1
|
Meijerink F, Wijdh-den Hamer IJ, Bouma W, Pouch AM, Aly AH, Lai EK, Eperjesi TJ, Acker MA, Yushkevich PA, Hung J, Mariani MA, Khabbaz KR, Gleason TG, Mahmood F, Gorman JH, Gorman RC. Intraoperative post-annuloplasty three-dimensional valve analysis does not predict recurrent ischemic mitral regurgitation. J Cardiothorac Surg 2020; 15:161. [PMID: 32616001 PMCID: PMC7333337 DOI: 10.1186/s13019-020-01138-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 05/04/2020] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND High ischemic mitral regurgitation (IMR) recurrence rates continue to plague IMR repair with undersized ring annuloplasty. We have previously shown that pre-repair three-dimensional echocardiography (3DE) analysis is highly predictive of IMR recurrence. The objective of this study was to determine the quantitative change in 3DE annular and leaflet tethering parameters immediately after repair and to determine if intraoperative post-repair 3DE parameters would be able to predict IMR recurrence 6 months after repair. METHODS Intraoperative pre- and post-repair transesophageal real-time 3DE was performed in 35 patients undergoing undersized ring annuloplasty for IMR. An advanced modeling algorhythm was used to assess 3D annular geometry and regional leaflet tethering. IMR recurrence (≥ grade 2) was assessed with transthoracic echocardiography 6 months after repair. RESULTS Annuloplasty significantly reduced septolateral diameter, commissural width, annular area, and tethering volume and significantly increased all segmental tethering angles (except A2). Intraoperative post-repair annular geometry and leaflet tethering did not differ significantly between patients with recurrent IMR (n = 9) and patients with non-recurrent IMR (n = 26). No intraoperative post-repair predictors of IMR recurrence could be identified. CONCLUSIONS Undersized ring annuloplasty changes mitral geometry acutely, exacerbates leaflet tethering, and generally fixes IMR acutely, but it does not always fix the delicate underlying chronic problem of continued left ventricular dilatation and remodeling. This may explain why pre-repair 3D valve geometry (which reflects chronic left ventricular remodeling) is highly predictive of recurrent IMR, whereas immediate post-repair 3D valve geometry (which does not completely reflect chronic left ventricular remodeling anymore) is not.
Collapse
Affiliation(s)
- Frank Meijerink
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA.
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
| | - Inez J Wijdh-den Hamer
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Wobbe Bouma
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Alison M Pouch
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA
| | - Ahmed H Aly
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA
| | - Eric K Lai
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA
| | - Thomas J Eperjesi
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael A Acker
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Paul A Yushkevich
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Judy Hung
- Department of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Massimo A Mariani
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Kamal R Khabbaz
- Department of Cardiothoracic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Thomas G Gleason
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Feroze Mahmood
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Joseph H Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert C Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
2
|
Yamazaki S, Numata S, Yaku H. Surgical intervention for ischemic mitral regurgitation: how can we achieve better outcomes? Surg Today 2019; 50:540-550. [PMID: 31147764 DOI: 10.1007/s00595-019-01823-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 04/15/2019] [Indexed: 12/31/2022]
Abstract
Ischemic mitral regurgitation (MR) is a common complication of myocardial infarction. Left ventricular (LV) dysfunction and distortion of the subvalvular apparatus are the main contributors to ischemic MR. Coronary artery bypass grafting alone, mitral valve replacement, and mitral valve repair, with or without subvalvular procedures, have been performed for moderate-to-severe ischemic MR. Several randomized studies on the surgical treatment of ischemic MR have been performed; however, the optimal surgical strategy remains controversial because none have demonstrated a clear survival benefit. Since the mechanisms of ischemic MR are complex and multifactorial, comprehensive preoperative assessment of LV function and geometry (both global and regional), mitral valve configuration, viability testing, and exercise echocardiography are needed. A better understanding of this complicated disease and of the advantages and limitations of each procedure may help us devise more effective patient-specific surgical treatment strategies and achieve better outcomes.
Collapse
Affiliation(s)
- Sachiko Yamazaki
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan.
| | - Satoshi Numata
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Hitoshi Yaku
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan
| |
Collapse
|
3
|
Mihos CG, Capoulade R, Yucel E, Melnitchouk S, Hung J. Combined papillary muscle sling and ring annuloplasty for moderate-to-severe secondary mitral regurgitation. J Card Surg 2016; 31:664-671. [DOI: 10.1111/jocs.12843] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Christos G. Mihos
- Cardiac Ultrasound Laboratory; Massachusetts General Hospital; Harvard Medical School; Boston Massachusetts
- Mount Sinai Heart Institute; Columbia University; Miami Beach Florida
| | - Romain Capoulade
- Cardiac Ultrasound Laboratory; Massachusetts General Hospital; Harvard Medical School; Boston Massachusetts
| | - Evin Yucel
- Cardiac Ultrasound Laboratory; Massachusetts General Hospital; Harvard Medical School; Boston Massachusetts
| | - Serguei Melnitchouk
- Department of Cardiac Surgery; Massachusetts General Hospital; Harvard Medical School; Boston Massachusetts
| | - Judy Hung
- Cardiac Ultrasound Laboratory; Massachusetts General Hospital; Harvard Medical School; Boston Massachusetts
| |
Collapse
|
4
|
Wijdh-den Hamer IJ, Bouma W, Lai EK, Levack MM, Shang EK, Pouch AM, Eperjesi TJ, Plappert TJ, Yushkevich PA, Hung J, Mariani MA, Khabbaz KR, Gleason TG, Mahmood F, Acker MA, Woo YJ, Cheung AT, Gillespie MJ, Jackson BM, Gorman JH, Gorman RC. The value of preoperative 3-dimensional over 2-dimensional valve analysis in predicting recurrent ischemic mitral regurgitation after mitral annuloplasty. J Thorac Cardiovasc Surg 2016; 152:847-59. [PMID: 27530639 DOI: 10.1016/j.jtcvs.2016.06.040] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 05/05/2016] [Accepted: 06/10/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Repair for ischemic mitral regurgitation with undersized annuloplasty is characterized by high recurrence rates. We sought to determine the value of pre-repair 3-dimensional echocardiography over 2-dimensional echocardiography in predicting recurrence at 6 months. METHODS Intraoperative transesophageal 2-dimensional echocardiography and 3-dimensional echocardiography were performed in 50 patients undergoing undersized annuloplasty for ischemic mitral regurgitation. Two-dimensional echocardiography annular diameter and tethering parameters were measured in the apical 2- and 4-chamber views. A customized protocol was used to assess 3-dimensional annular geometry and regional leaflet tethering. Recurrence (grade ≥2) was assessed with 2-dimensional transthoracic echocardiography at 6 months. RESULTS Preoperative 2- and 3-dimensional annular geometry were similar in all patients with ischemic mitral regurgitation. Preoperative 2- and 3-dimensional leaflet tethering were significantly higher in patients with recurrence (n = 13) when compared with patients without recurrence (n = 37). Multivariate logistic regression revealed preoperative 2-dimensional echocardiography posterior tethering angle as an independent predictor of recurrence with an optimal cutoff value of 32.0° (area under the curve, 0.81; 95% confidence interval, 0.68-0.95; P = .002) and preoperative 3-dimensional echocardiography P3 tethering angle as an independent predictor of recurrence with an optimal cutoff value of 29.9° (area under the curve, 0.92; 95% confidence interval, 0.84-1.00; P < .001). The predictive value of the 3-dimensional geometric multivariate model can be augmented by adding basal aneurysm/dyskinesis (area under the curve, 0.94; 95% confidence interval, 0.87-1.00; P < .001). CONCLUSIONS Preoperative 3-dimensional echocardiography P3 tethering angle is a stronger predictor of ischemic mitral regurgitation recurrence after annuloplasty than preoperative 2-dimensional echocardiography posterior tethering angle, which is highly influenced by viewing plane. In patients with a preoperative P3 tethering angle of 29.9° or larger (especially when combined with basal aneurysm/dyskinesis), chordal-sparing valve replacement should be strongly considered.
Collapse
Affiliation(s)
- Inez J Wijdh-den Hamer
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa; Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Wobbe Bouma
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa; Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Eric K Lai
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa
| | - Melissa M Levack
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa
| | - Eric K Shang
- Department of Surgery, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa
| | - Alison M Pouch
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa
| | - Thomas J Eperjesi
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa
| | - Theodore J Plappert
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa
| | - Paul A Yushkevich
- Department of Radiology, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa
| | - Judy Hung
- Department of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Massimo A Mariani
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Kamal R Khabbaz
- Department of Cardiothoracic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | | | - Feroze Mahmood
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Michael A Acker
- Department of Surgery, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
| | - Albert T Cheung
- Department of Anesthesia, Stanford University, Stanford, Calif
| | - Matthew J Gillespie
- Department of Cardiology, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa
| | - Benjamin M Jackson
- Department of Surgery, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa
| | - Joseph H Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa; Department of Surgery, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa
| | - Robert C Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa; Department of Surgery, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa.
| |
Collapse
|
5
|
Konstantinou DM, Papadopoulou K, Giannakoulas G, Kamperidis V, Dalamanga EG, Damvopoulou E, Parcharidou DG, Karamitsos TD, Karvounis HI. Determinants of functional mitral regurgitation severity in patients with ischemic cardiomyopathy versus nonischemic dilated cardiomyopathy. Echocardiography 2013; 31:21-8. [PMID: 23930844 DOI: 10.1111/echo.12304] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
AIMS Functional mitral regurgitation (MR) is prevalent among patients with left ventricular (LV) dysfunction and is associated with a poorer prognosis. Our aim was to assess the primary determinants of MR severity in patients with ischemic cardiomyopathy (ICM) and nonischemic dilated cardiomyopathy (DCM). METHODS AND RESULTS Patients with functional MR secondary to ICM (n = 55) and DCM (n = 48) were prospectively enrolled. Effective regurgitant orifice (ERO) area, global LV remodeling, regional wall-motion abnormalities, and mitral apparatus deformity indices were assessed utilizing conventional and tissue Doppler echocardiography. ICM patients had more severe MR compared with DCM patients despite similar ejection fraction and functional status (ERO = 0.16 ± 0.08 cm(2) vs. ERO = 0.12 ± 0.70 cm(2) , respectively, P = 0.002). Regional myocardial systolic velocities in mid-inferior and mid-lateral wall were negatively correlated with ERO in ICM and DCM patients, respectively. Multivariate analysis identified coaptation height as the only independent determinant of ERO in both groups. In a subset of ICM patients (n = 9) with relatively high ERO despite low coaptation height, a higher prevalence of left bundle branch block was detected (88.9% vs. 46.7%, P = 0.02). CONCLUSIONS Functional MR severity was chiefly determined by the extent of mitral apparatus deformity, and coaptation height can provide a rapid estimation of MR severity in heart failure patients. Additional contributory mechanisms in ICM patients include depressed myocardial systolic velocities in posteromedial papillary muscle attaching site and evidence of global LV dyssynchrony.
Collapse
Affiliation(s)
- Dimitrios M Konstantinou
- First Department of Cardiology, AHEPA University Hospital, Aristotle University Medical School, Thessaloniki, Greece; Heart Failure Care Group, Royal Brompton Hospital, London, United Kingdom
| | | | | | | | | | | | | | | | | |
Collapse
|