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Nakamae K, Oshitomi T, Uesugi H, Ideta I, Takaji K, Sassa T, Murata H, Hirota M. Long-term outcomes of left ventricular posterior wall plication for ischemic mitral regurgitation. Indian J Thorac Cardiovasc Surg 2023; 39:462-470. [PMID: 37609609 PMCID: PMC10442011 DOI: 10.1007/s12055-023-01527-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 04/19/2023] [Accepted: 04/21/2023] [Indexed: 08/24/2023] Open
Abstract
Purpose To evaluate the early and long-term outcomes of left ventricular posterior wall plication for ischemic mitral regurgitation. Methods Patients with ischemic mitral regurgitation who underwent left ventricular posterior wall plication via right-sided left atriotomy at our institution between 2010 and 2020 were retrospectively reviewed. Cases with normal cardiac function, left ventricular end-systolic diameter < 50 mm, and left ventriculotomy approach were excluded. Results The mean follow-up period was 5.3 years [standard deviation (SD) = 3.5], with a maximum of 10 years. Among the 21 patients enrolled, 9 had New York Heart Association (NYHA) class ≥ III. Three patients required preoperative inotrope support, while two preoperative ventilator support. The mean left ventricular ejection fraction was 31.4% (SD: 8.6), and 16 patients had mitral regurgitation grade ≥ III. All patients underwent coronary artery bypass grafting and mitral annuloplasty. Concomitant surgeries included 11 chordae cutting and 3 tricuspid annuloplasties. One in-hospital death occurred due to sepsis. At the follow-up, echocardiographic data showed significant improvement in cardiac dilation and function and good control of mitral regurgitation. The serum brain natriuretic peptide level was significantly reduced, and 85% of patients improved to NYHA class I. Four deaths occurred later due to sudden, unknown causes. The 5- and 8-year survival rates were 60.2% and 46.8%, respectively, and the 5- and 8-year hospitalization rates due to heart failure were 14.9% and 21.3%, respectively. Conclusion The long-term outcomes of left ventricular posterior wall plication were satisfactory for controlling heart failure and improving survival rate and patient prognosis. Supplementary Information The online version contains supplementary material available at 10.1007/s12055-023-01527-2.
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Affiliation(s)
- Kosuke Nakamae
- Division of Cardiovascular Surgery, Saiseikai Kumamoto Hospital, 5-3-1, Chikami, Minami-Ku, Kumamoto City, Kumamoto, 861-4193 Japan
| | - Takashi Oshitomi
- Division of Cardiovascular Surgery, Saiseikai Kumamoto Hospital, 5-3-1, Chikami, Minami-Ku, Kumamoto City, Kumamoto, 861-4193 Japan
| | - Hideyuki Uesugi
- Division of Cardiovascular Surgery, Saiseikai Kumamoto Hospital, 5-3-1, Chikami, Minami-Ku, Kumamoto City, Kumamoto, 861-4193 Japan
| | - Ichiro Ideta
- Division of Cardiovascular Surgery, Saiseikai Kumamoto Hospital, 5-3-1, Chikami, Minami-Ku, Kumamoto City, Kumamoto, 861-4193 Japan
| | - Kentaro Takaji
- Division of Cardiovascular Surgery, Saiseikai Kumamoto Hospital, 5-3-1, Chikami, Minami-Ku, Kumamoto City, Kumamoto, 861-4193 Japan
| | - Toshiharu Sassa
- Division of Cardiovascular Surgery, Saiseikai Kumamoto Hospital, 5-3-1, Chikami, Minami-Ku, Kumamoto City, Kumamoto, 861-4193 Japan
| | - Hidetaka Murata
- Division of Cardiovascular Surgery, Saiseikai Kumamoto Hospital, 5-3-1, Chikami, Minami-Ku, Kumamoto City, Kumamoto, 861-4193 Japan
| | - Masataka Hirota
- Division of Cardiovascular Surgery, Saiseikai Kumamoto Hospital, 5-3-1, Chikami, Minami-Ku, Kumamoto City, Kumamoto, 861-4193 Japan
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van Kampen A, Morningstar JE, Goudot G, Ingels N, Wenk JF, Nagata Y, Yaghoubian KM, Norris RA, Borger MA, Melnitchouk S, Levine RA, Jensen MO. Utilization of Engineering Advances for Detailed Biomechanical Characterization of the Mitral-Ventricular Relationship to Optimize Repair Strategies: A Comprehensive Review. Bioengineering (Basel) 2023; 10:601. [PMID: 37237671 PMCID: PMC10215167 DOI: 10.3390/bioengineering10050601] [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: 04/17/2023] [Revised: 05/10/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023] Open
Abstract
The geometrical details and biomechanical relationships of the mitral valve-left ventricular apparatus are very complex and have posed as an area of research interest for decades. These characteristics play a major role in identifying and perfecting the optimal approaches to treat diseases of this system when the restoration of biomechanical and mechano-biological conditions becomes the main target. Over the years, engineering approaches have helped to revolutionize the field in this regard. Furthermore, advanced modelling modalities have contributed greatly to the development of novel devices and less invasive strategies. This article provides an overview and narrative of the evolution of mitral valve therapy with special focus on two diseases frequently encountered by cardiac surgeons and interventional cardiologists: ischemic and degenerative mitral regurgitation.
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Affiliation(s)
- Antonia van Kampen
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- Leipzig Heart Centre, University Clinic of Cardiac Surgery, 02189 Leipzig, Germany
| | - Jordan E. Morningstar
- Department of Regenerative Medicine and Cell Biology, University of South Carolina, Charleston, SC 29425, USA
| | - Guillaume Goudot
- Cardiac Ultrasound Laboratory, Department of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Neil Ingels
- Department of Biomedical Engineering, University of Arkansas, Fayetteville, AR 72701, USA
| | - Jonathan F. Wenk
- Department of Mechanical Engineering, University of Kentucky, Lexington, KY 40508, USA;
| | - Yasufumi Nagata
- Cardiac Ultrasound Laboratory, Department of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Koushiar M. Yaghoubian
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Russell A. Norris
- Department of Regenerative Medicine and Cell Biology, University of South Carolina, Charleston, SC 29425, USA
| | - Michael A. Borger
- Leipzig Heart Centre, University Clinic of Cardiac Surgery, 02189 Leipzig, Germany
| | - Serguei Melnitchouk
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Robert A. Levine
- Cardiac Ultrasound Laboratory, Department of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Morten O. Jensen
- Department of Biomedical Engineering, University of Arkansas, Fayetteville, AR 72701, USA
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
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Exploring the Operative Strategy for Secondary Mitral Regurgitation: A Systematic Review. BIOMED RESEARCH INTERNATIONAL 2021; 2021:3466813. [PMID: 34258260 PMCID: PMC8245239 DOI: 10.1155/2021/3466813] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/05/2021] [Accepted: 06/16/2021] [Indexed: 01/16/2023]
Abstract
Background Mitral valve disease surgery is an evolving field with multiple possible interventions. There is an increasing body of evidence regarding the optimal strategy in secondary mitral regurgitation where the pathology lies within the ventricle. We conducted a systematic review to identify the benefits and limitations of each surgical option. Methods A systematic review of the literature was performed to identify pertinent randomized controlled trials (RCTs), propensity-matched observational series, and meta-analyses which were considered initially and followed by unmatched observational series using the MEDLINE, Ovid EMBASE, and Cochrane Library. Results We identified 6 different strategies for treating secondary mitral valve regurgitation: mitral valve replacement, restrictive mitral annuloplasty, surgical revascularization (with and without mitral annuloplasty), subvalvular procedures (papillary muscle approximation, papillary muscle relocation, ring and string procedure), and procedures directly targeting the mitral valve (edge-to-edge repair and anterior leaflet enlargement) alongside transcatheter heart valve therapy. We also highlighted the role of left ventricular assist devices in the management of this condition. The benefits and limitations of each intervention are highlighted. Conclusion There is currently no unanimous and shared strategy for the optimal treatment of patients with secondary IMR. The management of patients with secondary mitral regurgitation must be entrusted to a multidisciplinary Heart Team to ensure ideal intervention and patient matching for the best outcomes.
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Anatomy of Mitral Valve Complex as Revealed by Non-Invasive Imaging: Pathological, Surgical and Interventional Implications. J Cardiovasc Dev Dis 2020; 7:jcdd7040049. [PMID: 33158082 PMCID: PMC7712333 DOI: 10.3390/jcdd7040049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 10/27/2020] [Accepted: 11/02/2020] [Indexed: 12/18/2022] Open
Abstract
Knowledge of mitral valve (MV) anatomy has been accrued from anatomic specimens derived by cadavers, or from direct inspection during open heart surgery. However, today two-dimensional and three-dimensional transthoracic (2D/3D TTE) and transesophageal echocardiography (2D/3D TEE), computed tomography (CT) and cardiac magnetic resonance (CMR) provide images of the beating heart of unprecedented quality in both two and three-dimensional format. Indeed, over the last few years these non-invasive imaging techniques have been used for describing dynamic cardiac anatomy. Differently from the “dead” anatomy of anatomic specimens and the “static” anatomy observed during surgery, they have the unique ability of showing “dynamic” images from beating hearts. The “dynamic” anatomy gives us a better awareness, as any single anatomic arrangement corresponds perfectly to a specific function. Understanding normal anatomical aspects of MV apparatus is of a paramount importance for a correct interpretation of the wide spectrum of patho-morphological MV diseases. This review illustrates the anatomy of MV as revealed by non-invasive imaging describing physiological, pathological, surgical and interventional implications related to specific anatomical features of the MV complex.
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Drake DH, Zimmerman KG, Sidebotham DA. Past, current and future management of secondary mitral valve disease: the importance of anatomic staging. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:968. [PMID: 32953768 PMCID: PMC7475447 DOI: 10.21037/atm.2020.03.82] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Daniel H Drake
- Department of Surgery, Munson Medical Center, Traverse City, MI, USA
| | - Karen G Zimmerman
- Department of Cardiology, Henry Ford Health System, Detroit, MI, USA
| | - David A Sidebotham
- Department of Cardiothoracic Anesthesia and Cardiothoracic Intensive Care Unit, Auckland City Hospital, Grafton, Auckland, New Zealand
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Báez-Ferrer N, Izquierdo-Gómez MM, Marí-López B, Montoto-López J, Duque-Gómez A, García-Niebla J, Miranda-Bacallado J, de la Rosa Hernández A, Laynez-Cerdeña I, Lacalzada-Almeida J. Clinical manifestations, diagnosis, and treatment of ischemic mitral regurgitation: a review. J Thorac Dis 2018; 10:6969-6986. [PMID: 30746243 DOI: 10.21037/jtd.2018.10.64] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Ischemic mitral regurgitation (IMR) is a frequent complication after acute myocardial infarction (AMI) associated with a worse prognosis. The pathophysiological mechanisms of IMR are not fully understood, but it is known to be a complex process in which ventricular remodelling is the main causal factor. The various imaging techniques in cardiology and echocardiography fundamentally have contributed significantly to clarify the mechanisms that cause and progressively aggravate IMR. At present, different therapeutic options, the most important of which are cardio-surgical, address this problem. Nowadays the improvement in cardiac surgery and transcatheter therapies, have shown a therapeutic advance in IMR management. IMR is a predictor of poor prognosis in patients with heart failure and depressed left ventricular (LV) systolic function. However, it remains controversial whether mitral regurgitation (MR) in these patients is a consequence of dilation and dysfunction of the LV, or whether it contributes to worsening the prognosis of the ventricular dysfunction. Given that echocardiography has a fundamental reference role in the identification, graduation of severity and evaluation of the therapeutics used in the treatment of MR, we are going to focus on it over the rest of the imaging techniques. In contrast to primary MR the benefits of mitral surgery in patients with secondary MR are uncertain. Therefore, we will comment fundamentally on the role of mitral surgery in patients with IMR, with an update of the different surgical interventions available, without forgetting to mention the other therapeutic options currently available.
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Affiliation(s)
- Néstor Báez-Ferrer
- Department of Cardiology, Hospital Universitario de Canarias, Tenerife, Spain
| | | | - Belén Marí-López
- Department of Cardiology, Hospital Universitario de Canarias, Tenerife, Spain
| | - Javier Montoto-López
- Department of Cardiovascular Surgery, Hospital Universitario de Canarias, Tenerife, Spain
| | - Amelia Duque-Gómez
- Department of Cardiology, Hospital Universitario de Canarias, Tenerife, Spain
| | - Javier García-Niebla
- Servicios Sanitarios del Área de Salud de El Hierro, Valle del Golfo Health Center, El Hierro, Spain
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Abstract
Ischemic mitral regurgitation (IMR) is a frequent complication of left ventricular (LV) global or regional pathological remodeling due to chronic coronary artery disease. It is not a valve disease but represents the valvular consequences of increased tethering forces and reduced closing forces. IMR is defined as mitral regurgitation caused by chronic changes of LV structure and function due to ischemic heart disease and it worsens the prognosis. In this review, we discuss on etiology, pathophysiology, and mechanisms of IMR, its classification, evaluation, and therapeutic corrective methods of IMR.
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Affiliation(s)
- Praveen Kerala Varma
- Division of Cardiac Surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham (Amrita University), Kochi, Kerala, India
| | - Neethu Krishna
- Division of Cardiac Surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham (Amrita University), Kochi, Kerala, India
| | - Reshmi Liza Jose
- Division of Anesthesiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham (Amrita University), Kochi, Kerala, India
| | - Ashish Narayan Madkaiker
- Division of Cardiac Surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham (Amrita University), Kochi, Kerala, India
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8
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Shi W, McIver BV, Kalra K, Sarin EL, Schmarkey S, Duggan M, Thourani VH, Guyton RA, Padala M. A Swine Model of Percutaneous Intracoronary Ethanol Induced Acute Myocardial Infarction and Ischemic Mitral Regurgitation. J Cardiovasc Transl Res 2017; 10:391-400. [PMID: 28577038 DOI: 10.1007/s12265-017-9751-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 05/12/2017] [Indexed: 11/26/2022]
Abstract
Ischemic mitral regurgitation (IMR) is a frequent complication after a myocardial infarction (MI), which doubles mortality. Transcatheter mitral repairs are emerging as alternative treatment options to open heart surgery for IMR, but animal models to test them are lacking. We report a percutaneous swine model of IMR. Seventeen swine were randomized to (group 1, n = 12) MI causing IMR, and (group 2, n = 5) controls. In group 1, MI was induced via percutaneous ethanol injection into the obtuse marginal branches of the left circumflex artery, resulting in ST elevating myocardial infarction. Nine animals were survived to 8-10 weeks with weekly echocardiograms and three swine were survived to 16-20 weeks with MRI at termination. In group 1 animals, average IMR fraction at termination was 26.6 ± 2.3% in the echo group, and 24.51 ± 0.41% in the MRI group. None of the animals in group 2 had IMR. Left ventricular dysfunction and significant dilatation were evident in group 1 animals, compared to the controls. In conclusion, a reproducible model of IMR is reported for use in pre-clinical testing of new mitral technologies.
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Affiliation(s)
- Weiwei Shi
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Division of Cardiothoracic Surgery, Emory University, 380-B, Northyards Boulevard, Atlanta, GA, 30313, USA
| | - Bryant V McIver
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Division of Cardiothoracic Surgery, Emory University, 380-B, Northyards Boulevard, Atlanta, GA, 30313, USA
| | - Kanika Kalra
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Division of Cardiothoracic Surgery, Emory University, 380-B, Northyards Boulevard, Atlanta, GA, 30313, USA
| | - Eric L Sarin
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Division of Cardiothoracic Surgery, Emory University, 380-B, Northyards Boulevard, Atlanta, GA, 30313, USA
- INOVA Heart & Vascular Institute, Fairfax, VA, USA
| | - Susan Schmarkey
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Division of Cardiothoracic Surgery, Emory University, 380-B, Northyards Boulevard, Atlanta, GA, 30313, USA
| | - Michael Duggan
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Division of Cardiothoracic Surgery, Emory University, 380-B, Northyards Boulevard, Atlanta, GA, 30313, USA
- Division of Cardiac Anesthesiology, Emory University, Atlanta, USA
| | - Vinod H Thourani
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Division of Cardiothoracic Surgery, Emory University, 380-B, Northyards Boulevard, Atlanta, GA, 30313, USA
| | - Robert A Guyton
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Division of Cardiothoracic Surgery, Emory University, 380-B, Northyards Boulevard, Atlanta, GA, 30313, USA
| | - Muralidhar Padala
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Division of Cardiothoracic Surgery, Emory University, 380-B, Northyards Boulevard, Atlanta, GA, 30313, USA.
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9
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Wei L, Jiang L, Li Y. The use of artificial chordae in mitral valve repair. J Card Surg 2017; 32:250-258. [PMID: 28303614 DOI: 10.1111/jocs.13120] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Li Wei
- Heart and Vascular Center; Yan'an hospital of Kunming Medical University; Kunming City Yunnan China
| | - Lihong Jiang
- Heart and Vascular Center; Yan'an hospital of Kunming Medical University; Kunming City Yunnan China
| | - Yaxiong Li
- Heart and Vascular Center; Yan'an hospital of Kunming Medical University; Kunming City Yunnan China
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10
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Aquila I, Fernández-Golfín C, Rincon LM, González A, García Martín A, Hinojar R, Jimenez Nacher JJ, Indolfi C, Zamorano JL. Fully automated software for mitral annulus evaluation in chronic mitral regurgitation by 3-dimensional transesophageal echocardiography. Medicine (Baltimore) 2016; 95:e5387. [PMID: 27930514 PMCID: PMC5265986 DOI: 10.1097/md.0000000000005387] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Three-dimensional (3D) transesophageal echocardiography (TEE) is the gold standard for mitral valve (MV) anatomic and functional evaluation. Currently, dedicated MV analysis software has limitations for its use in clinical practice. Thus, we tested here a complete and reproducible evaluation of a new fully automatic software to characterize MV anatomy in different forms of mitral regurgitation (MR) by 3D TEE.Sixty patients were included: 45 with more than moderate MR (28 organic MR [OMR] and 17 functional MR [FMR]) and 15 controls. All patients underwent TEE. 3D MV images obtained using 3D zoom were imported into the new software for automatic analysis. Different MV parameters were obtained and compared. Anatomic and dynamic differences between FMR and OMR were detected. A significant increase in systolic (859.75 vs 801.83 vs 607.78 mm; P = 0.002) and diastolic (1040.60 vs. 1217.83 and 859.74 mm; P < 0.001) annular sizes was observed in both OMR and FMR compared to that in controls. FMR had a reduced mitral annular contraction compared to degenerative cases of OMR and to controls (17.14% vs 32.78% and 29.89%; P = 0.007). Good reproducibility was demonstrated along with a short analysis time (mean 4.30 minutes).Annular characteristics and dynamics are abnormal in both FMR and OMR. Full 3D software analysis automatically calculates several significant parameters that provide a correct and complete assessment of anatomy and dynamic mitral annulus geometry and displacement in the 3D space. This analysis allows a better characterization of MR pathophysiology and could be useful in designing new devices for MR repair or replacement.
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Affiliation(s)
- Iolanda Aquila
- Cardiology Department, Ramón y Cajal University Hospital, Madrid, Spain
- Cardiovascular Institute, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | | | | | - Ariana González
- Cardiology Department, Ramón y Cajal University Hospital, Madrid, Spain
| | - Ana García Martín
- Cardiology Department, Ramón y Cajal University Hospital, Madrid, Spain
| | - Rocio Hinojar
- Cardiology Department, Ramón y Cajal University Hospital, Madrid, Spain
| | | | - Ciro Indolfi
- Cardiovascular Institute, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
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Spartera M, Galderisi M, Mele D, Cameli M, D'Andrea A, Rossi A, Mondillo S, Novo G, Esposito R, D'Ascenzi F, Montisci R, Gallina S, Margonato A, Agricola E. Role of cardiac dyssynchrony and resynchronization therapy in functional mitral regurgitation. Eur Heart J Cardiovasc Imaging 2016; 17:471-80. [DOI: 10.1093/ehjci/jev352] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 12/14/2015] [Indexed: 12/28/2022] Open
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12
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LaPar DJ, Acker MA, Gelijns AC, Kron IL. Repair or replace for severe ischemic mitral regurgitation: prospective randomized multicenter data. Ann Cardiothorac Surg 2015; 4:411-6. [PMID: 26539344 DOI: 10.3978/j.issn.2225-319x.2015.04.11] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Ischemic mitral regurgitation (IMR) is a subset of functional mitral regurgitation (MR) that has the potential to impact an increasing number of patients in the future. This is in the context of a worldwide population, which continues to live longer with improved survival after myocardial infarction. Substantial data have accumulated over the past few decades demonstrating the negative effects of IMR. Further, significant research has been done to define the optimal surgical approach and several studies have compared mitral repair versus replacement for patients with severe mitral regurgitation (SMR). Studies supporting performance of mitral repair cite superior operative morbidity and mortality rates, while proponents of mitral replacement cite improved long-term durability and correction of MR. Lack of clinically robust Level I randomized controlled trial data have curtailed attempts to better define appropriate surgical treatment allocation over the past few decades. Recently, however, the Cardiothoracic Surgical Trials Network (CTSN) conducted the first randomized controlled trial, funded by the National Heart, Lung, and Blood Institute, the National Institute for Neurological Diseases and Stroke and the Canadian Institute for Health Research, to compare the performance of mitral repair versus replacement for SMR. Herein, the present review describes the design, results and implications of the CTSN SMR trial and its efforts to identify the most efficacious surgical approach to SMR. This review also describes CTSN investigation to predict the recurrence of MR after mitral repair.
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Affiliation(s)
- Damien J LaPar
- 1 Investigators for the Cardiothoracic Surgical Trials Network (CTSN): University of Virginia School of Medicine, Charlottesville, VA, USA ; 2 University of Pennsylvania School of Medicine, Philadelphia, PA, USA ; 3 Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michael A Acker
- 1 Investigators for the Cardiothoracic Surgical Trials Network (CTSN): University of Virginia School of Medicine, Charlottesville, VA, USA ; 2 University of Pennsylvania School of Medicine, Philadelphia, PA, USA ; 3 Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Annetine C Gelijns
- 1 Investigators for the Cardiothoracic Surgical Trials Network (CTSN): University of Virginia School of Medicine, Charlottesville, VA, USA ; 2 University of Pennsylvania School of Medicine, Philadelphia, PA, USA ; 3 Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Irving L Kron
- 1 Investigators for the Cardiothoracic Surgical Trials Network (CTSN): University of Virginia School of Medicine, Charlottesville, VA, USA ; 2 University of Pennsylvania School of Medicine, Philadelphia, PA, USA ; 3 Icahn School of Medicine at Mount Sinai, New York, NY, USA
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13
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Levine RA, Hagége AA, Judge DP, Padala M, Dal-Bianco JP, Aikawa E, Beaudoin J, Bischoff J, Bouatia-Naji N, Bruneval P, Butcher JT, Carpentier A, Chaput M, Chester AH, Clusel C, Delling FN, Dietz HC, Dina C, Durst R, Fernandez-Friera L, Handschumacher MD, Jensen MO, Jeunemaitre XP, Le Marec H, Le Tourneau T, Markwald RR, Mérot J, Messas E, Milan DP, Neri T, Norris RA, Peal D, Perrocheau M, Probst V, Pucéat M, Rosenthal N, Solis J, Schott JJ, Schwammenthal E, Slaugenhaupt SA, Song JK, Yacoub MH. Mitral valve disease--morphology and mechanisms. Nat Rev Cardiol 2015; 12:689-710. [PMID: 26483167 DOI: 10.1038/nrcardio.2015.161] [Citation(s) in RCA: 231] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Mitral valve disease is a frequent cause of heart failure and death. Emerging evidence indicates that the mitral valve is not a passive structure, but--even in adult life--remains dynamic and accessible for treatment. This concept motivates efforts to reduce the clinical progression of mitral valve disease through early detection and modification of underlying mechanisms. Discoveries of genetic mutations causing mitral valve elongation and prolapse have revealed that growth factor signalling and cell migration pathways are regulated by structural molecules in ways that can be modified to limit progression from developmental defects to valve degeneration with clinical complications. Mitral valve enlargement can determine left ventricular outflow tract obstruction in hypertrophic cardiomyopathy, and might be stimulated by potentially modifiable biological valvular-ventricular interactions. Mitral valve plasticity also allows adaptive growth in response to ventricular remodelling. However, adverse cellular and mechanobiological processes create relative leaflet deficiency in the ischaemic setting, leading to mitral regurgitation with increased heart failure and mortality. Our approach, which bridges clinicians and basic scientists, enables the correlation of observed disease with cellular and molecular mechanisms, leading to the discovery of new opportunities for improving the natural history of mitral valve disease.
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Affiliation(s)
- Robert A Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Yawkey 5E, Boston, MA 02114, USA
| | - Albert A Hagége
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | | | | | - Jacob P Dal-Bianco
- Massachusetts General Hospital, Cardiac Ultrasound Laboratory, Harvard Medical School, Boston, MA, USA
| | | | | | | | - Nabila Bouatia-Naji
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | - Patrick Bruneval
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | | | - Alain Carpentier
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | | | | | | | - Francesca N Delling
- Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | | | - Christian Dina
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | - Ronen Durst
- Hadassah-Hebrew University Medical Centre, Jerusalem, Israel
| | - Leticia Fernandez-Friera
- Hospital Universitario HM Monteprincipe and the Centro Nacional de Investigaciones Cardiovasculares, Carlos III (CNIC), Madrid, Spain
| | - Mark D Handschumacher
- Massachusetts General Hospital, Cardiac Ultrasound Laboratory, Harvard Medical School, Boston, MA, USA
| | | | - Xavier P Jeunemaitre
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | - Hervé Le Marec
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | - Thierry Le Tourneau
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | | | - Jean Mérot
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | - Emmanuel Messas
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | - David P Milan
- Cardiovascular Research Center, Harvard Medical School, Boston, MA, USA
| | - Tui Neri
- Aix-Marseille University, INSERM UMR 910, Marseille, France
| | | | - David Peal
- Cardiovascular Research Center, Harvard Medical School, Boston, MA, USA
| | - Maelle Perrocheau
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | - Vincent Probst
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | - Michael Pucéat
- Aix-Marseille University, INSERM UMR 910, Marseille, France
| | | | - Jorge Solis
- Hospital Universitario HM Monteprincipe and the Centro Nacional de Investigaciones Cardiovasculares, Carlos III (CNIC), Madrid, Spain
| | - Jean-Jacques Schott
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | | | - Susan A Slaugenhaupt
- Center for Human Genetic Research, MGH Research Institute, Harvard Medical School, Boston, MA, USA
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Gunnal SA, Wabale RN, Farooqui MS. Morphological study of chordae tendinae in human cadaveric hearts. Heart Views 2015; 16:1-12. [PMID: 25838872 PMCID: PMC4379635 DOI: 10.4103/1995-705x.152994] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objectives: The chordae tendinae (CT) are strong, fibrous connections between the valve leaflets and the papillary muscles. Dysfunction of the papillary muscles and chordae is frequent. Mitral valve replacement with preservation of CT and papillary muscles may preserve postoperative left ventricular function better than conventional mitral valve replacement in patients with chronic mitral regurgitation. Methods: The study was carried out on 116 human cadaveric hearts. The heart was opened through the atrioventricular valve to view the constituents of the complex. Origin, attachments, insertions, distribution, branching pattern and gross structure of CT were observed and studied in detail. Results: In the present study more than 21 terminologies of CT were defined by classifying it into six different types. Classification is done according to the origin, attachments, insertion, distribution, branching pattern and gross structure. Terminologies defined are as follows. Apical pillar chordae, Basal pillar chordae, True chordae, False chordae, Interpillar chordae, Pillar wall chordae, Cusp chordae, Cleft chordae, Commissural chordae, First order chordae, Second order chordae, Free zone chordae, Marginal chordae, Rough zone chordae, Straight chordae, Branched-fan shaped chordae, Spiral chordae, Irregular-web chordae, Tendinous chordae, Muscular chordae, Membranous chordae. Basal pillar chordae are found in 9.48%. Mean number of chordae taking origin from apical half of a single papillary muscle or single head of papillary muscle was 9.09 with the range of 3-18. Mean number of the marginal chordae attached to a single cusp was 22.63 ranging from 11 to 35. Strut chordae showed interesting insertion with broad aponeurosis in 38.79% and large muscular flaps in 13.79%. Chordae muscularis were found in 14% and membranous chordae were found in 6%. Conclusions: This knowledge may prove useful for cardiologists and cardiac surgeons.
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Affiliation(s)
- S A Gunnal
- Department of Anatomy, Rural Medical College, Maharashtra, India
| | - R N Wabale
- Department of Anatomy, Rural Medical College, Maharashtra, India
| | - M S Farooqui
- Department of Anatomy, Rural Medical College, Maharashtra, India
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15
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Dal-Bianco JP, Beaudoin J, Handschumacher MD, Levine RA. Basic mechanisms of mitral regurgitation. Can J Cardiol 2014; 30:971-81. [PMID: 25151282 DOI: 10.1016/j.cjca.2014.06.022] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Revised: 06/16/2014] [Accepted: 06/22/2014] [Indexed: 12/17/2022] Open
Abstract
Any structural or functional impairment of the mitral valve (MV) apparatus that exhausts MV tissue redundancy available for leaflet coaptation will result in mitral regurgitation (MR). The mechanism responsible for MV malcoaptation and MR can be dysfunction or structural change of the left ventricle, the papillary muscles, the chordae tendineae, the mitral annulus, and the MV leaflets. The rationale for MV treatment depends on the MR mechanism and therefore it is essential to identify and understand normal and abnormal MV and MV apparatus function.
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Affiliation(s)
- Jacob P Dal-Bianco
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan Beaudoin
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Department of Cardiology, Québec City, Québec, Canada
| | - Mark D Handschumacher
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert A Levine
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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16
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Murashita T, Okada Y, Kanemitsu H, Fukunaga N, Konishi Y, Nakamura K, Koyama T. Midterm outcomes of chordal cutting in combination with downsized ring annuloplasty for ischemic mitral regurgitation. Ann Thorac Cardiovasc Surg 2014; 20:1008-15. [PMID: 24492174 DOI: 10.5761/atcs.oa.13-00293] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE We describe midterm outcomes after division of secondary chords (chordal cutting) combined with downsized ring annuloplasty for ischemic mitral regurgitation (IMR). METHODS We compared the clinical outcomes in patients who underwent chordal cutting with downsized ring annuloplasty (CC-group, n = 15) and those who underwent conventional ring annuloplasty only (Conventional-group, n = 35) for IMR. Follow-up was complete in all patients. The median follow-up time was 4.1 years. RESULTS Thirty-day mortality was 0% in CC-group and 20% in Conventional-group. The overall survival rate at 5-year was 80.8% ± 12.6% in CC-group and 61.7% ± 8.4% in Conventional-group (Log-rank, p = 0.145). The freedom rate from valve-related events at 5 year was 84.6% ± 10.0% in CC-group and 65.3% ± 10.1% in Conventional-group (Log-rank, p = 0.213). Recurrence of severe mitral regurgitation was revealed in 3 patients of CC-group. Preoperative tenting height was the significant predictor of mitral regurgitation recurrence. In CC-group, the mean left ventricular ejection fraction was 38.0% ± 14.0%, which was similar to the preoperative value of 40.0% ± 13.2% (p = 0.349). CONCLUSIONS Chordal cutting with downsized ring annuloplasty for IMR is a simple method and provides satisfactory early outcomes. However, it carries with high recurrence of MR especially for patients with high tenting height.
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Affiliation(s)
- Takashi Murashita
- Department of Cardiovascular Surgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
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17
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Paparella D, Malvindi PG, Romito R, Fiore G, Tupputi Schinosa LDL. Ischemic mitral regurgitation: pathophysiology, diagnosis and surgical treatment. Expert Rev Cardiovasc Ther 2014; 4:827-38. [PMID: 17173499 DOI: 10.1586/14779072.4.6.827] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Ischemic mitral valve regurgitation often complicates acute myocardial infarction and also represents a negative prognostic factor for long-term survival in patients undergoing surgical myocardial revascularization. While severe mitral regurgitation should always be corrected during a coronary artery bypass operation, the decision making is more difficult in patients with a mild-to-moderate degree of regurgitation. Recent studies and experimental protocols have elucidated the pathophysiological mechanisms leading to mitral regurgitation with great interest in annular modifications and subvalvular alterations. These data suggest that new and integrated surgical approaches that address annuloplasty ring sizing, ring type selection and tethering phenomenon (i.e., chordal cutting, 'edge-to-edge' technique and left-ventricular plasty techniques) are required for a safer and durable valve repair. Transthoracic and transesophageal echocardiography are useful in determining the etiology and the degree of mitral regurgitation, to assess mitral deformation and to measure indexes of global and regional left-ventricular remodeling. Stress echocardiography may unmask higher degrees of mitral regurgitation. More data are needed in order to confirm the promising and interesting preliminary experimental findings of magnetic resonance imaging in diagnosis and clinical evaluation of ischemic mitral regurgitation.
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Affiliation(s)
- Domenico Paparella
- University of Bari, Division of Cardiac Surgery, Piazza Giulio Cesare 11, 70100 Bari, Italy.
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18
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Hu Y, Gurev V, Constantino J, Trayanova N. Efficient preloading of the ventricles by a properly timed atrial contraction underlies stroke work improvement in the acute response to cardiac resynchronization therapy. Heart Rhythm 2013; 10:1800-6. [PMID: 23928177 PMCID: PMC3852188 DOI: 10.1016/j.hrthm.2013.08.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Indexed: 11/16/2022]
Abstract
BACKGROUND The acute response to cardiac resynchronization therapy (CRT) has been shown to be due to 3 mechanisms: resynchronization of ventricular contraction, efficient preloading of the ventricles by a properly timed atrial contraction, and mitral regurgitation reduction. However, the contribution of each of the 3 mechanisms to the acute response to CRT, specifically stroke work improvement, has not been quantified. OBJECTIVE To use a magnetic resonance image-based anatomically accurate 3-dimensional model of failing canine ventricular electromechanics to quantify the contribution of each of the 3 mechanisms to stroke work improvement and identify the predominant mechanisms. METHODS An MRI-based electromechanical model of the failing canine ventricles assembled previously by our group was further developed and modified. Three different protocols were used to dissect the contribution of each of the 3 mechanisms to stroke work improvement. RESULTS Resynchronization of ventricular contraction did not lead to a significant stroke work improvement. Efficient preloading of the ventricles by a properly timed atrial contraction was the predominant mechanism underlying stroke work improvement. Stroke work improvement peaked at an intermediate atrioventricular delay, as it allowed ventricular filling by atrial contraction to occur at a low diastolic left ventricular pressure but also provided adequate time for ventricular filling before ventricular contraction. Reduction of mitral regurgitation by CRT led to stroke work worsening instead of improvement. CONCLUSION Efficient preloading of the ventricles by a properly timed atrial contraction is responsible for a significant stroke work improvement in the acute CRT response.
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Affiliation(s)
- Yuxuan Hu
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Viatcheslav Gurev
- Functional Genomics and Systems Biology, IBM T.J. Watson Research Center, Yorktown Heights, NY, USA
| | - Jason Constantino
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Natalia Trayanova
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA
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Abstract
The mitral valve apparatus is a complex 3-dimensional (3D) functional unit that is critical to unidirectional heart pump function. This review details the normal anatomy, histology, and function of the main mitral valve apparatus components: mitral annulus, mitral valve leaflets, chordae tendineae, and papillary muscles. Two-dimensional and 3D echocardiography is ideally suited to examine the mitral valve apparatus and has provided important insights into the mechanism of mitral valve disease. An overview of standardized echocardiography image acquisition and interpretation is provided. Understanding normal mitral valve apparatus function is essential to comprehend alterations in mitral valve disease and the rationale for repair strategies.
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20
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Szymanski C, Bel A, Cohen I, Touchot B, Handschumacher MD, Desnos M, Carpentier A, Menasché P, Hagège AA, Levine RA, Messas E. Comprehensive annular and subvalvular repair of chronic ischemic mitral regurgitation improves long-term results with the least ventricular remodeling. Circulation 2012; 126:2720-7. [PMID: 23139296 DOI: 10.1161/circulationaha.111.033472] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Undersized ring annuloplasty for ischemic mitral regurgitation (MR) is associated with variable results and >30% MR recurrence. We tested whether subvalvular repair by severing second-order mitral chordae can improve annuloplasty by reducing papillary muscle tethering. METHODS AND RESULTS Posterolateral myocardial infarction known to produce chronic remodeling and MR was created in 28 sheep. At 3 months, sheep were randomized to sham surgery versus isolated undersized annuloplasty versus isolated bileaflet chordal cutting versus the combined therapy (n=7 each). At baseline, chronic myocardial infarction (3 months), and euthanasia (6.6 months), we measured left ventricular (LV) volumes and ejection fraction, wall motion score index, MR regurgitation fraction and vena contracta, mitral annulus area, and posterior leaflet restriction angle (posterior leaflet to mitral annulus area) by 2-dimensional and 3-dimensional echocardiography. All groups were comparable at baseline and chronic myocardial infarction, with mild to moderate MR (MR vena contracta, 4.6±0.1 mm; MR regurgitation fraction, 24.2±2.9%) and mitral annulus dilatation (P<0.01). At euthanasia, MR progressed to moderate to severe in controls but decreased to trace with ring plus chordal cutting versus trace to mild with chordal cutting alone versus mild to moderate with ring alone (MR vena contracta, 5.9±1.1 mm in controls, 0.5±0.08 with both, 1.0±0.3 with chordal cutting alone, 2.0±0.4 with ring alone; P<0.01). In addition, LV end-systolic volume increased by 108% in controls versus 28% with ring plus chordal cutting, less than with each intervention alone (P<0.01). In multivariate analysis, LV end-systolic volume and mitral annulus area most strongly predicted MR (r(2)=0.82, P<0.01). CONCLUSIONS Comprehensive annular and subvalvular repair improves long-term reduction of both chronic ischemic MR and LV remodeling without decreasing global or segmental LV function at follow-up.
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Affiliation(s)
- Catherine Szymanski
- Department of Cardio-Vascular Medicine, Hôpital Européen Georges Pompidou, INSERM U 633, PARCC, 20 Rue Leblanc, 75015 Paris, France
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21
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Padala M, Gyoneva L, Yoganathan AP. Effect of anterior strut chordal transection on the force distribution on the marginal chordae of the mitral valve. J Thorac Cardiovasc Surg 2011; 144:624-633.e2. [PMID: 22154223 DOI: 10.1016/j.jtcvs.2011.10.032] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2011] [Revised: 09/12/2011] [Accepted: 10/20/2011] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Transection of the secondary chordae on the anterior leaflet of the mitral valve to relieve leaflet tethering and reduce regurgitation is an experimentally proven procedure to correct functional mitral regurgitation. In the present study, we sought to investigate whether transecting the secondary chordae would have an effect on the marginal chordal force on the same leaflet. METHODS Adult porcine mitral valves (n = 8) were studied in a pulsatile heart simulator, in which the papillary muscle positions can be precisely positioned. Miniature transducers were inserted into the anterior marginal chordae to measure the chordal forces. Each valve was studied under baseline conditions, 3 different tethering conditions (apical, apical-lateral, and apical-lateral-posterior), and after chordal cutting in the 3 tethering conditions. The temporal changes and peak and average marginal chordal forces under each condition are reported. RESULTS Apical tethering increased the marginal chordal force by an average of 96% but remained unchanged after chordal cutting. With apical-lateral tethering, the marginal chordal force increased by 210% from baseline and increased further to 350% of baseline after chordal cutting. After apical-lateral-posterior tethering, the marginal chordal force increased to 335% of baseline before transection and by 548% after transection. CONCLUSIONS The increase in the marginal chordal force after secondary chordal cutting depends on the location of the papillary muscles and the extent of leaflet tethering. Although chordal cutting might not alter the valve mechanics under minimal leaflet tethering, it significantly affects the mechanics when the leaflet tethering is more pronounced, which is typically seen in patients with functional mitral regurgitation.
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Affiliation(s)
- Muralidhar Padala
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA
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22
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Perrault LP, Moskowitz AJ, Kron IL, Acker MA, Miller MA, Horvath KA, Thourani VH, Argenziano M, D'Alessandro DA, Blackstone EH, Moy CS, Mathew JP, Hung J, Gardner TJ, Parides MK. Optimal surgical management of severe ischemic mitral regurgitation: to repair or to replace? J Thorac Cardiovasc Surg 2011; 143:1396-403. [PMID: 22054660 DOI: 10.1016/j.jtcvs.2011.05.030] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Accepted: 05/05/2011] [Indexed: 12/22/2022]
Abstract
BACKGROUND Ischemic mitral regurgitation, a complication of myocardial infarction and coronary artery disease more generally, is associated with a high mortality rate and is estimated to affect 2.8 million Americans. With 1-year mortality rates as high as 40%, recent practice guidelines of professional societies recommend repair or replacement, but there remains a lack of conclusive evidence supporting either intervention. The choice between therapeutic options is characterized by the trade-off between reduced operative morbidity and mortality with repair versus a better long-term correction of mitral insufficiency with replacement. The long-term benefits of repair versus replacement remain unknown, which has led to significant variation in surgical practice. METHODS AND RESULTS This article describes the design of a prospective randomized clinical trial to evaluate the safety and effectiveness of mitral valve repair and replacement in patients with severe ischemic mitral regurgitation. This trial is being conducted as part of the Cardiothoracic Surgical Trials Network. This article addresses challenges in selecting a feasible primary end point, characterizing the target population (including the degree of mitral regurgitation) and analytical challenges in this high mortality disease. CONCLUSIONS The article concludes by discussing the importance of information on functional status, survival, neurocognition, quality of life, and cardiac physiology in therapeutic decision making.
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Affiliation(s)
- Louis P Perrault
- Department of Surgery, Montreal Heart Institute, University of Montréal, Montréal, Québec, Canada
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23
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The Mitral Valve by Three-Dimensional Echocardiography. CURRENT CARDIOVASCULAR IMAGING REPORTS 2010. [DOI: 10.1007/s12410-010-9042-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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24
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Messas E, Bel A, Szymanski C, Cohen I, Touchot B, Handschumacher MD, Desnos M, Carpentier A, Menasché P, Hagège AA, Levine RA. Relief of mitral leaflet tethering following chronic myocardial infarction by chordal cutting diminishes left ventricular remodeling. Circ Cardiovasc Imaging 2010; 3:679-86. [PMID: 20826595 DOI: 10.1161/circimaging.109.931840] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND one of the key targets in treating mitral regurgitation (MR) is reducing the otherwise progressive left ventricular (LV) remodeling that exacerbates MR and conveys adverse prognosis. We have previously demonstrated that severing 2 second-order chordae to the anterior mitral leaflet relieves tethering and ischemic MR acutely. The purpose of this study was to test whether this technique reduces the progression of LV remodeling in the chronic ischemic MR setting. METHODS AND RESULTS a posterolateral MI was created in 18 sheep by obtuse marginal branch ligation. After chronic remodeling and MR development at 3 months, 6 sheep were randomized to sham surgery (control group) and 12 to second-order chordal cutting (6 each to anterior leaflet [AntL] and bileaflet [BiL] chordal cutting, techniques that are in clinical application). At baseline, chronic infarction (3 months), and follow-up at a mean of 6.6 months post-myocardial infarction (MI) (euthanasia), we measured LV end-diastolic (EDV) and end-systolic volume (ESV), ejection fraction, wall motion score index, and posterior leaflet (PL) restriction angle relative to the annulus by 2D and 3D echocardiography. All measurements were comparable among groups at baseline and chronic MI. At euthanasia, AntL and BiL chordal cutting limited the progressive remodeling seen in controls. LVESV increased relative to chronic MI by 109±8.7% in controls versus 30.5±6.1% with chordal cutting (P<0.01) (LVESV in controls, 82.5±2.6 mL; in AntL, 60.6±5.1 mL; in BiL, 61.8±4.1 mL). LVEDV increased by 63±2.0% in controls versus 26±5.5% and 22±3.4% with chordal cutting (P<0.01). LV ejection fraction and wall motion score index were not significantly different at follow-up among the chordal cutting and control groups. MR progressively increased to moderate in controls but decreased to trace-mild with AntL and BiL chordal cutting (MR vena contracta in controls, 5.9±1.1 mm; in AntL, 2.6±0.1 mm; in BiL, 1.7±0.1 mm; P<0.01). BiL chordal cutting provided greater PL mobility (decreased PL restriction angle to 54.2±5.0° versus 83±3.2° with AntL chordal cutting; P<0.01). CONCLUSIONS reduced leaflet tethering by chordal cutting in the chronic post-MI setting substantially decreases the progression of LV remodeling with sustained reduction of MR over a chronic follow-up. These benefits have the potential to improve clinical outcomes.
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Affiliation(s)
- Emmanuel Messas
- Hôpital Européen Georges Pompidou, Department of Cardiology, University Paris Descartes, Paris.
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25
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Affiliation(s)
- Mitesh V Badiwala
- Division of Cardiovascular Surgery, Toronto General Hospital, University of Toronto, 4N-464, 200 Elizabeth St, Toronto, Ontario M5G 2C4, Canada
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Slocum AH, Bosworth WR, Mazumdar A, Saez1 MA, Culpepper ML, Levine RA. Design of a Catheter-Based Device for Performing Percutaneous Chordal-Cutting Procedures. J Med Device 2009; 3:25001. [PMID: 20352058 DOI: 10.1115/1.3139835] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
This paper focuses on the design and implementation of a percutaneous catheter-based device to provide physicians with an externally controlled tool capable of manipulating and cutting specific chordae tendinae within the hear to alleviate problems associated with some forms of mitral valve regurgitationt. In the United States alone, approximately 500,000 people develop ischemic or functional MR per year, and the chordae tendinae cutting procedure and device are needed because many patients do not have the required level of health necessary to survive open-heart surgery. A deterministic design process was used to generate several design concepts and then evaluate and compare each concept based on a set of functional requirements. A final concept to be alpha prototyped was then chosen, further developed, and fabricated. Experiments showed that the design was capable of locating and grabbing a chord and that ultrasound imaging is a viable method for navigating the device inside of the human body. Once contact between the chord and an RF ablator tip was confirmed, the chord was successfully ablated.
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Affiliation(s)
- Alexander H Slocum
- Massachusetts Institute of Technology, Department of Mechanical Engineering, Cambridge, MA 02139
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27
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Calafiore AM, Iacò AL, Bivona A, Bosco P, Di Mauro M. La insuficiencia mitral isquémica crónica: el dilema quirúrgico de esta década. CIRUGIA CARDIOVASCULAR 2009. [DOI: 10.1016/s1134-0096(09)70167-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Shingu Y, Yamada S, Ooka T, Tachibana T, Kubota S, Tsutsui H, Matsui Y. Papillary Muscle Suspension Concomitant With Approximation for Functional Mitral Regurgitation. Circ J 2009; 73:2061-7. [DOI: 10.1253/circj.cj-09-0129] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yasushige Shingu
- Department of Cardiovascular Surgery, Hokkaido University Hospital
| | - Satoshi Yamada
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine
| | - Tomonori Ooka
- Department of Cardiovascular Surgery, Hokkaido University Hospital
| | | | - Suguru Kubota
- Department of Cardiovascular Surgery, Hokkaido University Hospital
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine
| | - Yoshiro Matsui
- Department of Cardiovascular Surgery, Hokkaido University Hospital
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29
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Affiliation(s)
- Yoshiro Matsui
- Department of Cardiovascular Surgery, Hokkaido University Hospital
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30
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Veronesi F, Corsi C, Sugeng L, Caiani EG, Weinert L, Mor-Avi V, Cerutti S, Lamberti C, Lang RM. Quantification of Mitral Apparatus Dynamics in Functional and Ischemic Mitral Regurgitation Using Real-time 3-Dimensional Echocardiography. J Am Soc Echocardiogr 2008; 21:347-54. [PMID: 17681731 DOI: 10.1016/j.echo.2007.06.017] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2007] [Indexed: 11/21/2022]
Abstract
Mitral regurgitation (MR) in dilated cardiomyopathy (DCM-MR) and MR in ischemic cardiomyopathy (ISC-MR) usually occurs as a result of mitral annulus (MA) dilatation and papillary muscle displacement secondary to global left ventricle remodelling. We propose a method to determine MA area and motion throughout the cardiac cycle and to define papillary muscle position in 3-dimensional space using real-time 3-dimensional echocardiography. Real-time 3-dimensional echocardiography was performed in 24 healthy individuals, and in 30 patients with DCM-MR (n = 15) or ISC-MR (n = 15). Significant intergroup differences were noted in MA surface area (control: 6.4 +/- 1.7 cm(2); DCM-MR: 11.1 +/- 2.6 cm(2); ISC-MR: 9.0 +/- 2.0 cm(2)) and in peak MA motion (control: 8.7 +/- 3.0 mm; DCM-MR: 3.4 +/- 1.7 mm; ISC-MR: 4.9 +/- 1.5 mm). In patients with DCM-MR, papillary muscle symmetry was preserved, whereas in patients with ISC-MR, papillary tethering lengths were unequal as a result of wall-motion abnormalities. Our methodology for dynamic volumetric measurements of the mitral apparatus allows better understanding of MR mechanisms.
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Fayad G, Modine T, Azzaoui R, Larrue B, Cracco A, Pansard E, Decoene C, Warembourg H. Chordal cutting technique through aortotomy to treat chronic ischemic mitral regurgitation: Surgical technique. Int J Surg 2008; 6:36-9. [DOI: 10.1016/j.ijsu.2007.09.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2007] [Revised: 08/31/2007] [Accepted: 09/21/2007] [Indexed: 11/29/2022]
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Sai-Sudhakar CB, Vandse R, Armen TA, Bickle KM, Nathan NS. Efficacy of chordal cutting in alleviating ischemic mitral regurgitation: insights from 3-dimensional echocardiography. J Cardiothorac Surg 2007; 2:39. [PMID: 17894872 PMCID: PMC2042986 DOI: 10.1186/1749-8090-2-39] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2007] [Accepted: 09/25/2007] [Indexed: 11/15/2022] Open
Abstract
Background Ischemic mitral regurgitation often complicates severe ischemic heart disease and adversely affects the prognosis in these patients. There is wide variation in the clinical spectrum of ischemic mitral regurgitation due to varying location and chronicity of ischemia and anomalies in annular and ventricular remodeling. As a result, there is lack of consensus in treating these patients. Treatment has to be individualized for each patient. Most of the available surgical options do not consistently correct this condition in all the patients. Chordal cutting is one of the newer surgical approaches in which cutting a limited number of critically positioned basal chordae have found success by relieving the leaflet tethering and thereby improving the coaptation of leaflets. Three-dimensional echocardiography is a potentially valuable tool in identifying the specific pattern of tethering and thus the suitability of this procedure in a given clinical scenario. Case Presentation A 66-year-old man with cardiomyopathy and ischemic mitral regurgitation presented to us with the features of congestive heart failure. The three-dimensional echocardiography revealed severe mitral regurgitation associated with the tethering of the lateral (P1) and medial (P3) scallops of the posterior leaflet of the mitral valve due to secondary chordal attachments. The ejection fraction was only 15% with severe global systolic and diastolic dysfunction. Mitral regurgitation was successfully corrected with mitral annuloplasty and resection of the secondary chordae tethering the medial and lateral scallops of the posterior leaflet of the mitral valve. Conclusion Cutting the second order chordae along with mitral annuloplasty could be a novel method to remedy Ischemic mitral regurgitation by relieving the tethering of the valve leaflets. The preoperative three-dimensional echocardiography should be considered in all patients with Ischemic mitral regurgitation to assess the complex three-dimensional interactions between the mitral valve apparatus and the left ventricle. This aids in timely surgical planning.
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Affiliation(s)
- Chittoor B Sai-Sudhakar
- Department of Cardiothoracic Surgery, Ohio State University Medical Center, N-816 Doan Hall, 410 W 10Avenue, Columbus, OH 43210, USA
| | - Rashmi Vandse
- Department of Anesthesiology, Ohio State University Medical Center, N-416 Doan Hall,410 W 10Avenue, Columbus, OH 43210, USA
| | - Todd A Armen
- Department of Anesthesiology, Ohio State University Medical Center, N-416 Doan Hall,410 W 10Avenue, Columbus, OH 43210, USA
| | - Katherine M Bickle
- Department of Anesthesiology, Ohio State University Medical Center, N-416 Doan Hall,410 W 10Avenue, Columbus, OH 43210, USA
| | - Nadia S Nathan
- Department of Anesthesiology, Ohio State University Medical Center, N-416 Doan Hall,410 W 10Avenue, Columbus, OH 43210, USA
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Kotoh K, Fukahara K, Doi T, Nagura S, Misaki T. Experimental Mitral Valve Plasty under the Beating Heart Guided by Real-Time 3-Dimensional Echocardiography. Heart Surg Forum 2007; 10:E213-6. [DOI: 10.1532/hsf98.20071001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Masroor S, Berkowitz R, Alexander JC. Chordal Tethering: A Unique Cause of Structural Mitral Regurgitation in Dilated Cardiomyopathy. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2007. [DOI: 10.1177/155698450700200305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Saqib Masroor
- Divisions of Cardiothoracic Surgery and Evanston Northwestern Hospital, Evanston, Illinois
| | - Robert Berkowitz
- Divisions of Cardiology, Hackensack University Medical Center, Hackensack, New Jersey, Evanston Northwestern Hospital, Evanston, Illinois
| | - John C. Alexander
- Division of Cardiothoracic Surgery, Evanston Northwestern Hospital, Evanston, Illinois
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Chordal Tethering: A Unique Cause of Structural Mitral Regurgitation in Dilated Cardiomyopathy. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2007; 2:122-3. [DOI: 10.1097/imi.0b013e31806165f5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Mitral regurgitation in dilated cardiomyopathy is usually considered “functional,” and many such patients are treated medically. Surgery is often offered as a last resort in select patients who have failed medical therapy. We report a patient with dilated cardiomyopathy with ventricular tachycardia and ventricular dyssynchrony and “structural mitral regurgitation” due to chordal tethering, which was managed surgically using a minimally invasive approach.
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Magne J, Pibarot P, Dagenais F, Hachicha Z, Dumesnil JG, Sénéchal M. Preoperative Posterior Leaflet Angle Accurately Predicts Outcome After Restrictive Mitral Valve Annuloplasty for Ischemic Mitral Regurgitation. Circulation 2007; 115:782-91. [PMID: 17283262 DOI: 10.1161/circulationaha.106.649236] [Citation(s) in RCA: 174] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background—
Ischemic mitral regurgitation (MR) often persists after restrictive mitral valve annuloplasty, in which case it is associated with worse clinical outcomes. The goal of the present study was to determine whether persistence of MR and/or clinical outcome could be predicted from preoperative analysis of mitral valve configuration.
Methods and Results—
In 51 consecutive patients undergoing restrictive annuloplasty for ischemic MR, posterior leaflet (PL) angle, anterior leaflet angle, coaptation distance, and tenting area were quantified by echocardiography before surgery (6±3 days), and MR severity was assessed before and early after surgery (9±4 days). Postoperatively, persistence of mild to moderate MR (vena contracta >3 mm) was observed in 11 (22%) of the patients. The best predictor of postoperative persistence of MR was a PL angle ≥45 degrees (sensitivity 100%, specificity 97%, positive predictive value 92%, negative predictive value 100%). Patients with persistent MR had markedly lower 3-year event-free survival (26±20%) compared with those with nonpersistent MR (75±12%,
P
=0.01). Preoperative presence of a PL angle ≥45 degrees also was associated with a markedly lower 3-year event-free survival (22±17% versus 76±12%;
P
<0.001).
Conclusions—
In patients undergoing restrictive annuloplasty for ischemic MR, persistence of MR and 3-year event-free survival can accurately be predicted by preoperative analysis of mitral valve configuration. Patients with a PL angle ≥45 degrees (ie, with high PL restriction) should thus be considered poor candidates for this procedure, and concomitant or alternative procedures should be contemplated.
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Affiliation(s)
- Julien Magne
- Quebec Heart Institute, Faculty of Medicine, Laval University, Quebec, Canada, G1V 4G5
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Three-dimensional versus two-dimensional transesophageal echocardiography in mitral valve repair. J Am Soc Echocardiogr 2007; 20:4-12. [PMID: 17218196 DOI: 10.1016/j.echo.2006.07.005] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2006] [Indexed: 11/21/2022]
Abstract
OBJECTIVES We sought to compare the diagnostic performance of 3-dimensional (3D) versus 2-dimensional (2D) echocardiography in patients with regurgitant mitral valve. BACKGROUND An accurate assessment of morphology and function of the mitral valve is essential for surgical repair. Two-dimensional echocardiography has certain spatial limitations that could be overcome by 3D imaging. METHODS Preoperative transesophageal 2D and 3D studies were compared with surgical findings in patients undergoing surgical repair for severe mitral regurgitation. RESULTS A total of 81 consecutive patients underwent surgical repair (2002-2004). There was a high concordance (88%-100%) between both 2D and 3D studies and surgical findings in classification of involved segments. 3D imaging more accurately classified A1 segment defects (P = .05) and commissural dysfunction (P = .02). The 2D study incorrectly classified 22 segments, mainly corresponding to complex disease. The 3D study incorrectly classified 14 segments, unrelated to complex disease. Good agreement (94%, kappa 0.845) was found between non-expert and expert interpretations of 3D images. CONCLUSIONS Three-dimensional echocardiography offers high accuracy in mitral valve evaluation. It may complement 2D study in patients with complex valve anatomy, where surgical decisions are more difficult. The images can be easily interpreted by professionals without a high degree of experience.
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Lorusso R, De Bonis M, De Cicco G, Maisano F, Fucci C, Alfieri O. Mitral insufficiency and its different aetiologies: old and new insights for appropriate surgical indications and treatment. J Cardiovasc Med (Hagerstown) 2007; 8:108-13. [PMID: 17299292 DOI: 10.2459/01.jcm.0000260211.02468.0a] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Mitral insufficiency, as many other fields in medicine, has witnessed profound changes in terms of knowledge, diagnostic process and therapeutic options. Mitral valve reconstruction has become the treatment of choice in the presence of a regurgitant valve, although numerous preoperative and operative clues have been shown to predict less satisfactory results of valve repair in the long term, calling for a careful revision of postoperative data and search for novel techniques of valve repair or reconsider valve replacement as an acceptable therapy in peculiar cases. Old scenarios, like rheumatic valve disease or acute endocarditis, are continuously under reassessment in an attempt to distinguish patient subsets amenable to tailored therapies, whereas new fields of intervention, like dilated cardiomyopathy, or better appraisal of pathophysiological mechanisms, like ischaemic mitral insufficiency, are emerging and represent new indications for surgical solutions. The most recent advances in the understanding of how some aetiologies and related mechanisms of mitral insufficiency exert substantial influence on the postoperative results represent new tools in the guidance of a more appropriate surgical decision-making.
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Okahashi N, Watanabe N, Yamaura Y, Wada N, Neishi Y, Kawamoto T, Toyota E, Okura H, Ogasawara Y, Yoshida K. Noninvasive Measurements of the Mitral Annulus Geometry by Newly-developed Quantitation Software With Real-time Three-dimensional Echocardiography: A Validation Study. J Echocardiogr 2007. [DOI: 10.2303/jecho.5.32] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Nixdorff U, Klinghammer L, Wüstefeld G, Mohr-Kahaly S, von Bardeleben RS. Chronic Development of Ischaemic Mitral Regurgitation during Post-Infarction Remodelling. Cardiology 2006; 107:239-47. [PMID: 16953109 DOI: 10.1159/000095500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2005] [Accepted: 04/06/2006] [Indexed: 02/01/2023]
Abstract
BACKGROUND/AIMS Mitral regurgitation (MR) following myocardial infarction (MI) may be a (sub)acute complication which independently predicts reduced survival. We sought to evaluate the chronic development of MR as potential consequence of left-ventricular (LV) remodelling, the latter being a long-term process. METHODS AND RESULTS Retrospectively, 103 post-MI patients were included according to a standardised Doppler echocardiogram <3 months following MI (20 +/- 25 days post-MI) and a follow-up examination >6 months after the first examination (5.1 +/- 3.1 years post-MI). Patients were clinically followed up for 7.6 +/- 2.7 years. Group I patients were defined as those showing new development or deterioration in one of three grades of MR, and group II those without this criterion (MR grade acute 0.17 vs. 0.27, p = 0.7, and chronic 1.53 vs. 0.19, p < 0.0001). Patient characteristics were similar in respect of age, gender, size and location of infarction. However, group I patients had coronary artery disease with more vessels involved. With regard to echocardiographic parameters of significantly enlarged LV chamber size in group I vs. group II, the significant decrease in LV performance was more pronounced and occurred concomitant with a higher degree of symptomatic congestive heart failure and greater need for heart failure medications in group I. Mortality in group I patients was 39 versus 9% in group II patients (p = 0.0002), approximating an odds ratio of 6.4697 (95% confidence interval: 2.211-18.931). CONCLUSION First of all, this retrospective study indicates that MR may be detected in patients after MI during a long-term follow-up most probably due to geometric distortions of LV remodelling resulting in a significantly higher mortality. Since this process is known to become irreversible at a certain point, serial echocardiography may help to detect MR in post-MI patients and thus pave the way for appropriate treatment.
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Affiliation(s)
- Uwe Nixdorff
- Second Medical Clinic, Friedrich Alexander University, Erlangen-Nuremberg, Germany.
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Filsoufi F, Rahmanian PB, Anyanwu A, Adams DH. Physiologic Basis for the Surgical Treatment of Ischemic Mitral Regurgitation. ACTA ACUST UNITED AC 2006; 4:261-8. [PMID: 17086006 DOI: 10.1111/j.1541-9215.2006.05932.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Ischemic mitral regurgitation (MR) can complicate severe coronary artery disease and myocardial infarction. Ischemic MR results from left ventricular remodeling after myocardial infarction and can also accompany acute myocardial ischemia. The most common mechanism of ischemic MR is Carpentier's type IIIb dysfunction due to an apical and lateral displacement of papillary muscles leading to a tethering of the mitral leaflets. This apical tenting of the leaflets prevents the free margin from reaching the plane of the annulus, significantly reduces the surface of coaptation, and causes MR. Recent advances in imaging studies have led to a better understanding of the pathophysiology of this condition as well as to the development of innovative surgical approaches to treat this disease. Current research efforts have mainly focused on 2 directions: (1) percutaneous approaches to correct MR, and (2) surgical therapy to address the ventricular component of the disease. In this article, the authors define ischemic MR and review its pathophysiology, current management strategies, and future directions.
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Affiliation(s)
- Farzan Filsoufi
- Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY 10029, USA.
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A. Levine R, Otsuji Y, Schwammenthal E, Sakata R, Tei C. Ischemic Mitral Regurgitation: From New Understanding to New Solutions Role of Echocardiography. J Echocardiogr 2006. [DOI: 10.2303/jecho.4.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Affiliation(s)
- Robert A Levine
- Massachusetts General Hospital, Department of Medicine, Harvard Medical School, Boston, MA, USA.
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Rodriguez F, Langer F, Harrington KB, Tibayan FA, Zasio MK, Liang D, Daughters GT, Ingels NB, Miller DC. Cutting second-order chords does not prevent acute ischemic mitral regurgitation. Circulation 2005; 110:II91-7. [PMID: 15364845 DOI: 10.1161/01.cir.0000138396.24335.6a] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cutting anterior mitral leaflet second-order chordae has been proposed for repair in ischemic mitral regurgitation (IMR). We examined the efficacy of such chordal cutting in preventing acute IMR. METHODS AND RESULTS Six sheep underwent radiopaque marker placement (left ventricle, mitral annulus, papillary muscles [PMs], and leaflets). The largest second-order chord from each PM was encircled with exteriorized wire snares. Three-dimensional marker coordinates were obtained with biplane videofluoroscopy before and during acute ischemia (80 seconds of mid-circumflex occlusion). Color Doppler transesophageal echocardiography was used to grade MR on a 0 to 4+ scale. Data were acquired immediately before and after dividing second-order chordae. Slope of the end-diastolic volume-stroke work relationship (PRSW) was calculated to assess systolic function. Chordal cutting increased anterior leaflet inflection angle (155+/-12 versus 162+/-9 degrees; P=0.03), resulting in a flatter leaflet, but did not increase effective leaflet length (1.97+/-0.24 versus 2.08+/-0.23 cm; P=0.15); PRSW decreased (63+/-15 versus 56+/-12 mm Hg; P=0.008). Both before and after chordal cutting, ischemia caused: Septal-lateral annular dilation (P=0.005), posterior PM displacement away from the mid-septal annulus (P=0.06), increased leaflet tenting area (P=0.001), and increased leaflet tenting volume (P=0.002). Before chordal cutting, MR increased significantly during ischemia (0.5+/-0.3 versus 1.7+/-0.4; P<0.001), and IMR increased similarly even after the second-order chords were cut (0.7+/-0.4 versus 1.9+/-0.9; P<0.001). CONCLUSIONS Cutting second-order chordae resulted in LV systolic dysfunction and neither prevented nor decreased the severity of acute IMR, septal-lateral annular dilation, leaflet tenting area, or leaflet tenting volume.
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Affiliation(s)
- Filiberto Rodriguez
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif 94305-5247, USA
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Mantovani V, Sala A. Mitral regurgitation: overview of current surgical techniques and future developments. Expert Rev Cardiovasc Ther 2005; 3:271-84. [PMID: 15853601 DOI: 10.1586/14779072.3.2.271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Mitral regurgitation is a complex disease with many different etiologies, underlying dysfunctions and histologic alterations. Surgical correction of this condition dramatically improves the life expectancy and life quality of affected patients. The structure of the mitral valve lends itself to many surgical techniques. The purpose of this review is to offer readers an overview on this subject.
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Affiliation(s)
- Vittorio Mantovani
- University of Insubria, Department of Cardiac Surgery, Ospedale di Circolo-Fondazione Macchi, Viale Borri 57, 21100 Varese, Italy.
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Rodriguez F, Langer F, Harrington KB, Tibayan FA, Zasio MK, Cheng A, Liang D, Daughters GT, Covell JW, Criscione JC, Ingels NB, Miller DC. Importance of Mitral Valve Second-Order Chordae for Left Ventricular Geometry, Wall Thickening Mechanics, and Global Systolic Function. Circulation 2004; 110:II115-22. [PMID: 15364849 DOI: 10.1161/01.cir.0000138580.57971.b4] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Mitral valvular–ventricular continuity is important for left ventricular (LV) systolic function, but the specific contributions of the anterior leaflet second-order “strut” chordae are unknown.
Methods and Results—
Eight sheep had radiopaque markers implanted to silhouette the LV, annulus, and papillary muscles (PMs); 3 transmural bead columns were inserted into the mid-lateral wall between the PMs. The strut chordae were encircled with exteriorized wire snares. Three-dimensional marker images and hemodynamic data were acquired before and after chordal cutting. Preload recruitable stroke work (PRSW) and end-systolic elastance (E
es
) were calculated to assess global LV systolic function (n=7). Transmural strains were measured from bead displacements (n=4). Chordal cutting caused global LV dysfunction: E
es
(1.48±1.12 versus 0.98±1.30 mm Hg/mL,
P
=0.04) and PRSW (69±16 versus 60±15 mm Hg,
P
=0.03) decreased. Although heart rate and time from ED to ES were unchanged, time of mid-ejection was delayed (125±18 versus 136±19 ms,
P
=0.01). Globally, the LV apex and posterior PM tip were displaced away from the fibrous annulus and LV base-apex length increased at end-diastole and end-systole (all +1 mm,
P
<0.05). Locally, subendocardial end-diastolic strains occurred: Longitudinal strain (
E
22
) 0.030±0.013 and radial thickening (
E
33
) 0.081±0.041 (both
P
<0.05 versus zero). Subendocardial systolic shear strains were also perturbed: Circumferential-longitudinal “micro-torsion” (
E
12
) (0.099±0.035 versus 0.075±0.025) and circumferential radial shear (
E
13
) (0.084±0.023 versus 0.039±0.008, both
P
<0.05).
Conclusion—
Cutting second-order chords altered LV geometry, remodeled the myocardium between the PMs, perturbed local systolic strain patterns affecting micro-torsion and wall-thickening, and caused global systolic dysfunction, demonstrating the importance of these chordae for LV structure and function.
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Affiliation(s)
- Filiberto Rodriguez
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif 94305-5247, USA
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