1
|
Guigui SA, Torres C, Escolar E, Mihos CG. Systolic anterior motion of the mitral valve in hypertrophic cardiomyopathy: a narrative review. J Thorac Dis 2022; 14:2309-2325. [PMID: 35813751 PMCID: PMC9264047 DOI: 10.21037/jtd-22-182] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 04/15/2022] [Indexed: 11/06/2022]
Abstract
Background and Objective The prevalence of hypertrophic cardiomyopathy (HCM) is estimated to be 1 in 200 to 500 individuals, with systolic anterior motion (SAM) of the mitral valve (MV) and left ventricular outflow tract (LVOT) obstruction present in 60% to 70%. In this narrative review, we aim to elucidate the pathophysiology of SAM-septal contact and LVOT obstruction in HCM by presenting a detailed review on the anatomy of the MV apparatus in HCM, examining the various existing theories pertaining to the SAM phenomenon as supported by cardiac imaging, and providing a critical assessment of management strategies for SAM in HCM. Methods A literature review was performed using PubMed, EMBASE, Ovid, and the Cochrane Library, of all scientific articles published through December 2021. A focus was placed on descriptive studies, reports correlating echocardiographic findings with pathologic diagnosis, and outcomes studies. Key Content and Findings The pathophysiology of SAM involves the complex interplay between HCM morphology, MV apparatus anatomic abnormalities, and labile hemodynamic derangements. Echocardiography and cardiac magnetic resonance (CMR) vector flow mapping have identified drag forces, as opposed to the "Venturi effect", as the main hydraulic forces responsible for SAM. The degree of mitral regurgitation with SAM is variable, and its severity is correlated with degree of LVOT obstruction and outcomes. First line therapy for the amelioration of SAM and LVOT obstruction is medical therapy with beta-blockers, non-dihydropyridine calcium-channel blockers, and disopyramide, in conjunction with lifestyle modifications. In refractory cases septal reduction therapy is performed, which may be combined with a 'resect-plicate-release' procedure, anterior mitral leaflet extension, surgical edge-to-edge MV repair, anterior mitral leaflet retention plasty, or secondary chordal cutting. Conclusions Recent scientific advances in the field of HCM have allowed for a maturation of our understanding of the SAM phenomenon. Cardiac imaging plays a critical role in its diagnosis, treatment, and surveillance, and in our ability to apply the appropriate therapeutic regimens. The increasing prevalence of HCM places an emphasis on continued basic and clinical research to further improve outcomes for this challenging population.
Collapse
Affiliation(s)
- Sarah A Guigui
- Echocardiography Laboratory, Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA.,Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
| | - Christian Torres
- Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
| | - Esteban Escolar
- Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA.,Coronary Care Unit, Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
| | - Christos G Mihos
- Echocardiography Laboratory, Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA.,Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
| |
Collapse
|
2
|
Abstract
PURPOSE OF REVIEW To provide a critical review of the application and outcomes of surgical edge-to-edge (E2E) or Alfieri repair for mitral valvulopathy. RECENT FINDINGS The E2E repair is a surgical technique to address mitral regurgitation, particularly suited when the responsible mechanism is bileaflet prolapse combined with enlarged annular area. It can also be used for a range of mitral valve pathologies. Surgically, the technique has been employed as a bailout for unsuccessful repair including residual mitral regurgitation because of systolic anterior motion (SAM). E2E repair should be accompanied by a ring annuloplasty for long-term repair durability. The simplicity of this approach makes it an ideal strategy during minimally-invasive mitral valve repair. It may also be performed via a transaortic approach at the time of aortic valve surgery to address less-than-severe mitral regurgitation or to address residual SAM following myectomy for hypertrophic obstructive cardiomyopathy. We review the surgical indication, potential complications including risk of mitral stenosis and the long-term outcomes of E2E repair. SUMMARY The E2E surgical repair is a simple and effective surgical strategy to address a wide range of mitral regurgitation. This is an important technique in the surgical armamentarium especially in cases of minimally-invasive mitral valve surgery.
Collapse
|
3
|
Transaortic repair of concomitant mitral insufficiency in patients with critical aortic stenosis undergoing aortic valvular replacement. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 27:9-14. [PMID: 32082821 DOI: 10.5606/tgkdc.dergisi.2019.16105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 06/25/2018] [Indexed: 11/21/2022]
Abstract
Background In this study, we present operation technique and outcomes of transaortic mitral valve repair in high-risk patients undergoing aortic valve replacement due to severe aortic stenosis. Methods Between January 2005 and March 2016, a total of 11 patients (7 females, 4 males; mean age 71.2±4.1 years; range, 65 to 77 years) with severe aortic valve stenosis (aortic valve area <1 cm2 or aortic valve area index <0.6 cm2/m2) and concomitant moderate or severe mitral regurgitation (non-ischemic, regurgitant jet origin between A2-P2 portions) secondary to left ventricular dysfunction (EuroSCORE logistic score >5%, left ventricular ejection fraction <30%) who were operated were retrospectively analyzed. Aortic valve replacement and transaortic mitral edge-to-edge repair was applied to all patients. Operations were performed through sternotomy, cardiopulmonary bypass, and bicaval venous return. Transesophageal echocardiography was used to evaluate mitral valve before surgery and valve functions after surgery. Postoperative course of all patients was monitored, and postoperative complications were recorded. Results The mean preoperative ejection fraction was 24.5±4.1% and the mean transaortic pressure gradient was 35.8±4.8 mmHg. The mean aortic cross-clamp time was 62.09±10.1 (range, 43 to 76) min and the median cardiopulmonary bypass time was 90.1±11.9 (range, 66 to 114) min. No hospital mortality was observed. In the postoperative period, two patients experienced renal insufficiency. Hemofiltration was initiated in these patients and no dialysis was required at two weeks. One patient had postoperative atrial fibrillation and one patient had pericardial effusion leading to cardiac tamponade and this patient underwent reoperation. The patients were followed up for a mean of four years and control echocardiography didn"t detect increase in mitral regurgitation degree. Conclusion Transaortic edge-to-edge mitral valve repair can be used in high-risk patients undergoing aortic valve replacement. This technique is feasible with shorter cross-clamp time and can reduce mortality and morbidity in selected high-risk patients.
Collapse
|
4
|
Yang A, Tan C, Daneman N, Hansen MS, Habib G, Salaun E, Lavoute C, Hubert S, Adhikari NKJ. Clinical and echocardiographic predictors of embolism in infective endocarditis: systematic review and meta-analysis. Clin Microbiol Infect 2018; 25:178-187. [PMID: 30145401 DOI: 10.1016/j.cmi.2018.08.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 07/30/2018] [Accepted: 08/11/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Prediction of embolic events (EEs) in infective endocarditis (IE) could inform clinical decisions, such as surgical timing. We conducted a systematic review to more precisely define associations between risk factors and EEs. METHODS We searched two bibliographic databases (1994-2018) for observational studies that reported EEs in IE patients and considered clinical, microbiological or echocardiographic risk factors. Studies that did not use Duke criteria or only investigated a subset of IE patients were excluded. Study quality was assessed using the Newcastle-Ottawa scale. A pooled risk ratio (RR) for each risk factor was estimated using random-effects models; statistical heterogeneity was estimated using I2. RESULTS Of 3862 unique citations, 47 cohort studies (11 215 IE cases) were included; 54 risk factors were analysed in at least two studies, with nine studies reporting other individual factors. Most studies were of high methodological quality. Major predictors of EEs were intravenous drug use (RR 1.69, 95% CI 1.32-2.17; I2 = 46%), Staphylococcus aureus infection (RR 1.64, 95% CI 1.45-1.86, I2 = 32%), mitral valve vegetation (RR 1.24, 95% CI 1.11-1.37, I2 = 30%), and vegetation size >10 mm (RR 1.87, 95% CI 1.57-2.21, I2 = 48%). EE risk was also higher with human immunodeficiency virus, chronic liver disease, elevated C-reactive protein, Staphylococcus spp. infection, vegetation presence, and multiple, mobile or prosthetic mechanical valve vegetation, and lower with Streptococcus spp. infection. Most findings were unchanged in sensitivity analyses that removed studies with pulmonary EEs from the outcome. CONCLUSIONS Given the serious consequences of embolism, surgical evaluation may be considered in patients with these risk factors.
Collapse
Affiliation(s)
- A Yang
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | - C Tan
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - N Daneman
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - M S Hansen
- Division of Cardiology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - G Habib
- Assistance Publique-Hôpitaux de Marseille, La Timone Hospital, Cardiology Department, Marseille, France; Aix-Marseille Université, IRD, APHM, MEPHI, IHU-Méditerranée Infection, Marseille, France
| | - E Salaun
- Assistance Publique-Hôpitaux de Marseille, La Timone Hospital, Cardiology Department, Marseille, France; Aix-Marseille Université, IRD, APHM, MEPHI, IHU-Méditerranée Infection, Marseille, France
| | - C Lavoute
- Assistance Publique-Hôpitaux de Marseille, La Timone Hospital, Cardiology Department, Marseille, France; Aix-Marseille Université, IRD, APHM, MEPHI, IHU-Méditerranée Infection, Marseille, France
| | - S Hubert
- Assistance Publique-Hôpitaux de Marseille, La Timone Hospital, Cardiology Department, Marseille, France; Aix-Marseille Université, IRD, APHM, MEPHI, IHU-Méditerranée Infection, Marseille, France
| | - N K J Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada; Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada.
| |
Collapse
|
5
|
Transaortic mitral valve surgery: Going down the rabbit hole again. J Thorac Cardiovasc Surg 2017; 154:1630-1631. [DOI: 10.1016/j.jtcvs.2017.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 07/10/2017] [Indexed: 11/18/2022]
|
6
|
Santana O, Xydas S, Williams RF, La Pietra A, Mawad M, Behrens V, Escolar E, Mihos CG. Aortic valve replacement in patients with a left ventricular ejection fraction ≤35% performed via a minimally invasive right thoracotomy. J Thorac Dis 2017; 9:S607-S613. [PMID: 28740714 PMCID: PMC5505940 DOI: 10.21037/jtd.2017.06.32] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 05/15/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND We evaluated the outcomes of patients with aortic valve pathology in the setting of a left ventricular ejection fraction ≤35% who underwent minimally invasive aortic valve replacement (AVR), with or without concomitant mitral valve (MV) surgery. METHODS All minimally invasive AVR in patients with a left ventricular ejection fraction ≤35%, performed via a right thoracotomy for aortic stenosis or regurgitation between January 2009 and March 2013, were retrospectively evaluated. The operative characteristics, perioperative outcomes, and 30-day mortality were analyzed. RESULTS There were 75 patients identified: 51 who underwent isolated AVR, and 24 who had combined AVR plus MV surgery for moderate to severe mitral regurgitation. In patients undergoing MV surgery, there were 22 (91.7%) MV repairs [ring annuloplasty =7 (37.5%), transaortic edge-to-edge repair =15 (62.5%)], and 2 (8.3%) replacements. No patient required conversion to sternotomy for inadequate surgical field exposure. The median total mechanical ventilation time and intensive care unit length of stay were 14 (IQR, 8-20) and 42 hours (IQR, 26-93 hours) in the isolated AVR group, and 16.5 hours (IQR, 12-61.5 hours) and 95.5 hours (IQR, 43.5-159 hours) in the AVR plus MV surgery group, respectively. The most common post-operative complication was new-onset atrial fibrillation, which occurred in 15 (29.4%) isolated AVR and 4 (16.7%) AVR plus MV surgery patients. The median hospital length of stay and 30-day mortality was 7 days (IQR, 5-12 days) and 1 (2%) in the isolated AVR group, and 10.5 days (IQR, 5-21 days) and 1 (4.3%) for AVR plus MV surgery. CONCLUSIONS In patients with aortic valve pathology in the setting of a left ventricular ejection fraction ≤35%, minimally invasive AVR can be performed, with or without concomitant MV surgery, with a low morbidity and mortality.
Collapse
Affiliation(s)
- Orlando Santana
- Division of Cardiology, The Columbia University, Mount Sinai Heart Institute, Miami Beach, USA
| | - Steve Xydas
- Division of Cardiac Surgery, Mount Sinai Heart Institute, Miami Beach, USA
| | - Roy F. Williams
- Division of Cardiac Surgery, Mount Sinai Heart Institute, Miami Beach, USA
| | - Angelo La Pietra
- Division of Cardiac Surgery, Mount Sinai Heart Institute, Miami Beach, USA
| | - Maurice Mawad
- Division of Cardiac Surgery, Mount Sinai Heart Institute, Miami Beach, USA
| | - Vicente Behrens
- Department of Anesthesiology, Mount Sinai Medical Center, Miami Beach, USA
| | - Esteban Escolar
- Division of Cardiology, The Columbia University, Mount Sinai Heart Institute, Miami Beach, USA
| | - Christos G. Mihos
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| |
Collapse
|