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Gomes NFA, Silva VR, Levine RA, Esteves WAM, de Castro ML, Passos LSA, Dal-Bianco JP, Pantaleão AN, da Silva JLP, Tan TC, Dutra WO, Aikawa E, Hung J, Nunes MCP. Progression of Mitral Regurgitation in Rheumatic Valve Disease: Role of Left Atrial Remodeling. Front Cardiovasc Med 2022; 9:862382. [PMID: 35360029 PMCID: PMC8962951 DOI: 10.3389/fcvm.2022.862382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 02/14/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Mitral regurgitation (MR) is the most common valve abnormality in rheumatic heart disease (RHD) often associated with stenosis. Although the mechanism by which MR develops in RHD is primary, longstanding volume overload with left atrial (LA) remodeling may trigger the development of secondary MR, which can impact on the overall progression of MR. This study is aimed to assess the incidence and predictors of MR progression in patients with RHD. Methods Consecutive RHD patients with non-severe MR associated with any degree of mitral stenosis were selected. The primary endpoint was a progression of MR, which was defined as an increase of one grade in MR severity from baseline to the last follow-up echocardiogram. The risk of MR progression was estimated accounting for competing risks. Results The study included 539 patients, age of 46.2 ± 12 years and 83% were women. At a mean follow-up time of 4.2 years (interquartile range [IQR]: 1.2–6.9 years), 54 patients (10%) displayed MR progression with an overall incidence of 2.4 per 100 patient-years. Predictors of MR progression by the Cox model were age (adjusted hazard ratio [HR] 1.541, 95% CI 1.222–1.944), and LA volume (HR 1.137, 95% CI 1.054–1.226). By considering competing risk analysis, the direction of the association was similar for the rate (Cox model) and incidence (Fine-Gray model) of MR progression. In the model with LA volume, atrial fibrillation (AF) was no longer a predictor of MR progression. In the subgroup of patients in sinus rhythm, 59 had an onset of AF during follow-up, which was associated with progression of MR (HR 2.682; 95% CI 1.133–6.350). Conclusions In RHD patients with a full spectrum of MR severity, progression of MR occurs over time is predicted by age and LA volume. LA enlargement may play a role in the link between primary MR and secondary MR in patients with RHD.
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Affiliation(s)
- Nayana F. A. Gomes
- School of Medicine, Hospital das Clínicas, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Vicente Rezende Silva
- School of Medicine, Hospital das Clínicas, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Robert A. Levine
- Cardiac Ultrasound Lab, Harvard Medical School, Massachusetts General Hospital, Boston, MA, United States
| | - William A. M. Esteves
- School of Medicine, Hospital das Clínicas, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Marildes Luiza de Castro
- School of Medicine, Hospital das Clínicas, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Livia S. A. Passos
- The Center for Excellence in Vascular Biology, Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Jacob P. Dal-Bianco
- Cardiac Ultrasound Lab, Harvard Medical School, Massachusetts General Hospital, Boston, MA, United States
| | | | | | - Timothy C. Tan
- Department of Cardiology, Blacktown Hospital, University of Western Sydney, Penrith, NSW, Australia
| | - Walderez O. Dutra
- Department of Morphology, Institute of Biological Sciences, Federal University of Minas Gerais, and National Institutes for Science and Technology, Belo Horizonte, Brazil
| | - Elena Aikawa
- The Center for Excellence in Vascular Biology, Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Judy Hung
- Cardiac Ultrasound Lab, Harvard Medical School, Massachusetts General Hospital, Boston, MA, United States
| | - Maria Carmo P. Nunes
- School of Medicine, Hospital das Clínicas, Federal University of Minas Gerais, Belo Horizonte, Brazil
- *Correspondence: Maria Carmo P. Nunes
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Ke F, Huang Y, Jin Z, Huang L, Xiong Q, Jia F, Chen Y, Chen G. Association between functional mitral regurgitation and recurrence of paroxysmal atrial fibrillation following catheter ablation: a prospective cohort study. J Int Med Res 2021; 49:3000605211014375. [PMID: 33983087 PMCID: PMC8127776 DOI: 10.1177/03000605211014375] [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] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE The present study aimed to investigate the effect of functional mitral regurgitation (FMR) on recurrence of paroxysmal atrial fibrillation (PAF) in patients undergoing radiofrequency catheter ablation. METHODS This prospective cohort study comprised 107 patients with PAF. The patients were divided into the FMR and non-FMR groups. FMR was assessed by Doppler echocardiography before index ablation. All patients initially underwent circumferential pulmonary vein isolation (CPVI) and were followed up for 12 months after ablation. PAF, atrial tachycardia, or atrial flutter served as the endpoint indicator. RESULTS The median duration of PAF was 24 (3-60) months. Binary logistic univariate and multivariate analyses showed that FMR was not a risk factor for recurrence of catheter ablation for PAF (hazard ratio=0.758, 95% confidence interval: 0.191-3.004; hazard ratio=0.665, 95% confidence interval: 0.134-3.300, respectively). Kaplan-Meier analysis showed no significant difference in the recurrence rate between the groups. Fifteen (15/107, 14%) cases of PAF were triggered by the pulmonary vein. Three (3/107, 2.8%) cases of PAF were triggered by the superior vena cava. CONCLUSIONS FMR is not an independent risk factor for predicting recurrence of catheter ablation for PAF. FMR does not affect patients undergoing radiofrequency catheter ablation for PAF.
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Affiliation(s)
- Fusheng Ke
- Department of Cardiology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, China
| | - Yinhui Huang
- Department of Neurology, Jinjiang Municipal Hospital, Jinjiang, China
| | - Zhexiu Jin
- Department of Cardiology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, China
| | - Lei Huang
- Department of Cardiology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, China
| | - Qiang Xiong
- Department of Emergency, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, China
| | - Fang Jia
- Department of Cardiology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, China
| | - Yu Chen
- Department of Pediatrics, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, China
| | - Gang Chen
- Department of Cardiology, Shanghai General Hospital, Shanghai, China
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Walmsley J, Squara P, Wolfhard U, Cornelussen R, Lumens J. Impact of abrupt versus gradual correction of mitral and tricuspid regurgitation: a modelling study. EUROINTERVENTION 2019; 15:902-911. [PMID: 31746755 DOI: 10.4244/eij-d-19-00598] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Correction of mitral and/or tricuspid regurgitation (MR, TR) frequently leads to poor outcomes in the days following intervention. We sought to understand how abrupt correction of MR and TR affects ventricular load and to investigate if gradual correction is beneficial. METHODS AND RESULTS MR and TR were simulated using the CircAdapt cardiovascular system model with effective regurgitant orifice (ERO) areas of 0.5 cm2 and 0.7 cm2. Ventricular and atrial contractility reductions to 40% of normal and pulmonary hypertension were simulated. Abrupt and gradual ERO closure were simulated with homeostatic regulation of blood pressure and volume. Abrupt correction of MR increased left and right ventricular fibre stress by 40% and 15%, respectively, whereas TR correction increased left and right ventricular fibre stress by 26% and 19%, respectively. This spike was followed by a rapid drop in fibre stress. Myocardial dysfunction prolonged the spike but reduced its amplitude. Right ventricular fibre stress increased more with pulmonary hypertension and TR. Gradual correction demonstrated no spike in tissue load. CONCLUSIONS Simulations demonstrated that abrupt ERO closure creates a transient increase in ventricular load that is prolonged by worsened myocardial condition and exacerbated by pulmonary hypertension. Gradual closure of the ERO abolishes this spike and merits clinical investigation.
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Affiliation(s)
- John Walmsley
- CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, the Netherlands
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Zhou ZW, Zhang BC, Yu Y, Guo K, Li W, Zhang R, Zhang PP, Li YG. Acute impact of pacing at different cardiac sites on left ventricular rotation and twist in dogs. PLoS One 2014; 9:e111231. [PMID: 25340769 PMCID: PMC4207788 DOI: 10.1371/journal.pone.0111231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 09/28/2014] [Indexed: 11/29/2022] Open
Abstract
Objectives We evaluated the acute impact of different cardiac pacing sites on two-dimensional speckle-tracking echocardiography (STE) derived left ventricular (LV) rotation and twist in healthy dogs. Methods Twelve dogs were used in this study. The steerable pacing electrodes were positioned into right heart through the superior or inferior vena cava, into LV through aorta across the aortic valve. The steerable pacing electrodes were positioned individually in the right atrium (RA), right ventricular apex (RVA), RV outflow tract (RVOT), His bundle (HB), LV apex (LVA) and LV high septum (LVS), individual pacing mode was applied at 10 minutes interval for at least 5 minutes from each position under fluoroscopy and ultrasound guidance and at stabilized hemodynamic conditions. LV short-axis images at the apical and basal levels were obtained during sinus rhythm and pacing. Offline STE analysis was performed. Rotation, twist, time to peak rotation (TPR), time to peak twist (TPT), and apical-basal rotation delay (rotational synchronization index, RSI) values were compared at various conditions. LV pressure was monitored simultaneously. Results Anesthetic death occurred in 1 dog, and another dog was excluded because of bad imaging quality. Data from 10 dogs were analyzed. RVA, RVOT, HB, LVA, LVS, RARV (RA+RVA) pacing resulted in significantly reduced apical and basal rotation and twist, significantly prolonged apical TPR, TPT and RSI compared to pre-pacing and RA pacing (all P<0.05). The apical and basal rotation and twist values were significantly higher during HB pacing than during pacing at ventricular sites (all P<0.05, except basal rotation at RVA pacing). The apical TPR during HB pacing was significantly shorter than during RVOT and RVA pacing (both P<0.05). The LV end systolic pressure (LVESP) was significantly lower during ventricular pacing than during pre-pacing and RA pacing. Conclusions Our results show that RA and HB pacing results in less acute reduction on LV twist, rotation and LVESP compared to ventricular pacing.
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Affiliation(s)
- Zhi-Wen Zhou
- Department of Cardiology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
- Department of Cardiology, Shanghai Xuhui Central Hospital, Shanghai, People's Republic of China
| | - Bu-Chun Zhang
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical College, Jiangsu province, People's Republic of China
| | - Yi Yu
- Department of Cardiology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Kai Guo
- Department of Cardiology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Wei Li
- Department of Cardiology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Rui Zhang
- Department of Cardiology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Peng-Pai Zhang
- Department of Cardiology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Yi-Gang Li
- Department of Cardiology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
- * E-mail:
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Song Y, Lee S, Kwak YL, Shim CY, Chang BC, Shim JK. Tissue Doppler Imaging Predicts Left Ventricular Reverse Remodeling After Surgery for Mitral Regurgitation. Ann Thorac Surg 2013; 96:2109-15. [DOI: 10.1016/j.athoracsur.2013.06.087] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Revised: 06/16/2013] [Accepted: 06/20/2013] [Indexed: 10/26/2022]
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Abstract
This article reviews the recent developments in echocardiography that have maintained this technology at the forefront of day-to-day imaging in clinical cardiology. The primary reason for most requests for imaging in cardiovascular medicine is to assess left ventricular structure and function. As our understanding of left ventricular mechanics has become more intricate, tissue Doppler and speckle tracking modalities have been developed that deliver greater insights into diagnosis of cardiomyopathy and earlier warning of ventricular dysfunction. Increased accuracy has been achieved with the dissemination of real-time three-dimensional echocardiography, which has also acquired a central role in the pre-operative assessment of patients prior to reparative valvular surgery. The use of contrast has broadened the indications for transthoracic echocardiography and has increased the accuracy of stress echocardiography, while reducing the number of patients who cannot be scanned because of a limited acoustic window. Finally, echocardiography will be seen in the future not only as a diagnostic tool in those affected by cardiovascular disease but also as a method for prediction of risk and perhaps activation of targeted treatment.
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Affiliation(s)
- R P Steeds
- Queen Elizabeth Hospital, Edgbaston, Birmingham, UK.
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Yared K, Lam KMT, Hung J. The use of exercise echocardiography in the evaluation of mitral regurgitation. Curr Cardiol Rev 2011; 5:312-22. [PMID: 21037848 PMCID: PMC2842963 DOI: 10.2174/157340309789317841] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2008] [Revised: 01/21/2009] [Accepted: 01/23/2009] [Indexed: 12/18/2022] Open
Abstract
Mitral regurgitation (MR) is the second most common valvular disease in western countries after aortic stenosis. Optimal management of patients with MR depends on the etiology of the regurgitation and is based predominantly on left ventricular function and functional status. Recent outcome studies report high risk subsets of asymptomatic patients with MR, and practice guidelines underscore the importance of a well-established estimation of exercise tolerance and recommend exercise testing to objectively assess functional status and hemodynamic factors.
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Affiliation(s)
- Kibar Yared
- Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Al-Amri HS, Al-Moghairi AM, El Oakley RM. Surgical treatment of functional mitral regurgitation in dilated cardiomyopathy. J Saudi Heart Assoc 2011; 23:125-34. [PMID: 24146526 DOI: 10.1016/j.jsha.2011.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Revised: 04/07/2011] [Accepted: 04/09/2011] [Indexed: 10/18/2022] Open
Abstract
Functional mitral regurgitation is a significant complication of end-stage cardiomyopathy. Dysfunction of one or more components of the mitral valve apparatus occurs in 39-74% and affects almost all heart failure patients. Survival is decreased in subjects with more than mild mitral regurgitation irrespective of the aetiology of heart failure. The goal of treating functional mitral regurgitation is to slow or reverse ventricular remodelling, improve symptoms and functional class, decrease the frequency of hospitalization for congestive heart failure, slow progression to advanced heart failure (time to transplant) and improve survival. This article reviews the role of mitral valve surgery in patients with heart failure and dilated cardiomyopathy.
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Affiliation(s)
- Hussein S Al-Amri
- Adult Cardiology Department, Prince Sultan Cardiac Centre, Riyadh, Saudi Arabia
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Levine RA, Nattel S. Looking into the left atrial crystal ball: a ray of hope for patients with organic mitral regurgitation. J Am Coll Cardiol 2010; 56:579-81. [PMID: 20688213 DOI: 10.1016/j.jacc.2009.11.103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2009] [Accepted: 11/19/2009] [Indexed: 01/20/2023]
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10
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Di Salvo TG, Acker MA, Dec GW, Byrne JG. Mitral valve surgery in advanced heart failure. J Am Coll Cardiol 2010; 55:271-82. [PMID: 20117430 DOI: 10.1016/j.jacc.2009.08.059] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2009] [Revised: 08/07/2009] [Accepted: 08/10/2009] [Indexed: 01/28/2023]
Abstract
The appropriateness and timing of mitral valve surgery in patients with advanced heart failure and severe mitral regurgitation remains controversial. Recent surgical results provide evidence for beneficial effects on left ventricular remodeling and functional capacity. Given the absence of randomized trials comparing the outcomes of mitral valve surgery to medical therapy, however, clinical decision making regarding surgery for these fragile patients poses a dilemma to thoughtful clinicians. This paper reviews the pathophysiology of mitral regurgitation in heart failure and proposes an integrated approach to management.
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Pu M, Gao Z, Zhang X, Liao D, Pu DK, Brennan T, Davidson WR. Impact of mitral regurgitation on left ventricular anatomic and molecular remodeling and systolic function: implication for outcome. Am J Physiol Heart Circ Physiol 2009; 296:H1727-32. [PMID: 19329766 DOI: 10.1152/ajpheart.00882.2008] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The aim of the study was to assess the impact of mitral regurgitation (MR) on left ventricular (LV) anatomic and molecular remodeling and function and to determine whether early LV remodeling and function predict long-term outcome in experimental organic MR. A new rodent model of chronic MR was created. Twenty-eight rats had surgically induced MR, twelve rats had a sham operation, and twelve rats had no operation. LV diameters, volume, and mass and LV ejection fraction (LVEF) and LV fractional shortening (LVFS) were assessed using echocardiography in the early stage of MR (6 and 12 wk after induction of MR). LV hemodynamics was assessed invasively. Cardiac alpha- and beta-myosin heavy chains and sarco(endo)plasmic reticulum Ca(2+)-ATPase 2 (SERCA2) were measured to assess molecular remodeling and contractility. Cox's proportional hazard ratios (HR) were used to identify outcome predictors. Early LV dilation was demonstrated in rats with MR when LVEF and LVFS were still normal. LV remodeling was associated with an increase in LV end-diastolic pressure and decrease in maximal change in pressure over time. Shifting of alpha- to beta-myosin and reduced SERCA2 were observed in rats with MR. Cox's proportional hazard analysis showed that LV end-diastolic diameters (HR, 1.2-2.4; P = 0.007) and LV end-diastolic volume (HR, 1.1-1.4; P = 0.005) at 6 wk and LV mass index (HR, 1.1-2.0; P = 0.004) at 12 wk after induction of MR were significantly associated with 1-yr mortality. However, LVEF (HR, 0.7-6.8 for the 6 wk, P > 0.05; and HR, 0.4-3.2 for the 12 wk, P > 0.05) and LVFS (HR, 0.4-1.4 for the 6 wk; and 0.4-3.1 for the 12 wk, P > 0.05) did not predict late death. Chronic MR leads to LV anatomic and cellular remodeling and impaired contractility. The time course of LV remodeling and function changes in the rat model of MR is similar to humans. Prediction of outcome may be achieved by assessments of early LV remodeling.
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Affiliation(s)
- Min Pu
- Division of Cardiovascular Medicine, Ohio State University, Columbus, OH 43210, USA
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Carlhäll CJ, Nguyen TC, Itoh A, Ennis DB, Bothe W, Liang D, Ingels NB, Miller DC. Alterations in transmural myocardial strain: an early marker of left ventricular dysfunction in mitral regurgitation? Circulation 2008; 118:S256-62. [PMID: 18824764 DOI: 10.1161/circulationaha.107.753525] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In asymptomatic patients with severe isolated mitral regurgitation (MR), identifying the onset of early left ventricular (LV) dysfunction can guide the timing of surgical intervention. We hypothesized that changes in LV transmural myocardial strain represent an early marker of LV dysfunction in an ovine chronic MR model. METHODS AND RESULTS Sheep were randomized to control (CTRL, n=8) or experimental (EXP, n=12) groups. In EXP, a 3.5- or 4.8-mm hole was created in the posterior mitral leaflet to generate "pure" MR. Transmural beadsets were inserted into the lateral and anterior LV wall to radiographically measure 3-dimensional transmural strains during systole and diastolic filling, at 1 and 12 weeks postoperatively. MR grade was higher in EXP than CTRL at 1 and 12 weeks (3.0 [2-4] versus 0.5 [0-2]; 3.0 [1-4] versus 0.5 [0-1], respectively, both P<0.001). At 12 weeks, LV mass index was greater in EXP than CTRL (201+/-18 versus 173+/-17 g/m(2); P<0.01). LVEDVI increased in EXP from 1 to 12 weeks (P=0.015). Between the 1 and 12 week values, the change in BNP (-4.5+/-4.4 versus -3.0+/-3.6 pmol/L), PRSW (9+/-13 versus 23+/-18 mm Hg), tau (-3+/-11 versus -4+/-7 ms), and systolic strains was similar between EXP and CTRL. The changes in longitudinal diastolic filling strains between 1 and 12 weeks, however, were greater in EXP versus CTRL in the subendocardium (lateral: -0.08+/-0.05 versus 0.02+/-0.14; anterior: -0.10+/-0.05 versus -0.02+/-0.07, both P<0.01). CONCLUSIONS Twelve weeks of ovine "pure" MR caused LV remodeling with early changes in LV function detected by alterations in transmural myocardial strain, but not by changes in BNP, PRSW, or tau.
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Affiliation(s)
- Carl J Carlhäll
- Department of Cardiothoracic Surgery, Falk Cardiovascular Research Center, Stanford University School of Medicine, Stanford, CA 94305-5247, USA
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