Cardiovasc Interv 2023. [PMID: 37178388 DOI: 10.1002/ccd.30686] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/27/2023] [Accepted: 04/30/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Mitral valve transcatheter edge-to-edge repair (M-TEER) is an effective option for treatment of mitral regurgitation (MR). We previously reported favorable 2-year outcomes for the PASCAL transcatheter valve repair system. OBJECTIVES We report 3-year outcomes from the multinational, prospective, single-arm CLASP study with analysis by functional MR (FMR) and degenerative MR (DMR). METHODS Patients with core-lab determined MR ≥ 3+ were deemed candidates for M-TEER by the local heart team. Major adverse events were assessed by an independent clinical events committee to 1 year and by sites thereafter. Echocardiographic outcomes were evaluated by the core laboratory to 3 years. RESULTS The study enrolled 124 patients, 69% FMR; 31% DMR (60% NYHA class III-IVa, 100% MR ≥ 3+). The 3-year Kaplan-Meier estimate for survival was 75% (66% FMR; 92% DMR) and freedom from heart failure hospitalization (HFH) was 73% (64% FMR; 91% DMR), with 85% reduction in annualized HFH rate (81% FMR; 96% DMR) (p < 0.001). MR ≤ 2+ was achieved and maintained in 93% of patients (93% FMR; 94% DMR) and MR ≤ 1+ in 70% of patients (71% FMR; 67% DMR) (p < 0.001). The mean left ventricular end-diastolic volume (181 mL at baseline) decreased progressively by 28 mL [p < 0.001]. NYHA class I/II was achieved in 89% of patients (p < 0.001). CONCLUSIONS The 3-year results from the CLASP study demonstrated favorable and durable outcomes with the PASCAL transcatheter valve repair system in patients with clinically significant MR. These results add to the growing body of evidence establishing the PASCAL system as a valuable therapy for patients with significant symptomatic MR.
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Affiliation(s)
| | - D Scott Lim
- University of Virginia Health System Hospital, Charlottesville, Virginia, USA
| | - Raj Makkar
- Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Saibal Kar
- Los Robles Regional Medical Center, Thousand Oaks, California, USA
| | - Robert M Kipperman
- Atlantic Health System Morristown Medical Center, Morristown, New Jersey, USA
| | | | - Martin K C Ng
- Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Robert L Smith
- Baylor Scott and White The Heart Hospital Plano, Plano, Texas, USA
| | - Neil P Fam
- St. Michael's Hospital, Toronto, Ontario, Canada
| | | | | | | | - Justin Levisay
- Evanston Hospital, NorthShore University Health System, Evanston, Illinois, USA
| | - Matteo Montorfano
- Interventional Cardiology Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | | | | | | | - Leo Marcoff
- Atlantic Health System Morristown Medical Center, Morristown, New Jersey, USA
| | - Gideon N Cohen
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Ulrich Schäfer
- Department of Cardiology, Heart and Vascular Centre Bad Bevensen, Bonn, Germany
| | - John G Webb
- St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Molly Szerlip
- Baylor Scott and White The Heart Hospital Plano, Plano, Texas, USA
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49
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Cammalleri V, Antonelli G, De Luca VM, Carpenito M, Nusca A, Bono MC, Mega S, Ussia GP, Grigioni F. Functional Mitral and Tricuspid Regurgitation across the Whole Spectrum of Left Ventricular Ejection Fraction: Recognizing the Elephant in the Room of Heart Failure. J Clin Med 2023; 12:jcm12093316. [PMID: 37176756 PMCID: PMC10178924 DOI: 10.3390/jcm12093316] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/21/2023] [Accepted: 04/22/2023] [Indexed: 05/15/2023] Open
Abstract
Functional mitral regurgitation (FMR) and tricuspid regurgitation (FTR) occur due to cardiac remodeling in the presence of structurally normal valve apparatus. Two main mechanisms are involved, distinguishing an atrial functional form (when annulus dilatation is predominant) and a ventricular form (when ventricular remodeling and dysfunction predominate). Both affect the prognosis of patients with heart failure (HF) across the entire spectrum of left ventricle ejection fraction (LVEF), including preserved (HFpEF), mildly reduced (HFmrEF), or reduced (HFrEF). Currently, data on the management of functional valve regurgitation in the various HF phenotypes are limited. This review summarizes the epidemiology, pathophysiology, and treatment of FMR and FTR within the different patterns of HF, as defined by LVEF.
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Affiliation(s)
- Valeria Cammalleri
- Research Unit of Cardiovascular Science, Università e Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Giorgio Antonelli
- Research Unit of Cardiovascular Science, Università e Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Valeria Maria De Luca
- Research Unit of Cardiovascular Science, Università e Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Myriam Carpenito
- Research Unit of Cardiovascular Science, Università e Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Annunziata Nusca
- Research Unit of Cardiovascular Science, Università e Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Maria Caterina Bono
- Research Unit of Cardiovascular Science, Università e Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Simona Mega
- Research Unit of Cardiovascular Science, Università e Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Gian Paolo Ussia
- Research Unit of Cardiovascular Science, Università e Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Francesco Grigioni
- Research Unit of Cardiovascular Science, Università e Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
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50
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Butcher SC, Essayagh B, Enriquez-Sarano M. Rescue surgery for degenerative mitral regurgitation should be recognized for what it is: indispensable but imperfect. Eur Heart J 2023:7146244. [PMID: 37114358 DOI: 10.1093/eurheartj/ehad242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/29/2023] Open
Affiliation(s)
- Steele C Butcher
- Department of Cardiology, Leiden University Medical Center, 2300RC Leiden, Netherlands
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Benjamin Essayagh
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
- Department of Echocardiography, Cardio X Clinic, Cannes, France
| | - Maurice Enriquez-Sarano
- Valve Science Center, Minneapolis Heart Institute, Albinusdreef 2, 2333 ZA Leiden, Netherlands
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