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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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Stetsiuk LR, Klishch IM, Stetsiuk IO, Todurov BM, Todurov MB, Fedoniuk LY. ECHOCARDIOGRAPHIC ASPECTS OF ASSESSMENT OF MITRAL INSUFFICIENCY IN PATIENTS WITH ACUTE MYOCARDIAL INFARCTION WITH REDUCED LEFT VENTRICULAR EJECTION FRACTION. WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2023; 76:2502-2509. [PMID: 38112372 DOI: 10.36740/wlek202311126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
OBJECTIVE The aim is to analyze patients with acute myocardial infarction with reduced ejection fraction in order to determine risk factors for mitral insufficiency. PATIENTS AND METHODS Materials and methods: The study included 149 patients with acute myocardial infarction. Among the patients, there were 113 males (75.8%) and 36 females (24.2%). The age of the patients ranged from 43 to 86 years. Echocardiography was performed using a Phillips Epiq 7 machine. Patients were examined three times: upon admission to the hospital, after revascularization, and six months after discharge. Patients received transthoracic echocardiography, which was used to determine the presence and degree of mitral regurgitation. RESULTS Results: According to the results of the study, it was found that the presence of concomitant somatic pathology worsens the course of an acute myocardial infarction, in turn increasing the likelihood of valvular pathology. An increase in left ventricular volume indicators, such as end-diastolic volume, end-systolic volume, end-diastolic index, and the index of contractile function (ejection fraction) contributes to the development of mitral valve insufficiency. CONCLUSION Conclusions: The presence of mitral regurgitation in patients with acute myocardial infarction and reduced left ventricular ejection fraction worsens the course of the disease and negatively affects the prognosis.
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Affiliation(s)
- Liubov R Stetsiuk
- I. HORBACHEVSKY TERNOPIL NATIONAL MEDICAL UNIVERSITY, TERNOPIL, UKRAINE
| | - Ivan M Klishch
- I. HORBACHEVSKY TERNOPIL NATIONAL MEDICAL UNIVERSITY, TERNOPIL, UKRAINE
| | - Ihor O Stetsiuk
- KYIV HEART INSTITUTE OF THE MINISTRY OF HEALTH OF UKRAINE, KYIV, UKRAINE
| | - Borys M Todurov
- KYIV HEART INSTITUTE OF THE MINISTRY OF HEALTH OF UKRAINE, KYIV, UKRAINE
| | - Mykhailo B Todurov
- P.L. SHUPYK NATIONAL MEDICAL ACADEMY OF POSTGRADUATE EDUCATION, KYIV, UKRAINE
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Girdauskas E, Pausch J, Reichenspurner H, Kempfert J, Kuntze T, Owais T, Holubec T, Krane M, Vitanova K, Borger M, Eden M, Hachaturyan V, Bramlage P, Falk V. Subannular repair for functional mitral regurgitation with reduced systolic ventricle function: rationale and design of REFORM-MR registry. J Cardiothorac Surg 2022; 17:343. [PMID: 36581901 PMCID: PMC9801540 DOI: 10.1186/s13019-022-02045-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 11/27/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Functional mitral regurgitation (FMR) is one of the most common heart valve diseases that is a sequel of left ventricular remodelling. Although mitral valve annuloplasty is a standard treatment of FMR, the recurrence of FMR is a major drawback and occurs in 10-50% of patients. The REFORM-MR registry aims to investigate the effectiveness of standardized papillary muscle relocation and ring annuloplasty and to identify the risk factors associated with recurrent FMR. METHODS REFORM-MR is a prospective, multicenter registry that enrols consecutive FMR patients across five sites in Germany. All patients with FMR and restricted movement of leaflets during systole (i.e., type IIIb mitral regurgitation) undergoing standardized subannular repair in combination with mitral valve annuloplasty are included in the study. The primary objective is to examine the effect of combined papillary muscle relocation and ring annuloplasty on the recurrence of FMR at 2 years postoperatively. The secondary objectives are MACCE rate, reinterventions on the mitral valve and cardiac-related mortality in the study cohort. Echocardiography core-lab and MRI core-lab will provide anonymized analysis of the imaging data in the REFORM-MR registry. Student's t-test or Mann-Whitney U test for continuous variables and the Chi-Square or Fisher exact test for categorical variables are used for group comparisons. Kaplan-Meier analyses is performed for survival and safety outcomes. RESULTS As of May 2021, a total of 97 patients were enrolled across five sites in Germany. CONCLUSIONS The results of this study will help define the outcomes of combined papillary muscle relocation and ring annuloplasty in the FMR treatment in a multicentre setting and to improve the understanding of the limitations of subannular repair procedures while treating patients with type III FMR. Trial registration clinicaltrials.gov Identifier: NCT03470155.
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Affiliation(s)
- Evaldas Girdauskas
- grid.13648.380000 0001 2180 3484Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany ,grid.419801.50000 0000 9312 0220Department of Cardiovascular and Thoracic Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Jonas Pausch
- grid.13648.380000 0001 2180 3484Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Hermann Reichenspurner
- grid.13648.380000 0001 2180 3484Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Jörg Kempfert
- grid.418209.60000 0001 0000 0404Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany ,grid.452396.f0000 0004 5937 5237German Center for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
| | - Thomas Kuntze
- Department of Cardiology, Central Hospital Bad Berka, Bad Berka, Germany
| | - Tamer Owais
- grid.419801.50000 0000 9312 0220Department of Cardiovascular and Thoracic Surgery, University Hospital Augsburg, Augsburg, Germany ,Department of Cardiology, Central Hospital Bad Berka, Bad Berka, Germany
| | - Tomas Holubec
- grid.7839.50000 0004 1936 9721Department of Cardiovascular Surgery, University Hospital Frankfurt, Johann Wolfgang Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Markus Krane
- grid.472754.70000 0001 0695 783XGerman Heart Center Munich, Munich, Germany
| | - Keti Vitanova
- grid.472754.70000 0001 0695 783XGerman Heart Center Munich, Munich, Germany
| | - Michael Borger
- grid.411339.d0000 0000 8517 9062Department Cardiac Surgery, Leipzig Heart Center, University Clinic Leipzig, Leipzig, Germany
| | - Matthias Eden
- grid.412468.d0000 0004 0646 2097Department for Internal Medicine III, Molecular Cardiology and Angiology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Violetta Hachaturyan
- grid.476473.50000 0004 8389 0378Institute for Pharmacology and Preventive Medicine, Bahnhofstrasse 20, 49661 Cloppenburg, Germany
| | - Peter Bramlage
- grid.476473.50000 0004 8389 0378Institute for Pharmacology and Preventive Medicine, Bahnhofstrasse 20, 49661 Cloppenburg, Germany
| | - Volkmar Falk
- grid.418209.60000 0001 0000 0404Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany ,grid.452396.f0000 0004 5937 5237German Center for Cardiovascular Research, Partner Site Berlin, Berlin, Germany ,grid.7468.d0000 0001 2248 7639Department of Cardiovascular Surgery, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin, Berlin, Germany ,grid.5801.c0000 0001 2156 2780Department of Health Sciences and Technology, ETH Zürich, Zurich, Switzerland
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Surgical mitral valve repair technique considerations based on the available evidence. TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2022; 30:302-316. [PMID: 36168574 PMCID: PMC9473589 DOI: 10.5606/tgkdc.dergisi.2022.23340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 02/21/2022] [Indexed: 11/21/2022]
Abstract
Mitral valve regurgitation is the second most common valve disease in the western world. Surgery is currently the best tool for generating a long-lasting elimination of mitral valve regurgitation. However, the mitral valve apparatus is a complex anatomical and functional structure, and repair results and durability show substantial heterogeneity. This is not only due to differences in the underlying mitral valve regurgitation pathophysiology but also due to differences in repair techniques. Repair philosophies differ substantially from one surgeon to the other, and consensus for the technically best repair strategy has not been reached yet. We had previously addressed this topic by suggesting that ring sizing is "voodoo". We now review the available evidence regarding the various repair techniques described for structural and functional mitral valve regurgitation. Herein, we illustrate that for structural mitral valve regurgitation, resuspension of prolapsing valve segments or torn chordae with polytetrafluoroethylene sutures and annuloplasty can generate the most durable results paired with the best achievable hemodynamics. For functional mitral valve regurgitation, the evidence suggests that annuloplasty alone is insufficient in most cases to generate durable results, and additional subvalvular strategies are associated with improved durability and possibly improved clinical outcomes. This review addresses current strategies but also implausibilities in mitral valve repair and informs the mitral valve surgeon about the current evidence. We believe that this information may help improve outcomes in mitral valve repair as the heterogeneity of mitral valve regurgitation pathophysiology does not allow a one-size-fits-all concept.
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Pausch J, Girdauskas E, Conradi L, Reichenspurner H. Secondary mitral regurgitation repair techniques and outcomes: Subannular repair techniques in secondary mitral regurgitation type IIIb. JTCVS Tech 2022; 10:92-97. [PMID: 34977710 PMCID: PMC8691802 DOI: 10.1016/j.xjtc.2021.09.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 09/02/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- Jonas Pausch
- Department of Cardiovascular Surgery University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Evaldas Girdauskas
- Department of Cardiothoracic Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Lenard Conradi
- Department of Cardiovascular Surgery University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery University Heart & Vascular Center Hamburg, Hamburg, Germany
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Islam S, Boström KI, Di Carlo D, Simmons CA, Tintut Y, Yao Y, Hsu JJ. The Mechanobiology of Endothelial-to-Mesenchymal Transition in Cardiovascular Disease. Front Physiol 2021; 12:734215. [PMID: 34566697 PMCID: PMC8458763 DOI: 10.3389/fphys.2021.734215] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/09/2021] [Indexed: 12/31/2022] Open
Abstract
Endothelial cells (ECs) lining the cardiovascular system are subjected to a highly dynamic microenvironment resulting from pulsatile pressure and circulating blood flow. Endothelial cells are remarkably sensitive to these forces, which are transduced to activate signaling pathways to maintain endothelial homeostasis and respond to changes in the environment. Aberrations in these biomechanical stresses, however, can trigger changes in endothelial cell phenotype and function. One process involved in this cellular plasticity is endothelial-to-mesenchymal transition (EndMT). As a result of EndMT, ECs lose cell-cell adhesion, alter their cytoskeletal organization, and gain increased migratory and invasive capabilities. EndMT has long been known to occur during cardiovascular development, but there is now a growing body of evidence also implicating it in many cardiovascular diseases (CVD), often associated with alterations in the cellular mechanical environment. In this review, we highlight the emerging role of shear stress, cyclic strain, matrix stiffness, and composition associated with EndMT in CVD. We first provide an overview of EndMT and context for how ECs sense, transduce, and respond to certain mechanical stimuli. We then describe the biomechanical features of EndMT and the role of mechanically driven EndMT in CVD. Finally, we indicate areas of open investigation to further elucidate the complexity of EndMT in the cardiovascular system. Understanding the mechanistic underpinnings of the mechanobiology of EndMT in CVD can provide insight into new opportunities for identification of novel diagnostic markers and therapeutic interventions.
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Affiliation(s)
- Shahrin Islam
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Kristina I Boström
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States.,UCLA Molecular Biology Institute, Los Angeles, CA, United States.,Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, United States
| | - Dino Di Carlo
- Department of Bioengineering, University of California, Los Angeles, Los Angeles, CA, United States.,Department of Electrical and Computer Engineering, University of California, Los Angeles, Los Angeles, CA, United States
| | - Craig A Simmons
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, ON, Canada.,Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada.,Translational Biology and Engineering Program, Ted Rogers Centre for Heart Research, Toronto, ON, Canada
| | - Yin Tintut
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States.,Department of Physiology, University of California, Los Angeles, Los Angeles, CA, United States.,Department of Orthopedic Surgery, University of California, Los Angeles, Los Angeles, CA, United States
| | - Yucheng Yao
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Jeffrey J Hsu
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States.,Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, United States
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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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Messika-Zeitoun D, Iung B, Armoiry X, Trochu JN, Donal E, Habib G, Brochet E, Thibault H, Piriou N, Cormier B, Tribouilloy C, Guerin P, Lefèvre T, Maucort-Boulch D, Vahanian A, Boutitie F, Obadia JF. Impact of Mitral Regurgitation Severity and Left Ventricular Remodeling on Outcome After MitraClip Implantation: Results From the Mitra-FR Trial. JACC Cardiovasc Imaging 2020; 14:742-752. [PMID: 32950444 DOI: 10.1016/j.jcmg.2020.07.021] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/17/2020] [Accepted: 07/23/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVES This study aimed to identify a subset of patients based on echocardiographic parameters who might have benefited from transcatheter correction using the MitraClip system in the MITRA-FR (Percutaneous Repair with the MitraClip Device for Severe Functional/Secondary Mitral Regurgitation) trial. BACKGROUND It has been suggested that differences in the degree of mitral regurgitation (MR) and left ventricular (LV) remodeling may explain the conflicting results between the MITRA-FR and the COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation) trials. METHODS In a post hoc analysis, we evaluated the interaction between the intervention and subsets of patients defined based on MR severity (effective regurgitant orifice [ERO], regurgitant volume [RVOL] and regurgitant fraction [RF]), LV remodeling (end-diastolic and end-systolic diameters and volumes) and combination of these parameters with respect to the composite of death from any cause or unplanned hospitalization for heart failure at 24 months. RESULTS We observed a neutral impact of the intervention in subsets with the highest MR degree (ERO ≥30 mm2, RVOL ≥45 ml or RF ≥50%) as in patients with milder MR degree. The same was seen in subsets with the milder LV remodeling using either diastolic or systolic diameters or volumes. When parameters of MR severity and LV remodeling were combined, there was still no benefit of the intervention including in the subset of patients with an ERO/end-diastolic volume ratio ≥ 0.15 despite similar ERO and LV end-diastolic volume compared with COAPT patients. CONCLUSIONS In the MITRA-FR trial, we could not identify a subset of patients defined based on the degree of the regurgitation, LV remodeling or on their combination, including those deemed as having disproportionate MR, that might have benefited from transcatheter correction using the MitraClip system. (Multicentre Study of Percutaneous Mitral Valve Repair MitraClip Device in Patients With Severe Secondary Mitral Regurgitation [MITRA-FR]; NCT01920698).
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Affiliation(s)
| | - Bernard Iung
- Université de Paris and INSERM 1148, Paris, France; APHP, Hôpital Bichat, DHU FIRE, Paris, France
| | - Xavier Armoiry
- Edouard Herriot Hospital, Pharmacy Department/Claude Bernard University-Laboratoire MATEIS, Lyon, France
| | - Jean-Noël Trochu
- Université Nantes, CHU Nantes, CNRS, INSERM, l'institut du Thorax, Nantes, France
| | - Erwan Donal
- CHU de Rennes, Hôpital Pontchaillou, Rennes, France and LTSI UMR1099, INSERM, Universite de Rennes-1, Rennes, France
| | - Gilbert Habib
- APHM, La Timone Hospital, Cardiology Department, Marseille France; Aix Marseille Univ, IRD, APHM, MEPHI, IHU-Méditerranée Infection, Marseille, France
| | | | - Hélène Thibault
- Groupement Hospitalier Est, Hospices Civils de Lyon, Service d'Explorations Fonctionnelles Cardiovasculaires, Bron, France
| | - Nicolas Piriou
- Université Nantes, CHU Nantes, CNRS, INSERM, l'institut du Thorax, Nantes, France
| | - Bertrand Cormier
- Institut Cardiovasculaire Paris Sud, Hôpital Privé Jacques Cartier, Massy, France
| | - Christophe Tribouilloy
- Department of Cardiology, Amiens University Hospital, EA 7517 MP3CV, Jules Verne University of Picardie, Amiens, France
| | - Patrice Guerin
- CHU Nantes, INSERM UMR 1229, Nantes University, Interventional Cardiology unit, Institut du Thorax, Nantes, France
| | - Thierry Lefèvre
- Institut Cardiovasculaire Paris Sud, Hôpital Privé Jacques Cartier, Massy, France
| | - Delphine Maucort-Boulch
- Université Lyon 1, Villeurbanne, France; CNRS, UMR5558, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Service de Biostatistique - Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, Villeurbanne, France
| | | | - Florent Boutitie
- Université Lyon 1, Villeurbanne, France; CNRS, UMR5558, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Service de Biostatistique - Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, Villeurbanne, France
| | - Jean-Francois Obadia
- Hopital Cardiovasculaire Louis Pradel, Chirurgie Cardio-Vasculaire et Transplantation Cardiaque, Hospices Civils de Lyon and Claude Bernard University, Lyon, France.
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Karagodin I, Singh A, Lang RM. Pathoanatomy of Mitral Regurgitation. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2020; 4:254-263. [PMID: 32885130 DOI: 10.1080/24748706.2020.1765055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Ilya Karagodin
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, IL
| | - Amita Singh
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, IL
| | - Roberto M Lang
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, IL
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10
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Zhang Y, Wang VY, Morgan AE, Kim J, Ge L, Guccione JM, Weinsaft JW, Ratcliffe MB. A Novel MRI-Based Finite Element Modeling Method for Calculation of Myocardial Ischemia Effect in Patients With Functional Mitral Regurgitation. Front Physiol 2020; 11:158. [PMID: 32231584 PMCID: PMC7082816 DOI: 10.3389/fphys.2020.00158] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 02/12/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Functional Mitral Regurgitation (FMR) associated with coronary artery disease affects nearly 3 million patients in the United States. Both myocardial infarction (MI) and ischemia contribute to FMR development but uncertainty as to which patients will respond to revascularization (REVASC) of ischemia alone prevents rational decision making about FMR therapy. The aim of this study was to create patient-specific cardiac MRI (CMR) informed finite element (FE) models of the left ventricle (LV), calculate regional LV systolic contractility and then use optimized systolic material properties to simulate the effect of revascularization (virtual REVASC). METHODS We describe a novel FE method able to predict the effect of myocardial ischemia on regional LV function. CMR was obtained in five patients with multi-vessel coronary disease and FMR before and 3 months after percutaneous REVASC and a single healthy volunteer. Patient-specific FE models were created and divided into 17 sectors where the systolic contractility parameter, T m a x of each sector was a function of regional stress perfusion (SP-CMR) and myocardial infarction (LGE-CMR) scores. Sector-specific circumferential and longitudinal end-systolic strain and LV volume from CSPAMM were used in a formal optimization to determine the sector based myocardial contractility, T m a x and ischemia effect, α. Virtual REVASC was simulated by setting α to zero. RESULTS The FE optimization successfully converged with good agreement between calculated and experimental end-systolic strain and LV volumes. Specifically, the optimized T max for the healthy myocardium for five patients and the volunteer was 495.1, 336.8, 173.5, 227.9, 401.4, and 218.9 kPa. The optimized α was found to be 1.0, 0.44, and 0.08 for Patients 1, 2, and 3, and 0 for Patients 4 and 5. The calculated average of radial strain for Patients 1, 2, and 3 at baseline and after virtual REVASC was 0.23 and 0.25, respectively. CONCLUSION We developed a novel computational method able to predict the effect of myocardial ischemia in patients with FMR. This method can be used to predict the effect of ischemia on the regional myocardium and promises to facilitate better understanding of FMR response to REVASC.
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Affiliation(s)
- Yue Zhang
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
- Department of Bioengineering, University of California, San Francisco, San Francisco, CA, United States
| | - Vicky Y. Wang
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
- Department of Bioengineering, University of California, San Francisco, San Francisco, CA, United States
| | - Ashley E. Morgan
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Jiwon Kim
- Department of Medicine, Weill Cornell Medicine, New York, NY, United States
| | - Liang Ge
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
- Department of Bioengineering, University of California, San Francisco, San Francisco, CA, United States
| | - Julius M. Guccione
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
- Department of Bioengineering, University of California, San Francisco, San Francisco, CA, United States
| | | | - Mark B. Ratcliffe
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
- Department of Bioengineering, University of California, San Francisco, San Francisco, CA, United States
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Micali LR, Qadrouh MN, Parise O, Parise G, Matteucci F, de Jong M, Tetta C, Moula AI, Johnson DM, Gelsomino S. Papillary muscle intervention vs mitral ring annuloplasty in ischemic mitral regurgitation. J Card Surg 2020; 35:645-653. [PMID: 31951676 PMCID: PMC7078820 DOI: 10.1111/jocs.14407] [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] [Indexed: 12/27/2022]
Abstract
Background and Aims The main pathophysiological factor of chronic ischemic mitral regurgitation (MR) is the outward displacement of the papillary muscles (PMs) leading to leaflet tethering. For this reason, papillary muscle intervention (PMI) in combination with mitral ring annuloplasty (MRA) has recently been introduced into clinical practice to correct this displacement, and to reduce the recurrence of regurgitation. Methods A meta‐analysis was conducted comparing the outcomes of PMI and MRA performed in combination vs MRA performed alone, in terms of MR recurrence and left ventricular reverse remodeling (LVRR). A meta‐regression was carried out to investigate the impact of the type of PMI procedure on the outcomes. Results MR recurrence in patients undergoing both PMI and MRA was lower than in those who only had MRA (log incidence rate ratio, −0.66; lower‐upper limits, −1.13 to 0.20; I2 = 0.0%; p = .44; Egger's test: intercept 0.35 [−0.78 to 1.51]; p = .42). The group with both PMI and MRA and that with only MRA showed a slightly higher reduction in left ventricular diameters (−5.94%; −8.75% to 3.13%,). However, in both groups, LVRR was <10%. No difference was detected between PM relocation/repositioning and papillary muscle approximation in terms of LVRR (p = .33). Conclusions Using PMI and MRA together has a lower MR recurrence than using MRA alone. No significant LVRR was observed between the two groups nor between the PMI techniques employed.
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Affiliation(s)
- Linda R Micali
- Department of Cardiothoracic Surgery, Maastricht University Hospital, Maastricht, The Netherlands
| | - Mohammad N Qadrouh
- Department of Cardiothoracic Surgery, Maastricht University Hospital, Maastricht, The Netherlands
| | - Orlando Parise
- Department of Cardiothoracic Surgery, Maastricht University Hospital, Maastricht, The Netherlands
| | - Gianmarco Parise
- Department of Cardiothoracic Surgery, Maastricht University Hospital, Maastricht, The Netherlands
| | - Francesco Matteucci
- Department of Cardiothoracic Surgery, Maastricht University Hospital, Maastricht, The Netherlands
| | - Monique de Jong
- Department of Cardiothoracic Surgery, Maastricht University Hospital, Maastricht, The Netherlands
| | - Cecilia Tetta
- Department of Cardiothoracic Surgery, Maastricht University Hospital, Maastricht, The Netherlands
| | - Amalia I Moula
- Department of Cardiothoracic Surgery, Maastricht University Hospital, Maastricht, The Netherlands
| | - Daniel M Johnson
- Department of Cardiothoracic Surgery, Maastricht University Hospital, Maastricht, The Netherlands
| | - Sandro Gelsomino
- Department of Cardiothoracic Surgery, Maastricht University Hospital, Maastricht, The Netherlands
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12
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Zhang Y, Wang VY, Morgan AE, Kim J, Handschumacher MD, Moskowitz CS, Levine RA, Ge L, Guccione JM, Weinsaft JW, Ratcliffe MB. Mechanical effects of MitraClip on leaflet stress and myocardial strain in functional mitral regurgitation - A finite element modeling study. PLoS One 2019; 14:e0223472. [PMID: 31600276 PMCID: PMC6786765 DOI: 10.1371/journal.pone.0223472] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 09/23/2019] [Indexed: 11/18/2022] Open
Abstract
Purpose MitraClip is the sole percutaneous device approved for functional mitral regurgitation (MR; FMR) but MR recurs in over one third of patients. As device-induced mechanical effects are a potential cause for MR recurrence, we tested the hypothesis that MitraClip increases leaflet stress and procedure-related strain in sub-valvular left ventricular (LV) myocardium in FMR associated with coronary disease (FMR-CAD). Methods Simulations were performed using finite element models of the LV + mitral valve based on MRI of 5 sheep with FMR-CAD. Models were modified to have a 20% increase in LV volume (↑LV_VOLUME) and MitraClip was simulated with contracting beam elements (virtual sutures) placed between nodes in the center edge of the anterior (AL) and posterior (PL) mitral leaflets. Effects of MitraClip on leaflet stress in the peri-MitraClip region of AL and PL, septo-lateral annular diameter (SLAD), and procedure-related radial strain (Err) in the sub-valvular myocardium were calculated. Results MitraClip increased peri-MitraClip leaflet stress at end-diastole (ED) by 22.3±7.1 kPa (p<0.0001) in AL and 14.8±1.2 kPa (p<0.0001) in PL. MitraClip decreased SLAD by 6.1±2.2 mm (p<0.0001) and increased Err in the sub-valvular lateral LV myocardium at ED by 0.09±0.04 (p<0.0001)). Furthermore, MitraClip in ↑LV_VOLUME was associated with persistent effects at ED but also at end-systole where peri-MitraClip leaflet stress was increased in AL by 31.9±14.4 kPa (p = 0.0268) and in PL by 22.5±23.7 kPa (p = 0.0101). Conclusions MitraClip for FMR-CAD increases mitral leaflet stress and radial strain in LV sub-valvular myocardium. Mechanical effects of MitraClip are augmented by LV enlargement.
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Affiliation(s)
- Yue Zhang
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States of America
- Department of Surgery, University of California, San Francisco, CA, United States of America
| | - Vicky Y. Wang
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States of America
- Department of Surgery, University of California, San Francisco, CA, United States of America
| | - Ashley E. Morgan
- Department of Surgery, University of California, San Francisco, CA, United States of America
| | - Jiwon Kim
- Department of Medicine, Weill Cornell Medicine, New York, NY, United States of America
| | - Mark D. Handschumacher
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Chaya S. Moskowitz
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Robert A. Levine
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Liang Ge
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States of America
- Department of Surgery, University of California, San Francisco, CA, United States of America
| | - Julius M. Guccione
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States of America
- Department of Surgery, University of California, San Francisco, CA, United States of America
| | - Jonathan W. Weinsaft
- Department of Medicine, Weill Cornell Medicine, New York, NY, United States of America
| | - Mark B. Ratcliffe
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States of America
- Department of Surgery, University of California, San Francisco, CA, United States of America
- * E-mail:
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13
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Yamazaki S, Numata S, Yaku H. Surgical intervention for ischemic mitral regurgitation: how can we achieve better outcomes? Surg Today 2019; 50:540-550. [PMID: 31147764 DOI: 10.1007/s00595-019-01823-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 04/15/2019] [Indexed: 12/31/2022]
Abstract
Ischemic mitral regurgitation (MR) is a common complication of myocardial infarction. Left ventricular (LV) dysfunction and distortion of the subvalvular apparatus are the main contributors to ischemic MR. Coronary artery bypass grafting alone, mitral valve replacement, and mitral valve repair, with or without subvalvular procedures, have been performed for moderate-to-severe ischemic MR. Several randomized studies on the surgical treatment of ischemic MR have been performed; however, the optimal surgical strategy remains controversial because none have demonstrated a clear survival benefit. Since the mechanisms of ischemic MR are complex and multifactorial, comprehensive preoperative assessment of LV function and geometry (both global and regional), mitral valve configuration, viability testing, and exercise echocardiography are needed. A better understanding of this complicated disease and of the advantages and limitations of each procedure may help us devise more effective patient-specific surgical treatment strategies and achieve better outcomes.
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Affiliation(s)
- Sachiko Yamazaki
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan.
| | - Satoshi Numata
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Hitoshi Yaku
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan
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14
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Khan MS, Biederman R. Dynamic cardiac anatomy: the "cypress tree" papillary muscle root. J Cardiovasc Thorac Res 2018; 10:138-143. [PMID: 30386533 PMCID: PMC6203870 DOI: 10.15171/jcvtr.2018.22] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Accepted: 09/05/2018] [Indexed: 11/09/2022] Open
Abstract
Introduction: The understanding of gross cardiac anatomy has been relatively stable over the last
80 years, reliant on well-established autopsy findings. The advent of dynamic imaging by cardiac
MRI and CT provides a window to view anatomic features in vivo, providing insights typically
masked at autopsy due to death.
Hypothesis: We hypothesize that cardiac magnetic resonance (CMR) with its high spatial and
temporal resolution allows detection of anatomic features not previously appreciated at autopsy.
Methods: Two hundred fifty-five sequential, CMR examinations were retrospectively examined
to describe the anatomic features of the LV (left ventricular) PM (papillary muscles). Specifically,
the origin of the base of the PM was delineated. The insertion of the PM was seen in 255/255
patients.
Results: In 249 out of 255 patients (97.6%), the appearance of the PM was not a uniform muscle
arising from the inner face of the LV myocardium, but was a finger-like series of long, slender
trabeculae carneae traversing >1 cm before inserting into the main body of PM challenging our
previous understanding of PM anatomy.
Conclusion: The capabilities of dynamic CMR to view cardiac features in vivo non-invasively
provides a useful tool to study cardiac anatomy. Unlike the widely accepted representation of
papillary muscles, uniformly arising from the floor of the LV, the base resolves into a ‘cypress-tree’
root-like structure with multiple thin projections before coalescing into a thick muscle head. Such
observations have far reaching clinical implications in areas such as mitral regurgitation, post-MI
remodeling and electrical transmission of the His-Purkinje system, and further work is indicated
to delineate the role of non-invasive imaging in these areas.
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Affiliation(s)
| | - Robert Biederman
- Department of Cardiac MRI, Allegheny General Hospital, Pittsburgh, USA
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15
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Sandoval Y, Sorajja P, Harris KM. Contemporary Management of Ischemic Mitral Regurgitation: A Review. Am J Med 2018; 131:887-895. [PMID: 29501456 DOI: 10.1016/j.amjmed.2018.01.048] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 01/19/2018] [Accepted: 01/22/2018] [Indexed: 10/17/2022]
Abstract
Ischemic mitral regurgitation occurs relatively frequently in patients with coronary artery disease and is associated with an increased long-term risk. The pathophysiology of ischemic mitral regurgitation is vexing and poses both diagnostic and therapeutic challenges, leading to the need for a comprehensive, multidisciplinary approach. The management is largely focused on medical therapy, and for those eligible, coronary revascularization or cardiac resynchronization therapy may be considered. In select patients, mitral valve surgery or catheter-based therapy may be undertaken with careful consideration of the underlying pathophysiology, surgical risk, and expected long-term outcomes. The appropriate evaluation of patients with ischemic mitral regurgitation involves a careful multidisciplinary approach that carefully considers symptomatology, the etiology and severity of the mitral regurgitation, and the assessment of comorbidities and operative risk to individualize the care of these patients.
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Affiliation(s)
- Yader Sandoval
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minn; Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minn; Division of Cardiology, Department of Medicine, Hennepin County Medical Center, Minneapolis, Minn
| | - Paul Sorajja
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minn; Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minn
| | - Kevin M Harris
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minn; Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minn.
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16
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Lavall D, Hagendorff A, Schirmer SH, Böhm M, Borger MA, Laufs U. Mitral valve interventions in heart failure. ESC Heart Fail 2018; 5:552-561. [PMID: 29676043 PMCID: PMC6073015 DOI: 10.1002/ehf2.12287] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 03/10/2018] [Indexed: 12/28/2022] Open
Abstract
Secondary mitral regurgitation (MR) results from left ventricular dilatation and dysfunction. Quantification of secondary MR is challenging because of the underlying myocardial disease. Clinical and echocardiographic evaluation requires a multi‐parametric approach. Severe secondary MR occurs in up to one‐fourth of patients with heart failure with reduced ejection fraction, which is associated with a mortality rate of 40% to 50% in 3 years. Percutaneous edge‐to‐edge mitral valve repair (MitraClip) has emerged as an alternative to surgical valve repair to improve symptoms, functional capacity, heart failure hospitalizations, and cardiac haemodynamics. Further new transcatheter strategies addressing MR are evolving. The Carillion, Cardioband, and Mitralign devices were designed to reduce the annulus dilatation, which is a frequent and important determinant of secondary MR. Several transcatheter mitral valve replacement systems (Tendyne, CardiAQ‐Edwards, Neovasc, Tiara, Intrepid, Caisson, HighLife, MValve System, and NCSI NaviGate Mitral) are emerging because valve replacement might be more durable compared with valve repair. In small studies, these interventional therapies demonstrated feasibility and efficiency to reduce MR and to improve heart failure symptoms. However, neither transcatheter nor surgical mitral valve repair or replacement has been proven to impact on the prognosis of heart failure patients with severe MR, which remains high with a mortality rate of 14–20% at 1 year. To date, the primary indication for treatment of secondary severe MR is the amelioration of symptoms, reinforcing the value of a Heart Team discussion. Randomized studies to investigate the treatment effect and long‐term outcome for any transcatheter or surgical mitral valve intervention compared with optimized medical treatment are urgently needed and underway.
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Affiliation(s)
- Daniel Lavall
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, D-04103, Germany
| | - Andreas Hagendorff
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, D-04103, Germany
| | - Stephan H Schirmer
- Klinik für Innere Medizin III - Kardiologie, Angiologie und internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, D-66421, Germany
| | - Michael Böhm
- Klinik für Innere Medizin III - Kardiologie, Angiologie und internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, D-66421, Germany
| | - Michael A Borger
- Herzzentrum Leipzig, Universitätsklinik für Herzchirurgie, Leipzig, D-04289, Germany
| | - Ulrich Laufs
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, D-04103, Germany
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17
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Connell PS, Vekilov DP, Diaz CM, Kim SE, Grande-Allen KJ. Eliminating Regurgitation Reduces Fibrotic Remodeling of Functional Mitral Regurgitation Conditioned Valves. Ann Biomed Eng 2018; 46:670-683. [PMID: 29404848 PMCID: PMC5897174 DOI: 10.1007/s10439-018-1987-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 01/29/2018] [Indexed: 01/06/2023]
Abstract
Functional mitral regurgitation (FMR) is an insidious and poorly understood condition affecting patients with myocardial disease. While current treatments reduce regurgitation, their ability to reverse mitral valve pathology is unclear. We utilized a pseudo-physiological flow loop to study how repair impacted valve composition. Porcine mitral valves were cultured in control geometry (native papillary muscle position and annular area) or high-tension FMR geometry (5 mm apical and 5 mm lateral displacement of papillary muscles, 65% increased annular area) for 2 weeks. To mimic repair, a reversal condition was created by returning one-week FMR conditioned valves to a non-regurgitant geometry and culturing for 1 week. Valve composition and material properties were analyzed. After two-week culture, FMR conditioned tissues were stiffer and stronger than control and underwent extensive fibrotic remodeling, with increased prolyl-4-hydroxylase, lysyl oxidase, matrix metalloproteinase-1, and decorin. The reversal condition displayed a heterogeneous, leaflet- and orientation-dependent response. Reversal-conditioned anterior leaflets and circumferential tissue sections continued to have significant fibrotic remodeling compared to control, whereas reversal-conditioned posterior leaflets, chordae tendineae, and radial tissue sections had significantly decreased remodeling compared to FMR-conditioned tissues. These findings suggest current repairs only partially reverse pathology, underscoring the need for innovation in the treatment of FMR.
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Affiliation(s)
- Patrick S Connell
- Department of Bioengineering, Rice University, 6100 Main St., MS 142, Houston, TX, 77005, USA.,Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Dragoslava P Vekilov
- Department of Bioengineering, Rice University, 6100 Main St., MS 142, Houston, TX, 77005, USA
| | - Christine M Diaz
- Department of Bioengineering, Rice University, 6100 Main St., MS 142, Houston, TX, 77005, USA
| | - Seulgi E Kim
- Department of Bioengineering, Rice University, 6100 Main St., MS 142, Houston, TX, 77005, USA
| | - K Jane Grande-Allen
- Department of Bioengineering, Rice University, 6100 Main St., MS 142, Houston, TX, 77005, USA.
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18
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Morgan AE, Zhang Y, Tartibi M, Goldburg S, Kim JJ, Nguyen TD, Guccione J, Ge L, Weinsaft JW, Ratcliffe MB. Ischemic Mitral Regurgitation: Abnormal Strain Overestimates Nonviable Myocardium. Ann Thorac Surg 2018; 105:1754-1761. [PMID: 29391146 DOI: 10.1016/j.athoracsur.2018.01.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Revised: 11/28/2017] [Accepted: 01/03/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Therapy for moderate ischemic mitral regurgitation remains unclear. Determination of myocardial viability, a necessary prerequisite for an improvement in regional contractility, is a likely key factor in determining response to revascularization alone. Myocardial strain has been proposed as a viability measure but has not been compared with late gadolinium enhancement (LGE) cardiac magnetic resonance imaging. We hypothesized that abnormal strain overestimates nonviable left ventricular (LV) segments measured with LGE and that ischemia and mechanical tethering by adjacent transmural myocardial infarction (TMI) also decreases strain in viable segments. METHODS Sixteen patients with mild or greater ischemic mitral regurgitation and 7 healthy volunteers underwent cardiac magnetic resonance imaging with noninvasive tags (complementary spatial modulation of magnetization [CSPAMM]), LGE, and stress perfusion. CSPAMM images were post-processed with harmonic phase and circumferential and longitudinal strains were calculated. Viability was defined as the absence of TMI on LGE (hyperenhancement >50% of wall thickness). The borderzone was defined as any segment bordering TMI. Abnormal strain thresholds (±1 to 2.5 SDs from normal mean) were compared with TMI, ischemia, and borderzone. RESULTS 7.4% of LV segments had TMI on LGE, and more than 14.5% of LV segments were nonviable by strain thresholds (p < 0.005). In viable segments, ischemia impaired longitudinal strain (least perfused one-third of LV segments: -0.18 ± 0.08 versus most perfused: -0.22 ± 0.1, p = 0.01) and circumferential strain (-0.12 ± 0.1 versus -0.16 ± 0.08, p < 0.05). In addition, infarct proximity impaired longitudinal strain (-0.16 ± 0.11 borderzone versus -0.18 ± 0.09 remote, p = 0.05). CONCLUSIONS Impaired LV strain overestimates nonviable myocardium compared with TMI on LGE. Ischemia and infarct proximity also decrease strain in viable segments.
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Affiliation(s)
- Ashley E Morgan
- East Bay Surgical Residency, University of California, San Francisco, California
| | - Yue Zhang
- Surgical Service, Veterans Affairs Medical Center, San Francisco, California
| | - Mehrzad Tartibi
- Surgical Service, Veterans Affairs Medical Center, San Francisco, California
| | - Samantha Goldburg
- Department of Medicine (Cardiology), Weill Cornell Medical College, New York, New York
| | - Jiwon J Kim
- Department of Medicine (Cardiology), Weill Cornell Medical College, New York, New York
| | - Thanh D Nguyen
- Department of Radiology, Weill Cornell Medical College, New York, New York
| | - Julius Guccione
- Department of Bioengineering, University of California, San Francisco, California; Surgical Service, Veterans Affairs Medical Center, San Francisco, California; Department of Surgery, University of California, San Francisco, California
| | - Liang Ge
- Department of Bioengineering, University of California, San Francisco, California; Surgical Service, Veterans Affairs Medical Center, San Francisco, California; Department of Surgery, University of California, San Francisco, California
| | - Jonathan W Weinsaft
- Department of Medicine (Cardiology), Weill Cornell Medical College, New York, New York
| | - Mark B Ratcliffe
- Department of Bioengineering, University of California, San Francisco, California; Surgical Service, Veterans Affairs Medical Center, San Francisco, California; Department of Surgery, University of California, San Francisco, California.
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19
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Ge L, Wu Y, Soleimani M, Khazalpour M, Takaba K, Tartibi M, Zhang Z, Acevedo-Bolton G, Saloner DA, Wallace AW, Mishra R, Grossi EA, Guccione JM, Ratcliffe MB. Moderate Ischemic Mitral Regurgitation After Posterolateral Myocardial Infarction in Sheep Alters Left Ventricular Shear but Not Normal Strain in the Infarct and Infarct Borderzone. Ann Thorac Surg 2016; 101:1691-9. [PMID: 26857634 DOI: 10.1016/j.athoracsur.2015.10.083] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Revised: 10/05/2015] [Accepted: 10/26/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Chronic ischemic mitral regurgitation (CIMR) is associated with poor outcome. Left ventricular (LV) strain after posterolateral myocardial infarction (MI) may drive LV remodeling. Although moderate CIMR has been previously shown to affect LV remodeling, the effect of CIMR on LV strain after posterolateral MI remains unknown. We tested the hypothesis that moderate CIMR alters LV strain after posterolateral MI. METHODS Posterolateral MI was created in 10 sheep. Cardiac magnetic resonance imaging with tags was performed 2 weeks before and 2, 8, and 16 weeks after MI. The left and right ventricular volumes were measured, and regurgitant volume indexed to body surface area (regurgitant volume index) was calculated as the difference between left ventricle and right ventricle stroke volumes divided by body surface area. Three-dimensional strain was calculated. RESULTS Circumferential strain (Ecc) and longitudinal strain (Ell) were reduced in the infarct proper, MI borderzone, and remote myocardium 16 weeks after MI. In addition, radial circumferential (Erc) and radial longitudinal (Erl) shear strains were reduced in remote myocardium but increased in the infarct and borderzone 16 weeks after MI. Of all strain components, however, only Erc was affected by regurgitant volume index (p = 0.0005). There was no statistically significant effect of regurgitant volume index on Ecc, Ell, Erl, or circumferential longitudinal shear strain (Ecl). CONCLUSIONS Moderate CIMR alters radial circumferential shear strain after posterolateral MI in sheep. Further studies are needed to determine the effect of shear strain on myocyte hypertrophy and the effect of mitral repair on myocardial strain.
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Affiliation(s)
- Liang Ge
- Department of Surgery, University of California, San Francisco, California; Department of Bioengineering, University of California, San Francisco, California; Veterans Affairs Medical Center, San Francisco, California
| | - Yife Wu
- Veterans Affairs Medical Center, San Francisco, California
| | | | | | - Kiyoaki Takaba
- Veterans Affairs Medical Center, San Francisco, California
| | | | - Zhihong Zhang
- Veterans Affairs Medical Center, San Francisco, California
| | - Gabriel Acevedo-Bolton
- Department of Radiology, University of California, San Francisco, California; Veterans Affairs Medical Center, San Francisco, California
| | - David A Saloner
- Department of Radiology, University of California, San Francisco, California; Veterans Affairs Medical Center, San Francisco, California
| | - Arthur W Wallace
- Department of Anesthesia, University of California, San Francisco, California; Veterans Affairs Medical Center, San Francisco, California
| | - Rakesh Mishra
- Department of Medicine, University of California, San Francisco, California; Veterans Affairs Medical Center, San Francisco, California
| | - Eugene A Grossi
- Department of Cardiothoracic Surgery, New York University School of Medicine, New York, New York
| | - Julius M Guccione
- Department of Surgery, University of California, San Francisco, California; Department of Bioengineering, University of California, San Francisco, California; Veterans Affairs Medical Center, San Francisco, California
| | - Mark B Ratcliffe
- Department of Surgery, University of California, San Francisco, California; Department of Bioengineering, University of California, San Francisco, California; Veterans Affairs Medical Center, San Francisco, California.
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20
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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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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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22
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Suri RM, Schaff HV. Posterior Leaflet Detachment, Augmentation, and Reconstruction for Treatment of Functional Mitral Valve Regurgitation. Semin Thorac Cardiovasc Surg 2015; 27:91-4. [PMID: 26686429 DOI: 10.1053/j.semtcvs.2015.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2015] [Indexed: 11/11/2022]
Abstract
Functional mitral regurgitation caused posterior leaflet tethering and central malcoaptation treated utilizing undersized annuloplasty alone is associated with high rates of early failure. We report the technical steps necessary for near complete near complete detachment, augmentation and reconstruction of a thin and diminutive posterior mitral leaflet to reproducibly re-establish normal mitral leaflet coaptation and eliminate functional MR.
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Affiliation(s)
- Rakesh M Suri
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.
| | - Hartzell V Schaff
- Division of Cardiac Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota
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23
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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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24
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Song JM, Kim JJ, Ha TY, Lee JW, Jung SH, Hwang IS, Lee I, Sun BJ, Kim DH, Kang DH, Song JK. Basal chordae sites on the mitral valve determine the severity of secondary mitral regurgitation. Heart 2015; 101:1024-31. [PMID: 25800999 DOI: 10.1136/heartjnl-2014-306854] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Accepted: 03/02/2015] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To evaluate the variation between individuals in terms of basal chordae (BC) attachment sites on the mitral valve (MV) and the influence of this variation on secondary mitral regurgitation (MR) severity. BACKGROUND BC-mediated MV tenting is the main cause of secondary MR. METHODS In this prospective cross-sectional study, 38 consecutive patients with dilated or ischaemic cardiomyopathy who were due for cardiac transplantation underwent preoperative 3D full volume/colour Doppler echocardiography in sinus rhythm, and MV apparatus geometry, LV volume and MR severity were assessed. The lengths and insertion sites of four BC in the explanted hearts were measured post-transplantation before fixation. RESULTS Multiple linear regression analyses revealed that the anterior leaflet systolic tenting angle and bending angle associated with the distance between the medial and lateral BC insertion sites. By contrast, the posterior leaflet tenting angle associated largely with LV volume indices. The mean longitudinal distance of the four BC from the MV edge was the main determinant of the distal length of the anterior MV from the angulation point. Square root of effective regurgitant orifice area (√EROA) only associated significantly with the mean longitudinal distance of the outer two BC from the MV edge (r=0.509, p=0.001) among pathological parameters, and the central MV tenting area (r=0.524, p=0.001) among echocardiographical parameters. √EROA did not correlate with LV volume indices, LVEF or BC lengths. CONCLUSIONS BC insertion sites were associated with systolic anterior MV configuration and secondary MR severity in dilated LV and severe systolic dysfunction.
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Affiliation(s)
- Jong-Min Song
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae-Joong Kim
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Yong Ha
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Won Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Ho Jung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Il-Seon Hwang
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Inchul Lee
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byung Joo Sun
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae-Hee Kim
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Duk-Hyun Kang
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae-Kwan Song
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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25
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Sanz J, Weinsaft JW. Ischemic mitral regurgitation: is mitral valve physiology moving from global to local? J Am Coll Cardiol 2014; 64:1880-2. [PMID: 25444140 DOI: 10.1016/j.jacc.2014.08.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 08/25/2014] [Accepted: 08/27/2014] [Indexed: 11/24/2022]
Affiliation(s)
- Javier Sanz
- Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Jonathan W Weinsaft
- Department of Medicine, Greenberg Cardiology Division, Weill Cornell Medical College, New York, New York
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26
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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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27
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Abstract
Echocardiography is one of the most valuable diagnostic tools in cardiology. Technological advances in ultrasound, computer and electronics enables three-dimensional (3-D) imaging to be a clinically viable modality which has significant impact on diagnosis, management and interventional procedures. Since the inception of 3D fully-sampled matrix transthoracic and transesophageal technology it has enabled easier acquisition, immediate on-line display, and availability of on-line analysis for the left ventricle, right ventricle and mitral valve. The use of 3D TTE has mainly focused on mitral valve disease, left and right ventricular volume and functional analysis. As structural heart disease procedures become more prevalent, 3D TEE has become a requirement for preparation of the procedure, intra-procedural guidance as well as monitoring for complications and device function. We anticipate that there will be further software development, improvement in image quality and workflow.
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28
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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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29
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Fedak PWM, David TE, Borger M, Verma S, Butany J, Weisel RD. Bicuspid aortic valve disease: recent insights in pathophysiology and treatment. Expert Rev Cardiovasc Ther 2014; 3:295-308. [PMID: 15853603 DOI: 10.1586/14779072.3.2.295] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Bicuspid aortic valve is a common congenital cardiac malformation with a broad spectrum of clinical outcomes. Bicuspid aortic valve may go undetected throughout an individual's lifetime or, alternatively, they may have devastating clinical consequences, resulting in death. Both clinicians and medical scientists have taken a renewed interest in the development, pathophysiology and treatment options for this subtle but often substantial clinical entity. Evidence is mounting to suggest that an underlying disease of the aorta is inherited with bicuspid aortic valve, although considerable controversy surrounds this theory. Novel molecular mechanisms underlying the valve and vascular pathologies, as well as new surgical therapies for these patients have been proposed in the past 10 years.
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Affiliation(s)
- Paul W M Fedak
- University of Toronto, Division of Cardiac Surgery, Toronto General Hospital, 14EN-200 Elizabeth Street, Toronto, Ontario, M5C 2G4, Canada.
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30
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Cappabianca G, Bichi S, Patrini D, Pellegrino P, Poloni C, Perlasca E, Redaelli M, Esposito G. Cut-and-Transfer Technique for Ischemic Mitral Regurgitation and Severe Tethering of Mitral Leaflets. Ann Thorac Surg 2013; 96:1607-13; discussion 1613. [DOI: 10.1016/j.athoracsur.2013.06.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 05/27/2013] [Accepted: 06/03/2013] [Indexed: 10/26/2022]
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31
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Chinitz JS, Chen D, Goyal P, Wilson S, Islam F, Nguyen T, Wang Y, Hurtado-Rua S, Simprini L, Cham M, Levine RA, Devereux RB, Weinsaft JW. Mitral apparatus assessment by delayed enhancement CMR: relative impact of infarct distribution on mitral regurgitation. JACC Cardiovasc Imaging 2013; 6:220-34. [PMID: 23489536 DOI: 10.1016/j.jcmg.2012.08.016] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Revised: 08/17/2012] [Accepted: 08/20/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVES This study sought to assess patterns and functional consequences of mitral apparatus infarction after acute myocardial infarction (AMI). BACKGROUND The mitral apparatus contains 2 myocardial components: papillary muscles and the adjacent left ventricular (LV) wall. Delayed-enhancement cardiac magnetic resonance (DE-CMR) enables in vivo study of inter-relationships and potential contributions of LV wall and papillary muscle infarction (PMI) to mitral regurgitation (MR). METHODS Multimodality imaging was performed: CMR was used to assess mitral geometry and infarct pattern, including 3D DE-CMR for PMI. Echocardiography was used to measure MR. Imaging occurred 27 ± 8 days after AMI (CMR, echocardiography within 1 day). RESULTS A total of 153 patients with first AMI were studied; PMI was present in 30% (n = 46 [72% posteromedial, 39% anterolateral]). When stratified by angiographic culprit vessel, PMI occurred in 65% of patients with left circumflex, 48% with right coronary, and only 14% of patients with left anterior descending infarctions (p <0.001). Patients with PMI had more advanced remodeling as measured by LV size and mitral annular diameter (p <0.05). Increased extent of PMI was accompanied by a stepwise increase in mean infarct transmurality within regional LV segments underlying each papillary muscle (p <0.001). Prevalence of lateral wall infarction was 3-fold higher among patients with PMI compared to patients without PMI (65% vs. 22%, p <0.001). Infarct distribution also impacted MR, with greater MR among patients with lateral wall infarction (p = 0.002). Conversely, MR severity did not differ on the basis of presence (p = 0.19) or extent (p = 0.12) of PMI, or by angiographic culprit vessel. In multivariable analysis, lateral wall infarct size (odds ratio 1.20/% LV myocardium [95% confidence interval: 1.05 to 1.39], p = 0.01) was independently associated with substantial (moderate or greater) MR even after controlling for mitral annular (odds ratio 1.22/mm [1.04 to 1.43], p = 0.01), and LV end-diastolic diameter (odds ratio 1.11/mm [0.99 to 1.23], p = 0.056). CONCLUSIONS Papillary muscle infarction is common after AMI, affecting nearly one-third of patients. Extent of PMI parallels adjacent LV wall injury, with lateral infarction-rather than PMI-associated with increased severity of post-AMI MR.
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Affiliation(s)
- Jason S Chinitz
- Department of Medicine, Greenberg Cardiology Division, Weill Cornell Medical College, New York, New York 10021, USA
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Yaku H, Doi K, Okawa K. Surgical management of ischemic mitral regurgitation: indications, procedures, and future prospects. Gen Thorac Cardiovasc Surg 2013; 61:497-503. [PMID: 23775235 DOI: 10.1007/s11748-013-0277-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Indexed: 11/24/2022]
Abstract
Ischemic mitral regurgitation (IMR) is one of the most important risk factors affecting prognosis of patients who suffer from myocardial infarction. The mechanisms of IMR, the indications for surgical intervention, the operative procedures, and the limitations of surgical procedures are discussed in this review article.
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Affiliation(s)
- Hitoshi Yaku
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan.
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33
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Functional mitral regurgitation: a 30-year unresolved surgical journey from valve replacement to complex valve repairs. Heart Fail Rev 2013; 19:341-58. [DOI: 10.1007/s10741-013-9392-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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34
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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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35
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Left ventricular myocardial contractility is depressed in the borderzone after posterolateral myocardial infarction. Ann Thorac Surg 2013; 95:1619-25. [PMID: 23523189 DOI: 10.1016/j.athoracsur.2013.02.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Revised: 01/29/2013] [Accepted: 02/04/2013] [Indexed: 11/23/2022]
Abstract
BACKGROUND Contractility in the borderzone (BZ) after anteroapical myocardial infarction (MI) is depressed. We tested the hypothesis that BZ contractility is also decreased after posterolateral MI. METHODS Five sheep underwent posterolateral MI. Magnetic resonance imaging (MRI) was performed 2 weeks before and 16 weeks after MI, and left ventricular (LV) volume and regional strain were measured. Finite element (FE) models were constructed, and the systolic material parameter, Tmax, was calculated in the BZ and remote myocardium by minimizing the difference between experimentally measured and calculated LV strain and volume. Sheep were sacrificed 17 weeks after MI, and myocardial muscle fibers were taken from the BZ and remote myocardium. Fibers were chemically demembranated, and isometric developed force, Fmax, was measured at supramaximal [Ca(2+)]. Routine light microscopy was also performed. RESULTS There was no difference in Tmax in the remote myocardium before and 16 weeks after MI. However, there was a large decrease (63.3%, p = 0.005) in Tmax in the BZ when compared with the remote myocardium 16 weeks after MI. In addition, there was a significant reduction of BZ Fmax for all samples (18.9%, p = 0.0067). Myocyte cross-sectional area increased by 61% (p = 0.021) in the BZ, but there was no increase in fibrosis. CONCLUSIONS Contractility in the BZ is significantly depressed relative to the remote myocardium after posterolateral MI. The reduction in contractility is due at least in part to a decrease in contractile protein function.
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Sá MPB, Soares EF, Santos CA, Figueiredo OJ, Lima RO, Escobar RR, Vasconcelos FP, Lima RC. Mitral valve replacement combined with coronary artery bypass graft surgery in patients with moderate-to-severe ischemic mitral regurgitation. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2013. [DOI: 10.1016/j.repce.2013.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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37
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Sá MPB, Soares EF, Santos CA, Figueiredo OJ, Lima RO, Escobar RR, Vasconcelos FP, Lima RC. Mitral valve replacement combined with coronary artery bypass graft surgery in patients with moderate-to-severe ischemic mitral regurgitation. Rev Port Cardiol 2013; 32:131-7. [DOI: 10.1016/j.repc.2012.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2012] [Accepted: 07/12/2012] [Indexed: 10/27/2022] Open
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38
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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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Karimov JH, Kobayashi M, Fukamachi K. Functional mitral regurgitation: modern concepts for ventricular geometry reshaping. Expert Rev Med Devices 2012; 9:131-8. [PMID: 22404774 DOI: 10.1586/erd.11.69] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Functional mitral valve regurgitation (MR), a condition affecting millions of primarily elderly patients worldwide, is associated with poor clinical outcomes. Functional MR has traditionally been considered a disorder of regional or global left ventricular (LV) remodeling secondary to myocardial disease, in which anatomically normal leaflets fail to coapt adequately. The primary mechanisms of MR are mitral annular dilatation and leaflet restriction secondary to LV remodeling. Although annuloplasty is commonly used to correct valve incompetence, the effects of altered ventricular mechanics on MR need to be specifically addressed. This review focuses on current concepts of geometric reconfiguration of the LV and mitral-ventricular apparatus to reduce MR.
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Affiliation(s)
- Jamshid H Karimov
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA
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Timek TA, Miller DC. Another multidisciplinary look at ischemic mitral regurgitation. Semin Thorac Cardiovasc Surg 2012; 23:220-31. [PMID: 22172360 DOI: 10.1053/j.semtcvs.2011.07.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2011] [Indexed: 12/31/2022]
Abstract
Ischemic mitral regurgitation (IMR) continues to challenge surgeons and scientists alike. This vexing clinical entity frequently complicates myocardial infarction and carries a poor prognosis both in the setting of coronary disease and idiopathic dilated cardiomyopathy. Ischemic mitral regurgitation encompasses a difficult patient population that is characterized by high operative mortality, poor long term outcomes, and frequent recurrent insufficiency after standard surgical repair. Yet optimal surgical repair and improved clinical outcomes can only be achieved with better knowledge of the pathophysiology of IMR which is still incompletely understood. The causative mechanism of IMR appears to lie in the annular and subvalvular frame of the valve rather than leaflet or chordal structure leading to such labels as "ischemic," "functional," "non-organic," and "cardiomyopathy associated" being applied in the clinical literature. Although ischemic mitral regurgitation is a prevailing clinical entity, it has not been consistently defined in the literature, contributing to considerable confusion and contradictory results of clinical studies. As the mechanisms of pathophysiology have been better elucidated, novel surgical and interventional strategies have been developed recently to provide better treatment for this difficult patient population. In this review, we undertake a multidisciplinary update of the pathophysiology, classification, and surgical and interventional treatment of ischemic mitral regurgitation in today's clinical practice.
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Affiliation(s)
- Tomasz A Timek
- West Michigan Cardiothoracic Surgeons and Spectrum Health System, Grand Rapids, Michigan, USA
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Mechanisms and predictors of mitral regurgitation after high-risk myocardial infarction. J Am Soc Echocardiogr 2012; 25:535-42. [PMID: 22305962 DOI: 10.1016/j.echo.2012.01.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Indexed: 11/21/2022]
Abstract
BACKGROUND Mitral regurgitation (MR) has been associated with adverse outcomes after myocardial infarction (MI). Without structural valve disease, functional MR has been related to left ventricular (LV) remodeling and geometric deformation of the mitral apparatus. The aims of this study were to elucidate the mechanistic components of MR after high-risk MI and to identify predictors of MR progression during follow-up. METHODS The Valsartan in Acute Myocardial Infarction Echo substudy prospectively enrolled 610 patients with LV dysfunction, heart failure, or both after MI. MR at baseline, 1 month, and 20 months was quantified by mapping jet expansion in the left atrium in 341 patients with good-quality echocardiograms. Indices of LV remodeling, left atrial size, and diastolic function and parameters of mitral valve deformation, including tenting area, coaptation depth, anterior leaflet concavity, annular diameters, and contractility, were assessed and related to baseline MR. The progression of MR was further analyzed, and predictors of worsening among the baseline characteristics were identified. RESULTS Tenting area, coaptation depth, annular dilatation, and left atrial size were all associated with the degree of baseline MR. Tenting area was the only significant and independent predictor of worsening MR; a tenting area of 4 cm(2) was a useful cutoff to identify worsening of MR after MI and moderate to severe MR after 20 months. CONCLUSIONS Increased mitral tenting and larger mitral annular area are determinants of MR degree at baseline, and tenting area is an independent predictor of progression of MR after MI. Although LV remodeling itself contributes to ischemic MR, this influence is directly dependent on alterations in mitral geometry.
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The effect of mitral annuloplasty shape in ischemic mitral regurgitation: a finite element simulation. Ann Thorac Surg 2012; 93:776-82. [PMID: 22245588 DOI: 10.1016/j.athoracsur.2011.08.080] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2011] [Revised: 08/24/2011] [Accepted: 08/26/2011] [Indexed: 11/21/2022]
Abstract
BACKGROUND Undersized mitral annuloplasty (MA) is the preferred surgical treatment for chronic ischemic mitral regurgitation. However, the preferred shape of undersized MA is unclear. METHODS A previously described finite element model of the left ventricle with mitral valve based on magnetic resonance images of a sheep with chronic ischemic mitral regurgitation after posterolateral myocardial infarction was used. Saddle-shape (Edwards Physio II) and asymmetric (IMR ETlogix) MA rings were digitized and meshed. Virtual annuloplasty was performed using virtual sutures to attach the MA ring. Left ventricular diastole and systole were performed before and after virtual MA of each type. RESULTS Both types of MA reduced the septolateral dimension of the mitral annulus and abolished mitral regurgitation. The asymmetric MA was associated with lower virtual suture force in the P2 region but higher force in P1 and P3 regions. Although both types of MA reduced fiber stress at the left ventricular base, fiber stress reduction after asymmetric MA was slightly greater. Neither type of MA affected fiber stress at the left ventricular equator or apex. Although both types of MA increased leaflet curvature and reduced leaflet stress, stress reduction with saddle-shape MA was slightly greater. Both MA types reduced stress on the mitral chordae. CONCLUSIONS The effects of saddle-shape and asymmetric MA rings are similar. Finite element simulations are a powerful tool that may reduce the need for animal and clinical trials.
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Bin J, Zhibin C, Weidong R, Baosheng G, Chunyan M, Kexin J, Yangjie X, Xiaojie J, Fan X, Xiaomeng G. Assessment of Mitral Annulus (P3 Segment) Asymmetric Deformity in Myocardial Infarction with Ischemic Regurgitation by Real Time Three-Dimensional Echocardiography. Echocardiography 2012; 29:42-50. [DOI: 10.1111/j.1540-8175.2011.01531.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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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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Lang RM, Tsang W, Weinert L, Mor-Avi V, Chandra S. Valvular Heart Disease. J Am Coll Cardiol 2011; 58:1933-44. [DOI: 10.1016/j.jacc.2011.07.035] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Revised: 07/14/2011] [Accepted: 07/18/2011] [Indexed: 10/16/2022]
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Moderate mitral regurgitation accelerates left ventricular remodeling after posterolateral myocardial infarction. Ann Thorac Surg 2011; 92:1614-20. [PMID: 21945222 DOI: 10.1016/j.athoracsur.2011.05.117] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Revised: 05/25/2011] [Accepted: 05/31/2011] [Indexed: 01/06/2023]
Abstract
BACKGROUND Chronic ischemic mitral regurgitation (MR) is associated with poor outcome. However, the effect of chronic ischemic MR on left ventricular (LV) remodeling after posterolateral myocardial infarction (MI) remains controversial. We tested the hypothesis that moderate MR accelerates LV remodeling after posterolateral MI. METHODS Posterolateral MI was created in 10 sheep. Cardiac magnetic resonance imaging was performed 2 weeks before and 2, 8, and 16 weeks after MI. Left ventricular and right ventricular volumes were measured, and regurgitant volume was calculated as the difference between LV and right ventricle stroke volumes. RESULTS Multivariate mixed effects regression showed that LV volumes at end diastole and end systole and LV sphericity were strongly correlated with both regurgitant volume (p < 0.0001, p = 0.0086, and p = 0.0007, respectively) and percent infarct area (p = 0.0156, p = 0.0307, and p < 0.0001, respectively). Conversely, whereas LV hypertrophy (LV wall volume) increased from 2 weeks to 16 weeks after MI, there was no effect of either regurgitant volume or percent infarct. CONCLUSIONS Moderate MR accelerates LV remodeling after posterolateral MI. Further studies are needed to determine whether mitral valve repair is able to slow or reverse MI remodeling after posterolateral MI.
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Hung CL, Tien SL, Lo CI, Hung TC, Yeh HI, Wang YS. The incremental value of regional dyssynchrony in determining functional mitral regurgitation beyond left ventricular geometry after narrow QRS anterior myocardial infarction: a real time three-dimensional echocardiography study. Echocardiography 2011; 28:665-75. [PMID: 21718355 DOI: 10.1111/j.1540-8175.2011.01403.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Determinants of functional mitral regurgitation (FMR) severity after acute anterior myocardial infarction (MI) remained unclear. Our aim was to: (1) test whether LV dyssynchrony upon real time three-dimensional echocardiography (RT-3DE) is independently associated with FMR severity; and (2) to investigate the role of regional systolic dyssynchrony index (SDI) in identifying FMR severity. METHODS RT-3DE was successfully performed on 64 consecutive patients following acute anterior MI with a narrow QRS complex (<130 ms) and another 30 healthy volunteers. MR severity was assessed using vena contracta method. SDI was derived from the dispersion of the time to minimum regional volume for all 16 LV segments. Multiple linear regression analysis was used to identify the independent relationship between FMR and SDI with and without multivariate adjustment. RESULTS The mean LV ejection fraction was 49.6%± 11.9% in the MI group. All regional (except apical) and global SDIs were associated with regional LV remodeling and were significantly correlated with FMR even after multivariate adjustment, with midwall SDI being most strongly associated with MR severity (R(2) = 0.55, P < 0.001). Regional midwall SDI superimposed on LV global geometry and mitral leaflet deformation substantially expanded the area under curve in identifying FMR (AUC increased from 0.69 to 0.93, c-statistics: P = 0.041). CONCLUSIONS While both global and regional dyssynchrony following anterior MI were independently related to FMR severity, regional midwall dyssynchrony further added incremental value in predicting FMR severity beyond traditional parameters. This finding provides a new insight into the understanding of FMR after anterior MI and may further potentiate specific therapeutic approaches.
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Affiliation(s)
- Chung-Lieh Hung
- Division of Cardiovascular Medicine and Medical Research, Mackay Memorial Hospital, Taipei, Taiwan.
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Mechanistic Insights into Ischemic Mitral Regurgitation: Echocardiographic and Surgical Implications. J Am Soc Echocardiogr 2011; 24:707-19. [DOI: 10.1016/j.echo.2011.04.001] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2010] [Indexed: 11/24/2022]
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Hong SJ, Kim SA, Hur J, Rhee SJ, Shim CY, Kim JS, Ko YG, Choi EY, Choi D, Jang Y, Chung N, Ha JW. Mechanism of Mitral Regurgitation in the Acute Phase of Inferior Wall Myocardial Infarction - Reduced Closing Force as a Consequence of Left Ventricular Systolic Dysfunction in the Presence of Tethering as a Determinant of Mitral Regurgitation -. Circ J 2011; 75:619-25. [DOI: 10.1253/circj.cj-10-0859] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Sung-Jin Hong
- Cardiology Division, Yonsei University College of Medicine
| | - Sung-Ai Kim
- Cardiology Division, Yonsei University College of Medicine
| | - Jin Hur
- Department of Radiology, Yonsei University College of Medicine
| | - Sang-Jae Rhee
- Cardiology Division, Yonsei University College of Medicine
| | - Chi Young Shim
- Cardiology Division, Yonsei University College of Medicine
| | - Jung-Sun Kim
- Cardiology Division, Yonsei University College of Medicine
| | - Young-Guk Ko
- Cardiology Division, Yonsei University College of Medicine
| | - Eui-Young Choi
- Cardiology Division, Yonsei University College of Medicine
| | - Donghoon Choi
- Cardiology Division, Yonsei University College of Medicine
| | - Yangsoo Jang
- Cardiology Division, Yonsei University College of Medicine
| | - Namsik Chung
- Cardiology Division, Yonsei University College of Medicine
| | - Jong-Won Ha
- Cardiology Division, Yonsei University College of Medicine
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Jensen H, Jensen MO, Smerup MH, Ringgaard S, Sørensen TS, Andersen NT, Wierup P, Hasenkam JM, Nielsen SL. Three-dimensional assessment of papillary muscle displacement in a porcine model of ischemic mitral regurgitation. J Thorac Cardiovasc Surg 2010; 140:1312-8. [DOI: 10.1016/j.jtcvs.2009.12.042] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2009] [Revised: 11/09/2009] [Accepted: 12/31/2009] [Indexed: 11/28/2022]
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