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Li X, Hou B, Hou S, Jiang W, Liu Y, Zhang H. Efficacy of mitral valve repair in combination with coronary revascularization for moderate ischaemic mitral regurgitation: a systematic review and meta-analysis of randomized controlled trials. Int J Surg 2024; 110:3879-3887. [PMID: 38502857 PMCID: PMC11175805 DOI: 10.1097/js9.0000000000001277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 02/22/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND The efficacy of mitral valve repair (MVR) in combination with coronary artery bypass grafting (CABG) for moderate ischaemic mitral regurgitation (IMR) remains unclear. To evaluate whether MVR + CABG is superior to CABG alone, the authors conducted a systematic review and meta-analysis of existing randomized controlled trials (RCTs). METHODS The authors searched PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials for eligible RCTs from the date of their inception to October 2023. The primary outcomes were operative (in-hospital or within 30 days) and long-term (≥ 1 year) mortality. The secondary outcomes were postoperative stroke, worsening renal function (WRF), and reoperation for bleeding or tamponade. The authors performed random-effects meta-analyses and reported the results as risk ratios (RRs) with 95% CIs. RESULTS Six RCTs were eligible for inclusion. Compared with CABG alone, MVR + CABG did not increase the risk of operative mortality (RR, 1.244; 95% CI, 0.514-3.014); however, it was also not associated with a lower risk of long-term mortality (RR, 0.676; 95% CI, 0.417-1.097). Meanwhile, there was no difference between the two groups in terms of postoperative stroke (RR, 2.425; 95% CI, 0.743-7.915), WRF (RR, 1.257; 95% CI, 0.533-2.964), and reoperation for bleeding or tamponade (RR, 1.667; 95% CI, 0.527-5.270). CONCLUSIONS The findings of this meta-analysis suggest that MVR + CABG fails to improve the clinical outcomes of patients with moderate IMR compared to CABG alone.
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Affiliation(s)
- Xin Li
- Department of Cardiac Surgery Center, Beijing Anzhen Hospital, Beijing Institute of Heart, Lung, and Blood Vascular Diseases, Capital Medical University, Chaoyang district, Beijing
| | - Biao Hou
- Department of Cardiac Surgery Center, Beijing Anzhen Hospital, Beijing Institute of Heart, Lung, and Blood Vascular Diseases, Capital Medical University, Chaoyang district, Beijing
| | - Shuwen Hou
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Anhui Medical University, Shushan district, Hefei, China
| | - Wenjian Jiang
- Department of Cardiac Surgery Center, Beijing Anzhen Hospital, Beijing Institute of Heart, Lung, and Blood Vascular Diseases, Capital Medical University, Chaoyang district, Beijing
| | - Yuyong Liu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Anhui Medical University, Shushan district, Hefei, China
| | - Hongjia Zhang
- Department of Cardiac Surgery Center, Beijing Anzhen Hospital, Beijing Institute of Heart, Lung, and Blood Vascular Diseases, Capital Medical University, Chaoyang district, Beijing
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Gambardella I, Spadaccio C, Singh SSA, Shingu Y, Kunihara T, Wakasa S, Nappi F. Interpapillary muscle distance independently predicts recurrent mitral regurgitation. J Cardiothorac Surg 2024; 19:147. [PMID: 38509555 PMCID: PMC10953136 DOI: 10.1186/s13019-024-02631-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 03/10/2024] [Indexed: 03/22/2024] Open
Abstract
OBJECTIVE Ischaemic secondary mitral regurgitation (ISMR) after surgery is due to the displacement of papillary muscles resulting from progressive enlargement of the left ventricle end-diastolic diameter (LVEDD). Our aim was to prove that if the interpapillary muscle distance (IPMD) is surgically stabilized, an increase in LVEDD will not lead to a recurrence of ischaemic mitral regurgitation (MR). METHODS Ninety-six patients with ISMR, who underwent surgical revascularisation and annuloplasty, were randomly assigned in a 1:1 ratio to undergo papillary muscle approximation (PMA). At the 5-year follow-up, we assessed the correlation between PMA and echocardiographic improvements, the effect size of PMA on echocardiographic improvements, and a prediction model for recurrent MR using inferential tree analysis. RESULTS There was a significant correlation between PMA and enhancements in both the α and β angles (Spearman's rho > 0.7, p < 0.01). The α angle represents the angle between the annular plane and either the A2 annular-coaptation line or the P2 annular-coaptation line. The β angle indicates the angle between the annular plane and either the A2 annular-leaflet tip line or the P2 annular-leaflet tip line. PMA led to substantial improvements in LVEDD, tenting area, α and β angles, with a large effect size (Hedge's g ≥ 8, 95% CI ORs ≠ 1). The most reliable predictor of recurrent MR grade was the interpapillary distance, as only patients with an interpapillary distance greater than 40 mm developed ≥ 3 + grade MR. For patients with an IPMD of 40 mm or less, the best predictor of recurrent MR grade was LVEDD. Among the patients, only those with LVEDD greater than 62 mm showed moderate (2+) MR, while only those with LVEDD less than or equal to 62 mm had absent to mild (1+) MR. CONCLUSION Prediction of recurrent ischaemic MR is not independent of progressive LVEDD increase. PMA-based surgical procedure stabilises IPMD.
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Affiliation(s)
| | | | - Sanjeet S A Singh
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Yasushige Shingu
- Department of Cardiovascular Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Takashi Kunihara
- Department of Cardiac Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Satoru Wakasa
- Department of Cardiovascular Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, Saint-Denis, France.
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Akashi J, Iwataki M, Nabeshima Y, Onoue T, Hayashi A, Tanaga T, Nishino S, Kimura T, Yano M, Watanabe N, Tsuda Y, Araki M, Shibata Y, Nishimura Y, Otsuji Y, Kataoka M. Potential Effects of Mild Atrial Secondary Mitral Regurgitation in Patients With Isolated Atrial Fibrillation. Circ Cardiovasc Imaging 2024; 17:e016239. [PMID: 38415386 DOI: 10.1161/circimaging.123.016239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 01/17/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND Patients with only moderate atrial secondary mitral regurgitation (asMR) frequently develop heart failure (HF). Mechanisms of HF with moderate asMR and the impact of mild asMR remain unclarified. Although mild/moderate primary mitral regurgitation is compensated by left ventricular (LV) dilatation, the LV is not dilated in asMR. We hypothesized that patients with mild asMR without LV dilatation may have impaired hemodynamics and higher risks of subsequent symptomatic HF deterioration. METHODS Stroke volume, cardiac output, and systolic pulmonary artery pressure were measured by echocardiography in 142 patients with isolated atrial fibrillation and 30 healthy controls. The prognosis of patients with isolated atrial fibrillation was followed up. RESULTS In the 142 patients with isolated atrial fibrillation, asMR was no/trivial in 55, mild in 83, moderate in 4, while none had severe asMR. Compared with controls and patients with no/trivial asMR, LV end-diastolic volume index was not increased and hemodynamic parameters were abnormal in patients with mild asMR (LV end-diastolic volume index, 65±6 versus 58±8 versus 60±8 mL/m²; stroke volume index, 42±4 versus 35±4 versus 29±6 mL/m²; P<0.001 versus other 2 groups; cardiac output index, 2.8±0.4 versus 2.8±0.5 versus 2.3±0.6 L/min per m²; P<0.001; systolic pulmonary artery pressure, 21±3 versus 26±5 versus 37±9 mm Hg; P<0.001). Although the event-free rate of HF symptomatic deterioration or hospitalization in patients with no/trivial asMR during a median 13.9 months follow-up was 86.9% and 100%, the rate in mild asMR was 59.4% and 85.0% (P<0.001 or P=0.032), respectively. CONCLUSIONS In the presence of isolated AF and no compensatory LV dilatation, impaired hemodynamics and higher risks of symptomatic HF deterioration were associated with mild asMR, requiring further studies of causalities.
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Affiliation(s)
- Jun Akashi
- Second Department of Internal Medicine (J.A., M.I., Y. Nabeshima, T.O., Y.T., M.A., Y.O., M.K.)
| | - Mai Iwataki
- Second Department of Internal Medicine (J.A., M.I., Y. Nabeshima, T.O., Y.T., M.A., Y.O., M.K.)
| | - Yosuke Nabeshima
- Second Department of Internal Medicine (J.A., M.I., Y. Nabeshima, T.O., Y.T., M.A., Y.O., M.K.)
| | - Takeshi Onoue
- Second Department of Internal Medicine (J.A., M.I., Y. Nabeshima, T.O., Y.T., M.A., Y.O., M.K.)
| | - Atsushi Hayashi
- Division of Cardiovascular Medicine, Shiga University of Medical Science, Japan (A.H.)
| | - Tetsuo Tanaga
- Departments of Clinical Laboratory (T.T.), Miyazaki Medical Association Hospital Cardiovascular Center, Japan
| | - Shun Nishino
- Cardiology (S.N., T.K., Y.S.), Miyazaki Medical Association Hospital Cardiovascular Center, Japan
| | - Toshiyuki Kimura
- Cardiology (S.N., T.K., Y.S.), Miyazaki Medical Association Hospital Cardiovascular Center, Japan
| | - Mitsuhiro Yano
- Cardiovascular Surgery (M.Y.), Miyazaki Medical Association Hospital Cardiovascular Center, Japan
| | - Nozomi Watanabe
- Cardiovascular Physiology, Faculty of Medicine, University of Miyazaki, Japan (N.W.)
| | - Yuki Tsuda
- Second Department of Internal Medicine (J.A., M.I., Y. Nabeshima, T.O., Y.T., M.A., Y.O., M.K.)
| | - Masaru Araki
- Second Department of Internal Medicine (J.A., M.I., Y. Nabeshima, T.O., Y.T., M.A., Y.O., M.K.)
| | - Yoshisato Shibata
- Cardiology (S.N., T.K., Y.S.), Miyazaki Medical Association Hospital Cardiovascular Center, Japan
| | - Yosuke Nishimura
- Department of Cardiovascular Surgery, University of Occupational and Environmental Health, Kitakyushu, Japan (Y. Nishimura)
| | - Yutaka Otsuji
- Second Department of Internal Medicine (J.A., M.I., Y. Nabeshima, T.O., Y.T., M.A., Y.O., M.K.)
| | - Masaharu Kataoka
- Second Department of Internal Medicine (J.A., M.I., Y. Nabeshima, T.O., Y.T., M.A., Y.O., M.K.)
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Bursi F, Enriquez-Sarano M. The Left Atrium: Passive Receptacle or Active Contributor to Mitral Regurgitation Severity and Outcome. JACC Case Rep 2024; 29:102195. [PMID: 38361572 PMCID: PMC10865207 DOI: 10.1016/j.jaccas.2023.102195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Affiliation(s)
- Francesca Bursi
- University of Milan, Department of Health Sciences, Division of Cardiology, San Paolo Hospital, Milan, Italy
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Zhou N, Liu A, Weng H, Liu W, Tian F, Zhao W, Ma J, Guo W, Chen H, Pan C, Shu X. Three-dimensional echocardiography reveals early mitral valve alterations in hypertrophic cardiomyopathy genetic mutation carriers. Int J Cardiol 2024; 395:131576. [PMID: 37949234 DOI: 10.1016/j.ijcard.2023.131576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 09/23/2023] [Accepted: 11/06/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND The mitral valve undergoes structural modifications in response to cardiac functional changes, often predating cardiac decompensation and overt clinical signs. Our study assessed the potential of mitral valve morphological changes as early indicators for detecting carriers of hypertrophic cardiomyopathy (HCM)-associated gene mutations. METHODS We studied 505 participants: 189 without the pathogenic gene mutations and left ventricular hypertrophy (G-/LVH-), 149 carriers without LV hypertrophy (G+/LVH-), and 167 manifest HCM patients (G+/LVH+). We juxtaposed the mitral valve morphology and associated metrics across these groups, emphasizing those carrying MYH7 and MYBPC3 mutations. RESULTS We discerned pronounced disparities in the mitral annulus and leaflet structures across the groups. The mitral valve apparatus in mutation carriers exhibited a tendency towards a flattened profile. Detailed analysis spotlighted MYBPC3 mutation carriers, whose mitral valves were notably flatter (with notably lower AHCWR values than non-carriers); this contrast was not evident in MYH7 mutation carriers. This mitral valve flattening, manifest in the mutation carriers, suggests it might be an adaptive response to incipient cardiac dysfunction in HCM's nascent stages. CONCLUSIONS Three-dimensional echocardiography illuminates the initial mitral valve structural changes in HCM patients bearing pathogenic gene mutations. These morphological signatures hold promise as sensitive imaging markers, especially for asymptomatic carriers of the MYBPC3 mutation.
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Affiliation(s)
- Nianwei Zhou
- Department of Echocardiography, Zhongshan Hospital,Fudan University,Shanghai Institute of Cardiovascular Disease, Shanghai Institute of Medical Imaging, Fenglin Road 180, Xuhui District, Shanghai, China
| | - Ao Liu
- Department of Echocardiography, Zhongshan Hospital,Fudan University,Shanghai Institute of Cardiovascular Disease, Shanghai Institute of Medical Imaging, Fenglin Road 180, Xuhui District, Shanghai, China
| | - Haobo Weng
- Department of Echocardiography, Zhongshan Hospital,Fudan University,Shanghai Institute of Cardiovascular Disease, Shanghai Institute of Medical Imaging, Fenglin Road 180, Xuhui District, Shanghai, China
| | - Wen Liu
- Department of Echocardiography, Zhongshan Hospital,Fudan University,Shanghai Institute of Cardiovascular Disease, Shanghai Institute of Medical Imaging, Fenglin Road 180, Xuhui District, Shanghai, China
| | - Fangyan Tian
- Department of Echocardiography, Zhongshan Hospital,Fudan University,Shanghai Institute of Cardiovascular Disease, Shanghai Institute of Medical Imaging, Fenglin Road 180, Xuhui District, Shanghai, China
| | - Weipeng Zhao
- Department of Echocardiography, Zhongshan Hospital,Fudan University,Shanghai Institute of Cardiovascular Disease, Shanghai Institute of Medical Imaging, Fenglin Road 180, Xuhui District, Shanghai, China
| | - Jing Ma
- Department of Echocardiography, Shanghai Xuhui District Central Hospital, Huaihai Middle Road 966, Xuhui District, Shanghai, China
| | - Wei Guo
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Fenglin Road 180, Xuhui District, Shanghai, China
| | - Haiyan Chen
- Department of Echocardiography, Zhongshan Hospital,Fudan University,Shanghai Institute of Cardiovascular Disease, Shanghai Institute of Medical Imaging, Fenglin Road 180, Xuhui District, Shanghai, China
| | - Cuizhen Pan
- Department of Echocardiography, Zhongshan Hospital,Fudan University,Shanghai Institute of Cardiovascular Disease, Shanghai Institute of Medical Imaging, Fenglin Road 180, Xuhui District, Shanghai, China
| | - Xianhong Shu
- Department of Echocardiography, Zhongshan Hospital,Fudan University,Shanghai Institute of Cardiovascular Disease, Shanghai Institute of Medical Imaging, Fenglin Road 180, Xuhui District, Shanghai, China; Department of Echocardiography, Shanghai Xuhui District Central Hospital, Huaihai Middle Road 966, Xuhui District, Shanghai, China.
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Presume J, Paiva MS, Guerreiro S, Ribeiras R. Parameters of the mitral apparatus in patients with ischemic and nonischemic dilated cardiomyopathy. J Int Med Res 2023; 51:3000605231218645. [PMID: 38150557 PMCID: PMC10754024 DOI: 10.1177/03000605231218645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 11/10/2023] [Indexed: 12/29/2023] Open
Abstract
The mitral valve apparatus is a complex structure consisting of several coordinating components: the annulus, two leaflets, the chordae tendineae, and the papillary muscles. Due to the intricate interplay between the mitral valve and the left ventricle, a disease of the latter may influence the normal function of the former. As a consequence, valve insufficiency may arise despite the absence of organic valve disease. This is designated as functional or secondary mitral regurgitation, and it arises from a series of distortions to the valve components. This narrative review describes the normal anatomy and the pathophysiology behind the mitral valve changes in ischemic and non-ischemic dilated cardiomyopathies. It also explains the value of a complete multiparametric assessment of this structure. Not only must an assessment include quantitative measures of regurgitation, but also various anatomical parameters from the mitral apparatus and left ventricle, since they carry prognostic value and are predictors of mitral valve repair success and durability.
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Affiliation(s)
- João Presume
- Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
- Comprehensive Health Research Centre, NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Mariana S Paiva
- Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Sara Guerreiro
- Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Regina Ribeiras
- Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
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Horinouchi H, Nagai T, Ohno Y, Miyamoto J, Kamioka N, Murakami T, Yoshioka K, Ikari Y. Mechanisms and implications of mitral regurgitation in patients with severe aortic stenosis who received transcatheter aortic valve replacement. Echocardiography 2023; 40:1187-1195. [PMID: 37715609 DOI: 10.1111/echo.15693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 09/08/2023] [Indexed: 09/17/2023] Open
Abstract
INTRODUCTION This study aimed to investigate the mechanisms and clinical implications of mitral regurgitation (MR) in patients with severe aortic stenosis (AS) who received transcatheter aortic valve replacement (TAVR). METHODS We conducted retrospective echocardiographic analyses at baseline and 6 months after TAVR in 140 patients with symptomatic AS (85 ± 5 years) who underwent TAVR. We defined significant MR as ≥ moderate based on evaluation of transthoracic echocardiography (TTE). RESULTS There were 48 patients (34%) with preexisting MR at the baseline. Among measured TTE parameters, end-systolic wall stress (ESWS), mitral annulus area, and mitral valve thickening index were independent factors associated with preexisting MR (odds ratio [OR]: 1.013, 95% confidence interval [CI]: 1.005-1.021; OR: 1.740, 95% CI: 1.314-2.376; OR: 2.306, 95% CI: 1.426-3.848; respectively). Six months after TAVR, there were 34 patients with post-existing MR, A history of atrial fibrillation and ESWS after TAVR were independent factors (OR: 3.013, 95% CI: 1.208-7.556; OR: 1.013, 95% CI: 1.000-1.023; respectively). The Kaplan-Meier plot indicated that preexisting MR was a risk factor for heart failure-related events within 1 year of discharge after TAVR (p = .012). CONCLUSIONS In patients who underwent TAVR for severe AS, preexisting MR was associated with having a thickened mitral valve and large mitral annulus size induced by high ESWS. These patients may have worse prognosis after TAVR and should be closely monitored in the long term.
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Affiliation(s)
- Hitomi Horinouchi
- Division of Cardiology, Department of Internal Medicine, Tokai University School of Medicine, Isehara-shi, Kanagawa, Japan
| | - Tomoo Nagai
- Division of Cardiology, Department of Internal Medicine, Tokai University School of Medicine, Isehara-shi, Kanagawa, Japan
| | - Yohei Ohno
- Division of Cardiology, Department of Internal Medicine, Tokai University School of Medicine, Isehara-shi, Kanagawa, Japan
| | - Junichi Miyamoto
- Division of Cardiology, Department of Internal Medicine, Tokai University School of Medicine, Isehara-shi, Kanagawa, Japan
| | - Norihiko Kamioka
- Division of Cardiology, Department of Internal Medicine, Tokai University School of Medicine, Isehara-shi, Kanagawa, Japan
| | - Tsutomu Murakami
- Division of Cardiology, Department of Internal Medicine, Tokai University School of Medicine, Isehara-shi, Kanagawa, Japan
| | - Koichiro Yoshioka
- Division of Cardiology, Department of Internal Medicine, Tokai University School of Medicine, Isehara-shi, Kanagawa, Japan
| | - Yuji Ikari
- Division of Cardiology, Department of Internal Medicine, Tokai University School of Medicine, Isehara-shi, Kanagawa, Japan
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Kumar M, Thompson PD, Chen K. New Perspective on Pathophysiology and Management of Functional Mitral Regurgitation. Trends Cardiovasc Med 2023; 33:386-392. [PMID: 35259483 DOI: 10.1016/j.tcm.2022.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/15/2022] [Accepted: 03/01/2022] [Indexed: 12/31/2022]
Abstract
Functional mitral regurgitation (FMR) occurs as a result of global or segmental left ventricular (LV) dysfunction or left atrial dilatation, leading to mitral annular dilatation, papillary muscle displacement, mitral valve (MV) leaflet tethering, and leaflet remodeling. The prevalence of FMR continues to rise in the United States. Even mild FMR is associated with adverse clinical outcomes. Echocardiography is the primary imaging modality used to assess the type and severity of mitral regurgitation. FMR treatment depends on the etiology. Evidence-based pharmacologic and cardiac resynchronization therapies for underlying LV dysfunction remain the mainstay of treatment. Patients who remain symptomatic despite optimal medical therapy can be considered for surgical or percutaneous MV intervention. This article reviews the pathophysiology, imaging evaluation, and therapeutic options of FMR, highlighting the most recent developments in a rapidly evolving field.
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Affiliation(s)
- Manish Kumar
- Pat and Jim Calhoun Cardiology Center, Department of Internal Medicine, University of Connecticut Health Center, Farmington, CT, 06030, United States.
| | - Paul D Thompson
- Department of Cardiology, Hartford Hospital, Hartford, 06106, United States
| | - Kai Chen
- Pat and Jim Calhoun Cardiology Center, Department of Internal Medicine, University of Connecticut Health Center, Farmington, CT, 06030, United States.
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Stassen J, Galloo X, Hirasawa K, van der Bijl P, Leon MB, Marsan NA, Bax JJ. Interaction between secondary mitral regurgitation and left atrial function and their prognostic implications after cardiac resynchronization therapy. Eur Heart J Cardiovasc Imaging 2023; 24:532-541. [PMID: 35900222 PMCID: PMC10029846 DOI: 10.1093/ehjci/jeac149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 07/07/2022] [Accepted: 07/15/2022] [Indexed: 11/13/2022] Open
Abstract
AIMS Left atrial (LA) function is a strong prognostic marker in patients with heart failure and functional mitral regurgitation (MR). Although cardiac resynchronization therapy (CRT) has shown to improve MR severity, the interaction between a reduction in MR severity and an increase in LA function, as well as its association with outcomes, has not been investigated. METHODS AND RESULTS LA reservoir strain (RS) was evaluated with speckle tracking echocardiography in patients with at least moderate functional MR undergoing CRT implantation. MR improvement was defined as at least 1 grade improvement in MR severity at 6 months after CRT implantation. The primary endpoint was all-cause mortality. A total of 340 patients (mean age 66 ± 10 years, 73% male) were included, of whom 200 (59%) showed MR improvement at 6 months follow-up. On multivariable analysis, an improvement in MR severity was independently associated with an increase in LARS (odds ratio 1.008; 95% confidence interval 1.003-1.013; P = 0.002). After multivariable adjustment, including baseline and follow-up variables, an increase in LARS was significantly associated with lower mortality. MR improvers showing LARS increasement had the lowest mortality rate, whereas outcomes were not significantly different between MR non-improvers and MR improvers showing no LARS increasement (P = 0.236). CONCLUSION A significant reduction in MR severity at 6 months after CRT implantation is independently associated with an increase in LARS. In addition, an increase in LARS is independently associated with lower all-cause mortality in patients with heart failure and significant functional MR.
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Affiliation(s)
- Jan Stassen
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2300 RC Leiden, The Netherlands
- Department of Cardiology, Jessa Hospital, Stadsomvaart 11, 3500 Hasselt, Belgium
| | - Xavier Galloo
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2300 RC Leiden, The Netherlands
- Department of Cardiology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Kensuke Hirasawa
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2300 RC Leiden, The Netherlands
| | - Pieter van der Bijl
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2300 RC Leiden, The Netherlands
| | - Martin B Leon
- Department of Cardiology, Columbia University Irving Medical Center/Presbyterian Hospital and Cardiovascular Research Foundation, New York, NY 10032, USA
| | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2300 RC Leiden, The Netherlands
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2300 RC Leiden, The Netherlands
- Turku Heart Center, University of Turku and Turku University Hospital, Kiinamyllynkatu 4-8, FI-20520 Turku, Finland
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Pambianchi G, Giannetti M, Marchitelli L, Cundari G, Maestrini V, Mancone M, Francone M, Catalano C, Galea N. Papillary Muscle Involvement during Acute Myocardial Infarction: Detection by Cardiovascular Magnetic Resonance Using T1 Mapping Technique and Papillary Longitudinal Strain. J Clin Med 2023; 12:jcm12041497. [PMID: 36836032 PMCID: PMC9963367 DOI: 10.3390/jcm12041497] [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: 01/11/2023] [Revised: 02/10/2023] [Accepted: 02/11/2023] [Indexed: 02/16/2023] Open
Abstract
Papillary muscle (PPM) involvement in myocardial infarction (MI) increases the risk of secondary mitral valve regurgitation or PPM rupture and may be diagnosed using late gadolinium enhancement (LGE) imaging. The native T1-mapping (nT1) technique and PPM longitudinal strain (PPM-ls) have been used to identify PPM infarction (iPPM) without the use of the contrast agent. This study aimed to assess the diagnostic performance of nT1 and PPM-ls in the identification of iPPM. Forty-six patients, who performed CMR within 14-30 days after MI, were retrospectively enrolled: sixteen showed signs of iPPM on LGE images. nT1 values were measured within the infarcted area (IA), remote myocardium (RM), blood pool (BP), and anterolateral and posteromedial PPMs and compared using ANOVA. PPM-ls values have been assessed on cineMR images as the percentage of shortening between end-diastolic and end-systolic phases. Higher nT1 values and lower PPM-ls were found in infarcted compared to non-infarcted PPMs (nT1: 1219.3 ± 102.5 ms vs. 1052.2 ± 80.5 ms and 17.6 ± 6.3% vs. 21.6 ± 4.3%; p-value < 0.001 for both), with no significant differences between the nT1 of infarcted PPMs and IA and between the non-infarcted PPMs and RM. ROC analysis demonstrated an excellent discriminatory power for nT1 in detecting the iPPM (AUC = 0.874; 95% CI: 0.784-0.963; p < 0.001). nT1 and PPM-ls are valid tools in assessing iPPM with the advantage of avoiding contrast media administration.
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Affiliation(s)
- Giacomo Pambianchi
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Martina Giannetti
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Livia Marchitelli
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Giulia Cundari
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Viviana Maestrini
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, “Policlinico Umberto I” Hospital, 00161 Rome, Italy
| | - Massimo Mancone
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, “Policlinico Umberto I” Hospital, 00161 Rome, Italy
| | - Marco Francone
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Carlo Catalano
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Nicola Galea
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, 00161 Rome, Italy
- Correspondence:
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Piątkowski R, Kochanowski J, Budnik M, Grabowski M, Ścisło P, Opolski G. NT-proBNP increase during stress echocardiography predicts significant changes in ischemic mitral regurgitation severity in patients qualified for surgical revascularization. Cardiol J 2022; 29:927-935. [PMID: 32515485 PMCID: PMC9788748 DOI: 10.5603/cj.a2020.0078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 04/13/2020] [Accepted: 04/21/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND In many patients, significant changes in ischemic mitral regurgitation (IMR) severity during exercise can be observed independent of the degree of IMR at rest. This study aimed to investigate the correlations between N-terminal fragment B-type natriuretic peptide (NT-proBNP) and echocardiography measurements at rest and at peak exercise in patients with moderate IMR who qualified for surgical revascularization. METHODS A total of 100 patients eligible for coronary artery bypass grafting, were included in this prospective study. All patients underwent exercise echocardiography. Additionally, the levels of NT-proBNP were measured at rest and after peak exercise. RESULTS A positive correlation of absolute NT-proBNP levels with effective regurgitant orifice area (EROA) were observed and with tricuspid regurgitant peak gradient (TRPG) at peak exercise. Absolute ΔNT-proBNP during exercise and the tenting area at rest were independent predictors of severe IMR at peak exercise. The level of absolute ΔNT-proBNP during exercise and coaptation height at rest were the most important predictors of significant increases in TRPG. The best cutoff value for ΔNT-proBNP as a predictor for increases in EROA at peak exercise was 68.9 pg/mL and to predict an increase in TRPG ≥ 50 mmHg at peak exercise was 68 pg/mL. CONCLUSIONS The level of ΔNT-proBNP during exercise was the most important parameter in predicting significant changes in IMR severity and pulmonary pressure. Based on the present data, it can be speculated that integration of the assessment of NT-proBNP at rest and at exercise might improve patient selection for valve surgery.
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Nogara A, Minacapelli A, Zambelli G, V LC, Fattouch K. Functional anatomy and echocardiographic assessment in secondary mitral regurgitation. J Card Surg 2022; 37:4103-4111. [PMID: 35998280 DOI: 10.1111/jocs.16863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 08/02/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Mitral valve apparatus is complex and involves the mitral annulus, the leaflets, the chordae tendinae, the papillary muscles as well as the left atrial and ventricular myocardium. Secondary mitral regurgitation is a consequence of regional or global left ventricle remodeling due to an acute myocardial infarction (75% of cases) or idiopathic dilated cardiomyopathy (25% of cases). It is associated with an increase in mortality and poor outcome. There is a potential survival benefit deriving from the reduction in the degree of severity of mitral regurgitation. So the correction of the valve defect can change the clinical course and prognosis of the patient. The rationale for mitral valve treatment depends on the mitral regurgitation mechanism. Therefore, it is essential to identify and understand the pathophysiology of mitral valve regurgitation. AIM OF THE STUDY The aim of this review is to describe the crucial role of transthoracic and trans-esophageal echocardiography, in particular with three-dimensional echocardiography, for the assessment of the severity of secondary mitral regurgitation, anatomy, and hemodynamic changes in the left ventricle. Moreover, the concept that the mitral valve has no organic lesions has been abandoned. The echocardiography must allow a complete anatomical and functional evaluation of each component of the mitral valve complex, also useful to the surgeon in choosing the best surgical approach to repair the valve. CONCLUSIONS Echocardiography is the first-line imaging modality for a better selection of patients, according to geometrical modifications of mitral apparatus and left ventricle viability, especially in preoperative phase.
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Affiliation(s)
- Angela Nogara
- Department of Cardiovascular Surgery, GVM Care and Research, Maria Eleonora Hospital, Palermo, Italy
| | - Alberto Minacapelli
- Department of Cardiovascular Surgery, GVM Care and Research, Maria Eleonora Hospital, Palermo, Italy
| | - Giulia Zambelli
- Department of Cardiovascular Surgery, GVM Care and Research, Maria Eleonora Hospital, Palermo, Italy
| | - Lo Coco V
- Department of Cardiac Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Khalil Fattouch
- Department of Cardiovascular Surgery, GVM Care and Research, Maria Eleonora Hospital, Palermo, Italy
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Secondary Mitral Regurgitation: Cardiac Remodeling, Diagnosis, and Management. STRUCTURAL HEART 2022. [DOI: 10.1016/j.shj.2022.100129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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14
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Ceresa F, Micari A, Rubino AS, Mammana L, Pipitone V, Vizzari G, Costa F, Patanè F. Analysis of changes in "mitral valve reserve" after coronary artery bypass grafts in patients with functional mitral regurgitation. J Cardiothorac Surg 2022; 17:255. [PMID: 36199145 PMCID: PMC9536007 DOI: 10.1186/s13019-022-01993-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 09/18/2022] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION The treatment of moderate functionalmitral regurgitation (FMR) during coronary artery bypass grafting (CABG) is still debated. Our primary end point was to assess the improvement of "mitral valve reserve" (MVR) after CABG alone as a clinical demonstration of left ventricular (LV) recovery. MATERIALS AND METHODS Between June 2019 and June 2021, we prospectively enrolled 104 consecutive patients undergoing CABG with moderate FMR. Inclusion criteria were inferior-posterior-lateral wall hypokinesia and revascularization of the circumflex or right coronary artery. MVR was calculated as the ratio between anterior and posterior leaflets' straight length. All patients were followed for 1 year. The improvement of MVR has been considered as a reduction of the ratio between anterior and posterior leaflets straight length. RESULTS Compared to baseline, mean MVR was significantly reduced both at 6 (2.24 ± 0.95 vs. 1,91 ± 0.6; p = 0,047) and 12 months follow-up (2.24 ± 0.95 vs. 1,69 ± 0.49; p = 0,006). Left ventricular (LV) reverse remodeling, meant as improvement of LV ejection fraction and reduction of LV end-systolic volume index and mitral anulus diameter were evaluated at 6 months and 1 year. Mitral regurgitation grade were also significantly reduced at 6 months (p < .001). CONCLUSION The benefits of myocardial revascularization in term of improvement of mitral regurgitation's degree can be explained by the changes of MVR. The patients with FMR, who could have more advantages from CABG alone, should be the ones who have LVESVi just moderately increased.
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Affiliation(s)
- Fabrizio Ceresa
- Vascular and Thoracic Department, Papardo Hospital, Stagno d'Alcontress Street, 98121, Messina, Italy.
| | - Antonio Micari
- Division of Cardiology, G. Martino University Hospital, Messina, Italy
| | - Antonino Salvatore Rubino
- Vascular and Thoracic Department, Papardo Hospital, Stagno d'Alcontress Street, 98121, Messina, Italy
| | - Liborio Mammana
- Vascular and Thoracic Department, Papardo Hospital, Stagno d'Alcontress Street, 98121, Messina, Italy
| | - Vito Pipitone
- Division of Cardiology, Papardo Hospital, Messina, Italy
| | - Giampiero Vizzari
- Division of Cardiology, G. Martino University Hospital, Messina, Italy
| | - Francesco Costa
- Division of Cardiology, G. Martino University Hospital, Messina, Italy
| | - Francesco Patanè
- Vascular and Thoracic Department, Papardo Hospital, Stagno d'Alcontress Street, 98121, Messina, Italy
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Midterm Outcomes of Isolated CABG in the Setting of Moderate Ischemic Mitral Regurgitation. J Surg Res 2022; 278:317-324. [DOI: 10.1016/j.jss.2022.04.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 03/06/2022] [Accepted: 04/11/2022] [Indexed: 11/22/2022]
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Zyrianov A, Spirito P, Abete R, Margonato D, Poggio D, Vaccari G, Binaco I, Grillo M, Dorobantu L, Boni L, Ferrazzi P. Impact of secondary mitral valve chordal cutting on valve geometry in obstructive hypertrophic cardiomyopathy with marked septal hypertrophy. Eur Heart J Cardiovasc Imaging 2022; 24:678-686. [PMID: 36056887 DOI: 10.1093/ehjci/jeac179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 08/10/2022] [Accepted: 08/11/2022] [Indexed: 11/13/2022] Open
Abstract
AIMS In patients with obstructive hypertrophic cardiomyopathy (HCM) and mild septal thickness undergoing myectomy, resecting fibrotic anterior mitral leaflet (AML) secondary chordae moves the mitral valve (MV) away from the outflow tract and ejection flow, reducing the need for a deep septal excision. Aim of the present study was to assess whether chordal resection has similarly favourable effects in patients with important hypertrophy, who represent the majority of patients with obstructive HCM. METHODS AND RESULTS The MV position in the ventricular cavity, assessed from echocardiography as AML-annulus ratio, was compared before and after chordal resection in 150 consecutive HCM patients with important (≥20 mm) and 62 with mild (≤19 mm) septal thickness undergoing myectomy. Preoperatively, MV position was displaced towards the septum to a similar extent in both groups. Postoperatively, AML-annulus ratio increased of an equal degree in both groups, from 0.43 ± 0.05 to 0.55 ± 0.06 (P < 0.001) a 28% increase, and from 0.43 ± 0.06 to 0.55 ± 0.06 (P < 0.001) a 26% increase, respectively, indicating a similar MV shift away from the outflow tract. When AML-annulus ratio was compared in the study cohort and 124 normal subjects, MV position was within normal range in <4% of patients preoperatively and normalized in >50% postoperatively. CONCLUSIONS In obstructive HCM, displacement of the MV apparatus into the outflow tract interferes with the ejection flow. Resection of fibrotic secondary chordae moves the MV apparatus away from the outflow tract and enlarges the outflow area independently of septal thickness, facilitating septal myectomy by reducing the need for a deep muscular excision.
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Affiliation(s)
- Aleksei Zyrianov
- Centro per la Cardiomiopatia Ipertrofica, Policlinico di Monza, Monza 20900, Italy.,Cardiochirurgia, Università degli Studi di Milano, Milan 20900, Italy
| | - Paolo Spirito
- Centro per la Cardiomiopatia Ipertrofica, Policlinico di Monza, Monza 20900, Italy
| | - Raffaele Abete
- Centro per la Cardiomiopatia Ipertrofica, Policlinico di Monza, Monza 20900, Italy
| | - Davide Margonato
- Centro per la Cardiomiopatia Ipertrofica, Policlinico di Monza, Monza 20900, Italy
| | - Daniele Poggio
- Centro per la Cardiomiopatia Ipertrofica, Policlinico di Monza, Monza 20900, Italy
| | - Giuseppe Vaccari
- Centro per la Cardiomiopatia Ipertrofica, Policlinico di Monza, Monza 20900, Italy
| | - Irene Binaco
- Centro per la Cardiomiopatia Ipertrofica, Policlinico di Monza, Monza 20900, Italy.,UOC Cardiochirurgia Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan 20900, Italy
| | - Massimiliano Grillo
- Centro per la Cardiomiopatia Ipertrofica, Policlinico di Monza, Monza 20900, Italy
| | | | - Luca Boni
- Epidemiologia Clinica, IRCSS Ospedale Policlinico San Martino, Genoa 20900, Italy
| | - Paolo Ferrazzi
- Centro per la Cardiomiopatia Ipertrofica, Policlinico di Monza, Monza 20900, Italy
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Russo E, Russo G, Cassese M, Braccio M, Carella M, Compagnucci P, Dello Russo A, Casella M. The Role of Cardiac Resynchronization Therapy for the Management of Functional Mitral Regurgitation. Cells 2022; 11:cells11152407. [PMID: 35954250 PMCID: PMC9367730 DOI: 10.3390/cells11152407] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/31/2022] [Accepted: 08/02/2022] [Indexed: 02/04/2023] Open
Abstract
Valve leaflets and chordae structurally normal characterize functional mitral regurgitation (FMR), which in heart failure (HF) setting results from an imbalance between closing and tethering forces secondary to alterations in the left ventricle (LV) and left atrium geometry. In this context, FMR impacts the quality of life and increases mortality. Despite multiple medical and surgical attempts to treat FMR, to date, there is no univocal treatment for many patients. The pathophysiology of FMR is highly complex and involves several underlying mechanisms. Left ventricle dyssynchrony may contribute to FMR onset and worsening and represents an important target for FMR management. In this article, we discuss the mechanisms of FMR and review the potential therapeutic role of CRT, providing a comprehensive review of the available data coming from clinical studies and trials.
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Affiliation(s)
- Eleonora Russo
- Department of Cardiovascular Disease, IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy
- Correspondence:
| | - Giulio Russo
- Department of Biomedicine and Prevention, Policlinico Tor Vergata, University of Rome, 00133 Rome, Italy
| | - Mauro Cassese
- Department of Cardiac Surgery, Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy
| | - Maurizio Braccio
- Department of Cardiac Surgery, Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy
| | - Massimo Carella
- Scientific Research Department, IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy
| | - Paolo Compagnucci
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti Umberto I-Lancisi-Salesi”, 60126 Ancona, Italy
- Department of Biomedical Sciences and Public Health, University Hospital ”Umberto I-Lancisi-Salesi”, Marche Polytechnic University, 60126 Ancona, Italy
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti Umberto I-Lancisi-Salesi”, 60126 Ancona, Italy
- Department of Biomedical Sciences and Public Health, University Hospital ”Umberto I-Lancisi-Salesi”, Marche Polytechnic University, 60126 Ancona, Italy
| | - Michela Casella
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti Umberto I-Lancisi-Salesi”, 60126 Ancona, Italy
- Department of Clinical, Special and Dental Sciences, University Hospital “Umberto I-Lancisi-Salesi”, Marche Polytechnic University, 60126 Ancona, Italy
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Abstract
In order to achieve the classification of mitral regurgitation, a deep learning network VDS-UNET was designed to automatically segment the critical regions of echocardiography with three sections of apical two-chamber, apical three-chamber, and apical four-chamber. First, an expert-labeled dataset of 153 echocardiographic videos and 2183 images from 49 subjects was constructed. Then, the convolution layer in the VGG16 network was used to replace the contraction path in the original UNet network to extract image features, and depth supervision was added to the expansion path to achieve the segmentation of LA, LV, and MV. The results showed that the Dice coefficients of LA, LV, and MV were 0.935, 0.915, and 0.757, respectively. The proposed deep learning network can achieve simultaneous and accurate segmentation of LA, LV, and MV in multi-section echocardiography, laying a foundation for quantitative measurement of clinical parameters related to mitral regurgitation.
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Offen SM, Baker D, Puranik R, Celermajer DS. Right ventricular volume and its relationship to functional tricuspid regurgitation. IJC HEART & VASCULATURE 2022; 38:100940. [PMID: 35024430 PMCID: PMC8728462 DOI: 10.1016/j.ijcha.2021.100940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/14/2021] [Accepted: 12/22/2021] [Indexed: 11/12/2022]
Abstract
Background Significant right ventricular (RV) dilatation has long been considered integral to the pathogenesis of functional tricuspid regurgitation (FTR). Objectives To explore the relationship of RV dilatation and FTR in patients with ‘pure’ RV volume overload. Methods Patients (>17yrs) with RV dilatation due to pre-tricuspid shunts (atrial septal defect; ASD and/or partial anomalous pulmonary venous drainage; PAPVD) referred to our service (2000–2019) were retrospectively identified. Those with pulmonary hypertension, primum ASD or left-heart disease were excluded. Using standard cardiac MRI protocols, RV, right atrial and TV parameters were measured and compared. Results Of 52 consecutively eligible patients (42 ± 15yrs, 25 males), 25 had ASDs, 13 had PAPVD and 14 had both conditions. All were in sinus rhythm and none had pulmonary regurgitation. Left and right ventricular ejection fractions were normal (LVEF 63 ± 8%, RVEF 56 ± 8%). Indexed RV end-diastolic volumes (RVEDVi) were moderately increased (males 148 ± 33 mL/m2 and females 141 ± 42 mL/m2, range 95–267 mL/m2). Despite substantial RV volume overload, no patients had severe tricuspid regurgitation (TR). Only two had > mild TR. There was a weak correlation between tricuspid annular diameter and both degree of RV dilatation (r = 0.37; p = 0.01) and degree of TR (r = 0.38; p = 0.006). There was a similarly poor correlation between right atrial dimensions and the degree of TR (r = 0.34; p = 0.02). Conclusion When RV dilatation is simply due to volume overload, we find that significant TR is extremely rare. This gives an important and novel insight; that RV dilatation per se does not result in FTR.
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Affiliation(s)
- Sophie M Offen
- Faculty of Medicine and Health, University of Sydney, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Australia
| | - David Baker
- Department of Cardiology, Royal Prince Alfred Hospital, Australia
| | - Raj Puranik
- Faculty of Medicine and Health, University of Sydney, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Australia
| | - David S Celermajer
- Faculty of Medicine and Health, University of Sydney, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Australia.,Heart Research Institute, Australia
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6564254. [DOI: 10.1093/ejcts/ezac125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 02/09/2022] [Accepted: 02/14/2022] [Indexed: 11/12/2022] Open
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Stassen J, Namazi F, van der Bijl P, van Wijngaarden SE, Kamperidis V, Marsan NA, Delgado V, Bax JJ. Left atrial reservoir function and outcomes in secondary mitral regurgitation. J Am Soc Echocardiogr 2022; 35:477-485.e3. [DOI: 10.1016/j.echo.2022.01.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 01/05/2022] [Accepted: 01/12/2022] [Indexed: 11/27/2022]
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Ponnusamy SS, Syed T, Vijayaraman P. Response Of Functional Mitral Regurgitation In Non-ischemic Cardiomyopathy To Left Bundle Branch Pacing. Heart Rhythm 2022; 19:737-745. [DOI: 10.1016/j.hrthm.2022.01.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 01/11/2022] [Accepted: 01/12/2022] [Indexed: 11/04/2022]
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Hasin T, Mann D, Welt M, Barrett O, Shalev A, Godfrey M, Kovacs A, Bogot N, Carasso S, Glikson M, Wolak A. Loss of left ventricular rotation is a significant determinant of functional mitral regurgitation. Int J Cardiol 2021; 345:143-149. [PMID: 34626742 DOI: 10.1016/j.ijcard.2021.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/25/2021] [Accepted: 10/04/2021] [Indexed: 11/19/2022]
Abstract
AIM To evaluate insufficient rotational movement of the left ventricle (LV) as a potential novel mechanism for functional regurgitation of the mitral valve (FMR). METHODS AND RESULTS We compared reference subjects and patients with LV dysfunction (LVD, ejection fraction EF < 50%) with and without FMR (regurgitant volume RVol>10 ml). Subjects without structural mitral valve pathology undergoing cardiac MRI were evaluated. Delayed enhancement, global LV remodeling parameters, systolic twist and torsion were measured (using manual and novel automated cardiac MRI tissue-tracking). The study included 117 subjects with mean ± SD age 50.4 ± 17.8 years, of which 30.8% were female. Compared to subjects with LVD without FMR (n = 31), those with FMR (n = 37) had similar clinical characteristics, diagnoses, delayed enhancement, EF, and longitudinal strain. Subjects with FMR had significantly larger left ventricles (EDVi:136.6 ± 41.8 vs 97.5 ± 26.2 ml/m, p < 0.0001) with wider separation between papillary muscles (21.1 ± 7.6 vs 17.2 ± 5.7 mm, p = 0.023). Notably, they had lower apical (p < 0.0001) but not basal rotation and lower peak systolic twist (3.1 ± 2.4° vs 5.5 ± 2.5°, p < 0.0001) and torsion (0.56 ± 0.38°/cm vs 0.88 ± 0.52°/cm, p = 0.004). In a multivariate model for RVol including age, gender, twist, LV end-diastolic volume, sphericity index and separation between papillary muscles, only gender, volume and twist were significant. Twist was the most powerful correlate (beta -2.23, CI -3.26 to -1.23 p < 0.001). In patients with FMR, peak systolic twist negatively correlates with RVol (r = -0.73, p < 0.0001). CONCLUSION Reduced rotational systolic LV motion is significantly and independently associated with RVol among patients with FMR, suggesting a novel pathophysiological mechanism and a potential therapeutic target.
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Affiliation(s)
- Tal Hasin
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel; Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Daniel Mann
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Michael Welt
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel; Department of Cardiology, The Edith Wolfson Medical Center, Holon, Israel
| | - Orit Barrett
- Department of Cardiology, Soroka University Medical Center, Beer Sheva, Israel
| | - Aryeh Shalev
- Department of Cardiology, Soroka University Medical Center, Beer Sheva, Israel
| | - Max Godfrey
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Andras Kovacs
- Department of Cardiology, Hungarian Defense Forces Medical Center, Budapest, Hungary
| | - Naama Bogot
- Department of Radiology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Shemy Carasso
- Department of Cardiology, Padeh Poria Medical Center, Poria, Israel
| | - Michael Glikson
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Arik Wolak
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel.
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Castillo-Sang M, Lamelas J. Reply: Is papillary muscle approximation the answer to absent reverse remodeling in transcatheter edge-to-edge repair and reductive mitral annuloplasty? JTCVS OPEN 2021; 8:292-293. [PMID: 36004089 PMCID: PMC9390250 DOI: 10.1016/j.xjon.2021.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Echocardiographic Advances in Dilated Cardiomyopathy. J Clin Med 2021; 10:jcm10235518. [PMID: 34884220 PMCID: PMC8658091 DOI: 10.3390/jcm10235518] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/05/2021] [Accepted: 11/23/2021] [Indexed: 12/29/2022] Open
Abstract
Although the overall survival of patients with dilated cardiomyopathy (DCM) has improved significantly in the last decades, a non-negligible proportion of DCM patients still shows an unfavorable prognosis. DCM patients not only need imaging techniques that are effective in diagnosis, but also suitable for long-term follow-up with frequent re-evaluations. The exponential growth of echocardiography’s technology and performance in recent years has resulted in improved diagnostic accuracy, stratification, management and follow-up of patients with DCM. This review summarizes some new developments in echocardiography and their promising applications in DCM. Although nowadays cardiac magnetic resonance (CMR) remains the gold standard technique in DCM, the echocardiographic advances and novelties proposed in the manuscript, if properly integrated into clinical practice, could bring echocardiography closer to CMR in terms of accuracy and may certify ultrasound as the technique of choice in the follow-up of DCM patients. The application in DCM patients of novel echocardiographic techniques represents an interesting emergent research area for scholars in the near future.
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Piatkowski R, Kochanowski J, Budnik M, Peller M, Grabowski M, Opolski G. Stress Echocardiography Protocol for Deciding Type of Surgery in Ischemic Mitral Regurgitation: Predictors of Mitral Regurgitation Recurrence following CABG Alone. J Clin Med 2021; 10:jcm10214816. [PMID: 34768340 PMCID: PMC8585062 DOI: 10.3390/jcm10214816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 10/16/2021] [Accepted: 10/19/2021] [Indexed: 11/16/2022] Open
Abstract
Purpose: Although coronary artery bypass grafting alone (CABGa), or, with mitral annuloplasty (CABGmp), is considered the best therapeutic strategy for patients with ischemic mitral regurgitation (IMR), some recurrences are still reported. The aim of this study was to evaluate the use of the mitral deformation indices (MDI) as a predictor of recurrence of mitral regurgitation in a 12-month follow-up after CABG alone. Methods: A total of 145 patients after myocardial infarction with significant IMR, eligible for CABG, were prospectively enrolled in the study. Mitral valve morphology, left ventricle function, IMR degree as assessed by effective regurgitation orifice area (ERO), myocardial viability, and MDI were assessed prior to surgery. Patients were referred for CABGa (gr.1; n = 90) or CABGmp (gr.2; n = 55) based on clinical assessment, and the results of rest and stress echocardiography (exercise echocardiography and low dose dobutamine echocardiography-DBX). One year after surgery, each patient underwent the evaluation of cardiovascular events. Univariable logistic regression analysis was used to identify the factors of recurrence of IMR in 1 year follow-up. Serial echo examinations were performed in all patients at discharge, and at 1 and 12 months after surgery. Results: Logistic regression analysis revealed that in CABGa, group preoperative changes of tenting area (TA) and coaptation high (CH) during DBX remained the predictors of the recurrence of IMR in 12 months follow-up. TAdbx > 1 cm2 provided a sensitivity of 90% and specificity of 29%, (AUC 0.6436). The best cut-off value for CHdbx was 0.4 cm (sensitivity 90%, specificity 34%; AUC 0.6432). In both groups (CABGa vs. CABGmp) no significant differences were observed in 12-month mortality (1.2% vs. 0%; p = 1.0), hospitalizations due to the heart failure (HF) exacerbation (5.9% vs. 8.5%; p = 0.72), and in the incidence of the composite endpoint (deaths/CV hosp/stroke) (7% vs. 8.5%; p = 0.742). Conclusions: The preoperative assessment of MDI changes during dbx can be used to identify patients with IMR qualified to CABG alone at increased risk of recurrence of IMR in 1 year follow-up. Mitral deformation analysis should be used for a better qualification of patients with IMR to the exact surgical approach.
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Kato N, Thaden JJ, Miranda WR, Scott CG, Sarano ME, Greason KL, Pellikka PA. Impact of aortic valve replacement for severe aortic stenosis on organic and functional mitral regurgitation. ESC Heart Fail 2021; 8:5482-5492. [PMID: 34652057 PMCID: PMC8712890 DOI: 10.1002/ehf2.13649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 08/26/2021] [Accepted: 09/25/2021] [Indexed: 11/10/2022] Open
Abstract
Aims Concurrent mitral regurgitation (MR) influences treatment considerations in patients with severe aortic stenosis (sAS). Limited information exists regarding haemodynamic effects of sAS on MR severity and outcome of these patients. We assessed the impact of aortic valve replacement (AVR) on MR according to mechanism in patients with sAS and MR. Methods and results In patients with sAS who received surgical or transcatheter AVR from 2008 to 2017, those with effective mitral regurgitant orifice area (ERO) ≥ 10 mm2 prior to AVR were evaluated. The change in MR after AVR was considered significant when there was at least one grade difference. We compared the all‐cause mortality of patients with and without improvement in MR. Of 234 patients with sAS and MR (age 80 ± 9 years, 52% male, ERO 19 ± 7 mm2), organic and functional MR were present in 166 (71%) and 68 (29%), respectively. MR improved in 136 (58%); improvement occurred with similar frequency in organic versus functional MR (59% and 57%, P = 0.88). Associated determinants were absence of atrial fibrillation in organic MR [odds ratio (OR) 2.09, 95% confidence interval (CI) 1.00–4.37; P = 0.049] and indexed aortic valve area (iAVA) ≤ 0.40 cm2 in functional MR (OR 3.28, 95% CI 1.13–9.47; P = 0.028). In the overall cohort, mitral annulus diameter < 3 cm (OR 1.74, 95% CI 1.02–2.97; P = 0.041) and QRS duration < 115 ms (OR 1.73, 95% CI 1.00–2.98; P = 0.049) were independently associated with improvement in MR. During median follow‐up of 3.5 years, lack of improvement in MR was not associated with higher mortality in the overall cohort of patients with ERO ≥ 20 mm2 [adjusted hazard ratio (HR) 1.71, 95% CI 0.90–3.27; P = 0.10, adjusted for age, New York Heart Association III or IV, diabetes, and creatinine ≥ 2.0 mg/dL]. Lack of improvement in organic MR was associated with higher mortality (adjusted HR 3.36, 95% CI 1.40–8.05; P < 0.01). In patients with functional MR, change in MR was not associated with mortality (HR 1.24, 95% CI 0.44–3.47; P = 0.68). Conclusions In nearly 60% of patients with sAS and MR, MR improved after AVR, even in the majority of patients with organic MR. Absence of atrial fibrillation in organic MR, iAVA ≤ 0.40 cm2 in functional MR, and mitral annulus diameter < 3 cm and QRS duration < 115 ms in the overall population were associated with MR improvement. Post‐operative improvement in organic MR was associated with better survival.
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Affiliation(s)
- Nahoko Kato
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN, USA
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN, USA
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN, USA
| | | | - Maurice E Sarano
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN, USA
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Patricia A Pellikka
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN, USA
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Senthilnathan G, Dhandapani V, Ramraj B, Logaraj M. Clinical presentation and prognosis of non valvular mitral regurgitation-A single institution experience. CLINICAL EPIDEMIOLOGY AND GLOBAL HEALTH 2021. [DOI: 10.1016/j.cegh.2021.100781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Uno G, Omori T, Shimada S, Rader F, Siegel RJ, Shiota T. Differences in mitral valve geometry between atrial and ventricular functional mitral regurgitation in patients with atrial fibrillation: a 3D transoesophageal echocardiography study. Eur Heart J Cardiovasc Imaging 2021; 22:1106-1116. [PMID: 34405882 DOI: 10.1093/ehjci/jeab130] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 06/29/2021] [Indexed: 11/12/2022] Open
Abstract
AIMS This study investigated geometric differences in mitral valve apparatus between atrial functional mitral regurgitation (A-FMR) and functional mitral regurgitation (FMR) with left ventricular (LV) dysfunction in patients with atrial fibrillation (AF) using 3D transoesophageal echocardiography (TOE). METHODS AND RESULTS In total, 135 moderate or greater FMR patients with persistent AF or atrial flutter underwent 3D TOE. Fifty-six patients had A-FMR, defined as preserved LV ejection fraction (LVEF) of ≥50% and normal LV wall motion. Seventy-nine patients had ventricular FMR (V-FMR), defined as LV dysfunction (LVEF of <50%) or LV wall motion abnormality. To evaluate mitral leaflet coaptation, the coapted area was calculated as follows: total leaflet area (TLA) in end-diastole - closed leaflet area in mid-systole. Although annular area (AA) did not significantly differ between the two groups, TLA was significantly smaller in A-FMR than in V-FMR (P = 0.005). TLA/AA, indicating the degree of the leaflet remodelling, was significantly smaller in A-FMR than in V-FMR (P < 0.001). A-FMR had significantly smaller posterior mitral leaflet tethering height and angle measured at three anteroposterior planes (lateral, central, and medial) than V-FMR (all P < 0.001). However, vena contracta width (VCW) measured on long-axis view on TOE and coapted area, which correlated with VCW (r = -0.464, P < 0.001), were similar between the two groups. CONCLUSION Mitral leaflet remodelling may be less in A-FMR compared with V-FMR. However, leaflet tethering was smaller in A-FMR than in V-FMR, and this may result in a similar degree of mitral leaflet coaptation and mitral regurgitation severity.
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Affiliation(s)
- Goki Uno
- Smidt Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard A 3411, Los Angeles, CA 90048, USA
| | - Taku Omori
- Smidt Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard A 3411, Los Angeles, CA 90048, USA
| | - Shunsuke Shimada
- Smidt Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard A 3411, Los Angeles, CA 90048, USA
| | - Florian Rader
- Smidt Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard A 3411, Los Angeles, CA 90048, USA
| | - Robert J Siegel
- Smidt Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard A 3411, Los Angeles, CA 90048, USA
| | - Takahiro Shiota
- Smidt Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard A 3411, Los Angeles, CA 90048, USA
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Dreyfus GD, Essayagh B, Benfari G, Dulguerov F, Haley SR, Dommerc C, Albert A, Enriquez-Sarano M. Outcome of consistent guideline-based tricuspid management in patients undergoing degenerative mitral regurgitation correction. JTCVS OPEN 2021; 7:125-138. [PMID: 36003759 PMCID: PMC9390475 DOI: 10.1016/j.xjon.2021.07.010] [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: 05/15/2020] [Accepted: 07/14/2021] [Indexed: 01/05/2023]
Abstract
Objectives Despite coherent guidelines, management of functional tricuspid regurgitation (FTR) consequences on outcome in the context of degenerative mitral regurgitation (DMR) remains controversial due to lacking series of large magnitude with rigorous application of tricuspid guidelines and strict long-term echocardiographic follow-up. Thus, we aimed at gathering such a cohort to examine outcomes of patients undergoing DMR surgery following tricuspid surgery guidelines. Methods All consecutive patients with isolated DMR 2005-2015 operated on with baseline FTR assessment and tricuspid annulus diameter measurement were identified. Operative complications, postoperative tricuspid regurgitation incidence, and survival were assessed overall and stratified by guideline-based tricuspid annuloplasty (TA) indication (severe FTR or tricuspid annulus diameter ≥40 mm). Results Among 441 patients with DMR undergoing mitral repair (66 ± 13 years, 30% female, ejection fraction 66 ± 10%, systolic pulmonary artery pressures 39 ± 12 mm Hg) followed 6 [3-9] years, patients with TA (n = 234, 53%) had generally similar presentation versus without TA (n = 207, 47%; all P ≥ .2) except for more atrial fibrillation and larger left ventricle (both P ≥ .0003). Patients with TA showed longer bypass time, more maze procedures (all P ≤ .001), but hospital stay, renal-failure, pacemaker implantation, and operative mortality (overall 0.9%) were comparable (all P ≥ .2). Postoperative incidence of moderate/severe FTR (0% at 1 year) became over time greater among patients without TA (5-year 8% [4%-13%] vs 3% [1%-11%] and 10-year 10% [6%-16%] vs 4% [1%-16%], P = .01). Survival (95% confidence interval) throughout follow-up was 85% (77%-89%) at 10 years, with hazard ratio 0.57 (0.29-1.10), P = .09. for patients with TA versus without. Conclusions In this large surgical DMR cohort, guideline-based FTR management was safe and effective. While long-term mortality did not reach significance, postoperative incidence of moderate/severe FTR, overall low, was nevertheless greater in patients who did not appear to require TA at surgery and linked to tricuspid annular dimension. Thus, future multicenter prospective cohorts with long-term follow-up are warranted to re-examine thresholds for TA performance and impact on survival.
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Bartko PE, Heitzinger G, Spinka G, Pavo N, Prausmüller S, Kastl S, Winter MP, Arfsten H, Tan TC, Gebhard C, Mascherbauer J, Hengstenberg C, Strunk G, Hülsmann M, Goliasch G. Principal Morphomic and Functional Components of Secondary Mitral Regurgitation. JACC Cardiovasc Imaging 2021; 14:2288-2300. [PMID: 34274262 DOI: 10.1016/j.jcmg.2021.05.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 04/14/2021] [Accepted: 05/21/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The aim of this work was to identify the key morphological and functional features in secondary mitral regurgitation (sMR) and their prognostic impact on outcome. BACKGROUND Secondary sMR in patients with heart failure and reduced ejection fraction typically results from distortion of the underlying cardiac architecture. The morphological components which may account for the clinical impact of sMR have not been systematically assessed or correlated with clinical outcomes. METHODS Morphomic and functional network profiling were performed on a cohort of patients with stable heart failure optimized on guideline-based medical therapy. Principal component (PC) analysis and subsequent cluster analysis were used to condense the morphomic and functional data first into PCs with varimax rotation (PCVmax) and second into homogeneous clusters. Clusters and PCs were tested for their correlations with clinical outcomes. RESULTS Morphomic and functional data from 383 patients were profiled and subsequently condensed into PCs. PCVmax 1 describes high loadings of left atrial morphological information, and PCVmax 2 describes high loadings of left ventricular (LV) topology. Based on these components, 4 homogeneous clusters were derived. sMR was most prominent in clusters 3 and 4, with the morphological difference being left ventricular size (median end-diastolic volume 188 mL [interquartile range: 160 mL-224 mL] vs 315 mL [264 mL-408 mL]; P < 0.001). Clusters were associated with mortality (P < 0.001), but sMR remained independently associated with mortality after adjusting for the clusters (adjusted HR: 1.42; 95% CI: 1.14-1.77; P < 0.01). The detrimental association of sMR with mortality was mainly driven by cluster 3 (HR: 2.18; 95% CI: 1.32-3.60; P = 0.002), the "small LV cavity" phenotype. CONCLUSIONS These results challenge the current perceptions that sMR in heart failure with reduced ejection fraction results exclusively from global or local LV remodeling and are suggestive of a potential role of the left atrial component. The association of sMR with mortality cannot be purely attributed to cardiac morphology alone, supporting other complementary key aspects of mitral valve closure consistent with the force balance theory. Unsupervised clustering supports the association of sMR with mortality predominantly driven by the small LV cavity phenotype, as previously suggested by a conceptional framework and termed disproportionate sMR.
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Affiliation(s)
- Philipp E Bartko
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Gregor Heitzinger
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Georg Spinka
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Noemi Pavo
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Suriya Prausmüller
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Stefan Kastl
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Max-Paul Winter
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Henrike Arfsten
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Timothy C Tan
- Faculty of Medicine, Westmead Hospital, University of Sydney, Sydney, Australia; Department of Cardiology, Blacktown Hospital, Blacktown, Australia
| | - Catherine Gebhard
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Julia Mascherbauer
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | | | - Guido Strunk
- Department of Cardiology, Blacktown Hospital, Blacktown, Australia
| | - Martin Hülsmann
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Georg Goliasch
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria.
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Barros-Gomes S, Tarasoutchi F, Rodrigues ACT, Nhola LF, Lemos PA, Morhy SS, Fischer CH, Vieira MLC. Percutaneous Treatment of Secondary Mitral Regurgitation by MitraClip: Mitra-FR vs. COAPT. Arq Bras Cardiol 2021; 116:1011-1018. [PMID: 34008830 PMCID: PMC8121475 DOI: 10.36660/abc.20200063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 12/02/2020] [Indexed: 11/30/2022] Open
Affiliation(s)
- Sergio Barros-Gomes
- Instituto do Coração da Universidade de São Paulo, São Paulo, SP - Brasil.,Hospital Israelita Albert Einstein, São Paulo, SP - Brasil
| | | | | | | | - Pedro Alves Lemos
- Instituto do Coração da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Samira Saady Morhy
- Instituto do Coração da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Claudio Henrique Fischer
- Instituto do Coração da Universidade de São Paulo, São Paulo, SP - Brasil.,Universidade Federal de São Paulo, São Paulo, SP - Brasil
| | - Marcelo Luiz Campos Vieira
- Instituto do Coração da Universidade de São Paulo, São Paulo, SP - Brasil.,Hospital Israelita Albert Einstein, São Paulo, SP - Brasil
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Xu B, Kawata T, Nakao T, Nakanishi K, Hirokawa M, Sawada N, Kimura K, Abe Y, Komuro I, Yatomi Y, Daimon M. Mitral Valvular Coaptation-Zone Area Is Associated with the Severity of Atherosclerosis Assessed by Cardio-Ankle Vascular Index. Int Heart J 2021; 62:552-558. [PMID: 33994514 DOI: 10.1536/ihj.20-776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Preservation of the mitral valve (MV) size is essential for valve function, and a reduced MV coaptation-zone area increases the risk of developing functional mitral regurgitation (FMR). We aimed to determine if the MV leaflet and coaptation-zone areas were associated with the severity of atherosclerosis assessed by cardio-ankle vascular index (CAVI) in patients with normal left ventricle (LV) systolic function and size by real-time 3D echocardiography (RT3DE).We performed RT3DE analysis in 66 patients with normal LV size and ejection fraction who underwent 2D echocardiography and CAVI. MV coaptation-zone areas were measured by custom 3D software and indexed by body surface area (BSA). The associations of clinical factors and mean CAVI with MV leaflet and coaptation-zone areas were evaluated by univariable and multivariable linear regression analyses.On univariable analysis, MV leaflet area/BSA was significantly associated with age (r = -0.335, P = 0.0069) and mean CAVI (r = -0.464, P < 0.001), and MV coaptation-zone area was significantly associated with age (r = -0.626, P < 0.001), hypertension (r = -0.626, P < 0.001), dyslipidemia (r = -0.626, P < 0.001), E/e' (r = -0.626, P < 0.001), and CAVI (r = -0.740, P < 0.001). On multivariable analysis, mean CAVI was independently associated only with MV leaflet area/BSA (standardized coefficient = -0.611, P < 0.001) and MV coaptation-zone area/BSA (standardized coefficient = -0.74, P < 0.001).In patients with normal LV systolic function and size, MV leaflet and coaptation-zone areas might be reduced according to advancing atherosclerosis. Patients with atherosclerosis might be at increased risk of developing FMR.
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Affiliation(s)
- Boqing Xu
- Department of Clinical Laboratory, Graduate School of Medicine, The University of Tokyo
| | - Takayuki Kawata
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
| | - Tomoko Nakao
- Department of Clinical Laboratory, Graduate School of Medicine, The University of Tokyo
| | - Koki Nakanishi
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
| | - Megumi Hirokawa
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
| | - Naoko Sawada
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
| | - Koichi Kimura
- Department of General Medicine, The Institute of Medical Science, The University of Tokyo
| | - Yukio Abe
- Department of Cardiology, Osaka City General Hospital
| | - Issei Komuro
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
| | - Yutaka Yatomi
- Department of Clinical Laboratory, Graduate School of Medicine, The University of Tokyo
| | - Masao Daimon
- Department of Clinical Laboratory, Graduate School of Medicine, The University of Tokyo.,Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
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Bartko PE, Hülsmann M, Hung J, Pavo N, Levine RA, Pibarot P, Vahanian A, Stone GW, Goliasch G. Secondary valve regurgitation in patients with heart failure with preserved ejection fraction, heart failure with mid-range ejection fraction, and heart failure with reduced ejection fraction. Eur Heart J 2021; 41:2799-2810. [PMID: 32350503 DOI: 10.1093/eurheartj/ehaa129] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 01/12/2020] [Accepted: 02/12/2020] [Indexed: 12/27/2022] Open
Abstract
Secondary mitral regurgitation and secondary tricuspid regurgitation due to heart failure (HF) remain challenging in almost every aspect: increasing prevalence, poor prognosis, notoriously elusive in diagnosis, and complexity of therapeutic management. Recently, defined HF subgroups according to three ejection fraction (EF) ranges (reduced, mid-range, and preserved) have stimulated a structured understanding of the HF syndrome but the role of secondary valve regurgitation (SVR) across the spectrum of EF remains undefined. This review expands this structured understanding by consolidating the underlying phenotype of myocardial impairment with each type of SVR. Specifically, the current understanding, epidemiological considerations, impact, public health burden, mechanisms, and treatment options of SVR are discussed separately for each lesion across the HF spectrum. Furthermore, this review identifies important gaps in knowledge, future directions for research, and provides potential solutions for diagnosis and treatment. Mastering the challenge of SVR requires a multidisciplinary collaborative effort, both, in clinical practice and scientific approach to optimize patient outcomes.
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Affiliation(s)
- Philipp E Bartko
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Martin Hülsmann
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Judy Hung
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114-2696, USA
| | - Noemi Pavo
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Robert A Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114-2696, USA
| | - Philippe Pibarot
- Laval Hospital, Research Center Québec Heart Institute, Pavillon Ferdinand-Vandry 1050, avenue de la Médecine Local 4211, Laval University, Quebec City, Québec, Canada
| | - Alec Vahanian
- University of Paris, 5 Rue Thomas Mann, 75013 Paris, France
| | - Gregg W Stone
- Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, Cardiovascular Research Foundation, 1700 Broadway, New York, NY 10019, USA
| | - Georg Goliasch
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
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Hagendorff A, Knebel F, Helfen A, Stöbe S, Haghi D, Ruf T, Lavall D, Knierim J, Altiok E, Brandt R, Merke N, Ewen S. Echocardiographic assessment of mitral regurgitation: discussion of practical and methodologic aspects of severity quantification to improve diagnostic conclusiveness. Clin Res Cardiol 2021; 110:1704-1733. [PMID: 33839933 PMCID: PMC8563569 DOI: 10.1007/s00392-021-01841-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 03/08/2021] [Indexed: 12/28/2022]
Abstract
The echocardiographic assessment of mitral valve regurgitation (MR) by characterizing specific morphological features and grading its severity is still challenging. Analysis of MR etiology is necessary to clarify the underlying pathological mechanism of the valvular defect. Severity of mitral regurgitation is often quantified based on semi-quantitative parameters. However, incongruent findings and/or interpretations of regurgitation severity are frequently observed. This proposal seeks to offer practical support to overcome these obstacles by offering a standardized workflow, an easy means to identify non-severe mitral regurgitation, and by focusing on the quantitative approach with calculation of the individual regurgitant fraction. This work also indicates main methodological problems of semi-quantitative parameters when evaluating MR severity and offers appropriateness criteria for their use. It addresses the diagnostic importance of left-ventricular wall thickness, left-ventricular and left atrial volumes in relation to disease progression, and disease-related complaints to improve interpretation of echocardiographic findings. Finally, it highlights the conditions influencing the MR dynamics during echocardiographic examination. These considerations allow a reproducible, verifiable, and transparent in-depth echocardiographic evaluation of MR patients ensuring consistent haemodynamic plausibility of echocardiographic results.
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Affiliation(s)
- Andreas Hagendorff
- Department of Cardiology, Klinik und Poliklinik für Kardiologie, University of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany.
| | - Fabian Knebel
- Department of Cardiology, University of Berlin, Charité Universitätsmedizin Berlin, Campus Mitte, Medizinische Klinik mit Schwerpunkt Kardiologie und Angiologie, Charitéplatz 1, 10117, Berlin, Germany
| | - Andreas Helfen
- Department of Cardiology, Katholisches Klinikum Lünen Werne GmbH, St-Marien-Hospital Lünen, Altstadtstrasse 23, 44534, Lünen, Germany
| | - Stephan Stöbe
- Department of Cardiology, Klinik und Poliklinik für Kardiologie, University of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
| | - Dariush Haghi
- Kardiologische Praxisklinik Ludwigshafen, Akademische Lehrpraxis der Universität Mannheim, Ludwig-Guttmann-Strasse 11, 67071, Ludwigshafen, Germany
| | - Tobias Ruf
- Department of Cardiology, Center of Cardiology, Heart Valve Center, University Medical Center Mainz, University of Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Daniel Lavall
- Department of Cardiology, Klinik und Poliklinik für Kardiologie, University of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
| | - Jan Knierim
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Ertunc Altiok
- Department of Cardiology, University of Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Roland Brandt
- Department of Cardiology, Kerckhoff Heart Center, Benekestr. 2-8, 61231, Bad Nauheim, Germany
| | - Nicolas Merke
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Sebastian Ewen
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Kirrberger Str, IMED, 66421, Homburg, Germany
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Spinka G, Bartko PE, Pavo N, Freitag C, Zlabinger K, Prausmüller S, Arfsten H, Heitzinger G, Mascherbauer J, Hengstenberg C, Gyöngyösi M, Hülsmann M, Goliasch G. Secondary mitral regurgitation-Insights from microRNA assessment. Eur J Clin Invest 2021; 51:e13381. [PMID: 32780418 PMCID: PMC7900984 DOI: 10.1111/eci.13381] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/01/2020] [Accepted: 08/07/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND While secondary mitral regurgitation (sMR) is associated with adverse outcome in heart failure with reduced ejection fraction (HFrEF), key pathophysiologic mechanisms remain poorly understood and might be elucidated by microRNAs (miRNA/miR), that were recently related to cardiac remodelling. This study sought to assess (i) the differences of miRNA profiles in patients with severe sMR compared to matched disease controls, (ii) the correlation between circulating miRNAs and surrogates of sMR severity as well as (iii) the prognostic implications of miRNA levels in severe sMR. MATERIALS AND METHODS Sixty-six HFrEF patients were included, of these 44 patients with severe sMR 2:1 matched to HFrEF controls with no/mild sMR. A comprehensive set of miRNAs (miR-21, miR-29a, miR-122, miR-132, miR-133a, miR-let7i) were measured and correlated to echocardiographic sMR severity. RESULTS miRNA patterns differed distinctly between patients with severe sMR and HFrEF controls (P < .05). Among the panel of assessed miRNAs, miR-133a correlated most strongly with surrogates of sMR severity (r = -0.41, P = .001 with sMR vena contracta width). Interestingly, elevated levels of miR-133 were associated with an increased risk for cardiovascular death and/or HF hospitalizations with and adjusted HR of 1.85 (95% CI 1.24-2.76, P = .003). CONCLUSIONS This study unveils distinct pathophysiologic maladaptions at a cellular level in patients with severe sMR compared to no/mild sMR by showing significant differences in miRNA profiles and correlations with sMR severity, supporting the concept that sMR drives cardiac remodelling in heart failure. Moreover, the increased risk for adverse outcome in HFrEF patients with severe sMR conveyed by miR-133a might indicate irreversible myocardial damage.
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Affiliation(s)
- Georg Spinka
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Philipp E Bartko
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Noemi Pavo
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Claudia Freitag
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Katrin Zlabinger
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Suriya Prausmüller
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Henrike Arfsten
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Gregor Heitzinger
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Julia Mascherbauer
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | | | - Mariann Gyöngyösi
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Martin Hülsmann
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Georg Goliasch
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
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von Stumm M, Dudde F, Holst T, Sequeira-Gross T, Pausch J, Müller L, Sinning CR, Reichenspurner H, Girdauskas E. Predicting clinical outcome by indexed mitral valve tenting in functional mitral valve regurgitation. Open Heart 2021; 8:openhrt-2020-001483. [PMID: 33495382 PMCID: PMC7839912 DOI: 10.1136/openhrt-2020-001483] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/02/2020] [Accepted: 12/02/2020] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES Mitral valve (MV) tenting parameters are indicators of left ventricular remodelling severity and may predict outcome in functional mitral regurgitation (FMR). We hypothesised that indexing of MV tenting area to body surface area (BSA), to mitral annulus diameter or gender-adjusted analysis of tenting parameters may improve their prognostic value. METHODS We identified retrospectively 240 patients with consecutive FMR (mean age 68±10 years; men=135) from our institutional database who underwent isolated MV annuloplasty during a period of 7 years (2010-2016). Using preoperative two-dimensional transthoracic echocardiographic images, MV tenting parameters including tenting area, tenting height and annulus diameter were systematically assessed. Follow-up protocol consisted of chart review and structured clinical questionnaire. Primary study endpoint was the composite of death and adverse cardiac events (ie, MV reoperation, cardiac resynchronisation therapy implantation, ventricular assist device implantation or heart transplantation). RESULTS BSA-indexed MV tenting area was identified as independent predictor of primary study endpoint (HR 1.9; 95% CI 1.1 to 3.5; p=0.02). After cut-off point analysis, BSA-indexed MV tenting area >1.35 cm2/m2 was significantly associated with primary study outcome (HR 2.3; 95% CI 1.3 to 4.0; p=0.003). Annulus-indexed MV tenting area showed only a tendency towards primary study endpoint prediction (HR 2.8; 95% CI 0.6 to 12.6; p=0.17). Between female and male patients, BSA-indexed MV tenting area was similar (1.42±0.4 cm2/m2 vs 1.45±0.4cm2/cm2; p=0.6) and gender was not associated with primary study outcome (HR 0.8; 95% CI 0.5 to 1.4; p=0.5). CONCLUSION In our FMR cohort, BSA-indexed MV tenting area showed the strongest association with negative outcomes following isolated MV annuloplasty. Patients with BSA-indexed MV tenting area >1.35cm2/m2 could potentially benefit from additional surgical maneuvers addressing left ventricular remodelling.
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Affiliation(s)
- Maria von Stumm
- Cardiovascular Surgery, University Hospital Hamburg Eppendorf University Heart Centre, Hamburg, Germany
| | - Florian Dudde
- Cardiovascular Surgery, University Hospital Hamburg Eppendorf University Heart Centre, Hamburg, Germany
| | - Theresa Holst
- Cardiovascular Surgery, University Hospital Hamburg Eppendorf University Heart Centre, Hamburg, Germany
| | - Tatjana Sequeira-Gross
- Cardiovascular Surgery, University Hospital Hamburg Eppendorf University Heart Centre, Hamburg, Germany
| | - Jonas Pausch
- Cardiovascular Surgery, University Hospital Hamburg Eppendorf University Heart Centre, Hamburg, Germany
| | - Lisa Müller
- Cardiovascular Surgery, University Hospital Hamburg Eppendorf University Heart Centre, Hamburg, Germany
| | - Christoph R Sinning
- General and Interventional Cardiology, University Hospital Hamburg Eppendorf University Heart Centre, Hamburg, Germany
| | - Hermann Reichenspurner
- Cardiovascular Surgery, University Hospital Hamburg Eppendorf University Heart Centre, Hamburg, Germany
| | - E Girdauskas
- Cardiovascular Surgery, University Hospital Hamburg Eppendorf University Heart Centre, Hamburg, Germany
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Xu B, Daimon M, Kawata T, Nakao T, Hirokawa M, Sawada N, Kimura K, Yamanaka Y, Morita H, Komuro I, Yatomi Y. Relationship Between Mitral Leaflet Size and Coaptation and Their Associated Factors in Patients with Normal Left Ventricular Size and Systolic Function. Int Heart J 2021; 62:95-103. [PMID: 33455980 DOI: 10.1536/ihj.20-148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Enlargement of the mitral valve (MV) has gained attention as a compensatory mechanism for functional mitral regurgitation (FMR). We aimed to determine if MV leaflet area is associated with MV coaptation-zone area and identify the clinical factors associated with MV leaflet size and coaptation-zone area in patients with normal left ventricle (LV) systolic function and size using real-time 3D echocardiography (RT3DE).We performed RT3DE in 135 patients with normal LV size and ejection fraction. MV leaflet and coaptation-zone areas were measured using custom 3D software. The clinical factors associated with MV leaflet and coaptation-zone areas were evaluated using univariate and multivariate linear regression analyses.There was a significant relationship between MV leaflet and coaptation-zone areas (r = 0.499, P < 0.001). MV leaflet area was strongly associated with body surface area (BSA) (r = 0.905, P < 0.001) rather than LV size and age. MV leaflet area/BSA was independently associated with male gender (P = 0.002), lower diastolic blood pressure (P = 0.042), and LV end-diastolic volume (LVEDV) index (P = 0.048); MV coaptation-zone area/BSA was independently associated with lower LVEDV index (P = 0.01).In patients with normal LV systolic function and size, MV leaflet size has a significant impact on competent MV coaptation. MV leaflet area might be intrinsically determined by body size rather than age and LV size, and the MV leaflet area/BSA is relatively constant. On the other hand, some clinical factors might also influence MV leaflet and coaptation-zone area.
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Affiliation(s)
- Boqing Xu
- Department of Clinical Laboratory, The University of Tokyo Hospital
| | - Masao Daimon
- Department of Clinical Laboratory, The University of Tokyo Hospital.,Department of Cardiovascular Medicine, The University of Tokyo Hospital
| | - Takayuki Kawata
- Department of Cardiovascular Medicine, The University of Tokyo Hospital
| | - Tomoko Nakao
- Department of Clinical Laboratory, The University of Tokyo Hospital
| | - Megumi Hirokawa
- Department of Cardiovascular Medicine, The University of Tokyo Hospital
| | - Naoko Sawada
- Department of Cardiovascular Medicine, The University of Tokyo Hospital
| | - Koichi Kimura
- Department of Cardiovascular Medicine, The University of Tokyo Hospital
| | - Yuko Yamanaka
- Department of Cardiovascular Medicine, Jichi Medical University
| | - Hiroyuki Morita
- Department of Cardiovascular Medicine, The University of Tokyo Hospital
| | - Issei Komuro
- Department of Cardiovascular Medicine, The University of Tokyo Hospital
| | - Yutaka Yatomi
- Department of Clinical Laboratory, The University of Tokyo Hospital
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Abe Y, Takahashi Y, Shibata T. A new disease entity: Atrial functional mitral regurgitation. J Cardiol 2020; 77:565-569. [PMID: 33349550 DOI: 10.1016/j.jjcc.2020.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 11/25/2020] [Indexed: 11/18/2022]
Abstract
Functional mitral regurgitation (MR) has been traditionally known as secondary MR resulting from left ventricular (LV) dilatation and systolic dysfunction. However, deterioration of functional MR also relates to mitral annular (MA) dilatation. Furthermore, MA dilatation due to left atrial dilatation in patients with atrial fibrillation (AF) can also cause functional MR, even in the absence of LV systolic dysfunction, in a condition referred to as "atrial functional MR" (AFMR). AFMR also has other etiological factors, including disruption of the MA saddle shape, reduction in MA contractility, inadequate compensation for the MA dilatation resulting from the lack of leaflet remodeling, and hamstringing of the posterior mitral leaflet by atriogenic tethering. AFMR has recently received much attention as an important cause of heart failure, and it represents a considerable therapeutic target in heart failure patients with AF. The traditional functional MR occurring in patients with LV dilatation and systolic dysfunction has since been designated "ventricular functional MR" (VFMR) to distinguish it from AFMR. This review article compares the current perceptions of newly recognized AFMR with those of traditional VFMR.
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Affiliation(s)
- Yukio Abe
- Department of Cardiology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka 534-0021, Japan.
| | - Yosuke Takahashi
- Department of Cardiovascular Surgery, Osaka City University, Osaka, Japan
| | - Toshihiko Shibata
- Department of Cardiovascular Surgery, Osaka City University, Osaka, Japan
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Dziadzko V, Dziadzko M, Medina-Inojosa JR, Benfari G, Michelena HI, Crestanello JA, Maalouf J, Thapa P, Enriquez-Sarano M. Causes and mechanisms of isolated mitral regurgitation in the community: clinical context and outcome. Eur Heart J 2020; 40:2194-2202. [PMID: 31121021 DOI: 10.1093/eurheartj/ehz314] [Citation(s) in RCA: 138] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 02/15/2019] [Accepted: 05/06/2019] [Indexed: 11/13/2022] Open
Abstract
AIMS To define the hitherto unknown aetiology/mechanism distributions of mitral regurgitation (MR) in the community and the linked clinical characteristics/outcomes. METHODS AND RESULTS We identified all isolated, moderate/severe MR diagnosed in our community (Olmsted County, MN, USA) between 2000 and 2010 and classified MR aetiology/mechanisms. Eligible patients (n = 727) were 73 ± 18 years, 51% females, with ejection fraction (EF) 49 ± 17%. MR was functional (FMR) in 65%, organic (OMR) in 32% and 2% mixed. Functional MR was linked to left ventricular remodelling (FMR-v) 38% and isolated atrial dilatation (FMR-a) 27%. At diagnosis FMR-v vs. FMR-a, vs. OMR displayed profound differences (all P < 0.0001) in age (73 ± 14, 80 ± 10, 68 ± 21years), male-sex (59, 33, 51%), atrial-fibrillation (28, 54, 13%), EF (33 ± 14, 57 ± 11, 61 ± 10%), and regurgitant-volume (38 ± 13, 37 ± 11, 51 ± 24 mL/beat). Dominant MR mechanism was Type I (normal valve-movement) 38%, Type II (excessive valve-movement) 25%, Type IIIa (diastolic movement-restriction) 3%, and Type IIIb (systolic movement-restriction) 34%. Outcomes were mediocre with excess-mortality vs. general-population in FMR-v [risk ratio 3.45 (2.98-3.99), P < 0.0001] but also FMR-a [risk ratio 1.88 (1.52-2.25), P < 0.0001] and OMR [risk ratio 1.83 (1.50-2.22), P < 0.0001]. Heart failure was frequent, particularly in FMR-v (5-year 83 ± 3% vs. 59 ± 4% FMR-a, 40 ± 3% OMR, P < 0.0001). Mitral surgery during patients' lifetime was performed in 4% of FMR-v, 3% of FMR-a, and 37% of OMR. CONCLUSION Moderate/severe isolated MR in the community displays considerable aetiology/mechanism heterogeneity. Functional MR dominates, mostly FMR-v but FMR-a is frequent and degenerative MR dominates OMR. Outcomes are mediocre with excess-mortality particularly with FMR-v but FMR-a, despite normal EF incurs notable excess-mortality and frequent heart failure. Pervasive undertreatment warrants clinical trials of therapies tailored to specific MR cause/mechanisms.
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Affiliation(s)
- Volha Dziadzko
- Division of Cardiovascular Diseases, Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First St SW, Rochester, MN, USA
| | - Mikhail Dziadzko
- Division of Cardiovascular Diseases, Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First St SW, Rochester, MN, USA
| | - Jose R Medina-Inojosa
- Division of Cardiovascular Diseases, Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First St SW, Rochester, MN, USA
| | - Giovanni Benfari
- Division of Cardiovascular Diseases, Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First St SW, Rochester, MN, USA
| | - Hector I Michelena
- Division of Cardiovascular Diseases, Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First St SW, Rochester, MN, USA
| | - Juan A Crestanello
- Division of Cardiovascular Diseases, Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First St SW, Rochester, MN, USA
| | - Joseph Maalouf
- Division of Cardiovascular Diseases, Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First St SW, Rochester, MN, USA
| | - Prabin Thapa
- Division of Cardiovascular Diseases, Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First St SW, Rochester, MN, USA
| | - Maurice Enriquez-Sarano
- Division of Cardiovascular Diseases, Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First St SW, Rochester, MN, USA
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Izumi C, Eishi K, Ashihara K, Arita T, Otsuji Y, Kunihara T, Komiya T, Shibata T, Seo Y, Daimon M, Takanashi S, Tanaka H, Nakatani S, Ninami H, Nishi H, Hayashida K, Yaku H, Yamaguchi J, Yamamoto K, Watanabe H, Abe Y, Amaki M, Amano M, Obase K, Tabata M, Miura T, Miyake M, Murata M, Watanabe N, Akasaka T, Okita Y, Kimura T, Sawa Y, Yoshida K. JCS/JSCS/JATS/JSVS 2020 Guidelines on the Management of Valvular Heart Disease. Circ J 2020; 84:2037-2119. [DOI: 10.1253/circj.cj-20-0135] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kiyoyuki Eishi
- Division of Cardiovascular Surgery, Nagasaki University Graduate School of Biomedical Sciences
| | - Kyomi Ashihara
- Department of Cardiology, Tokyo Women’s Medical University Hospital
| | - Takeshi Arita
- Division of Cardiovascular Medicine Heart & Neuro-Vascular Center, Fukuoka Wajiro
| | - Yutaka Otsuji
- Department of Cardiology, Hospital of University of Occupational and Environmental Health
| | - Takashi Kunihara
- Department of Cardiac Surgery, The Jikei University School of Medicine
| | - Tatsuhiko Komiya
- Department of Cardiovascular Surgery, Kurashiki Central Hospital
| | - Toshihiko Shibata
- Department of Cardiovascular Surgery, Osaka City University Postgraduate of Medicine
| | - Yoshihiro Seo
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences
| | - Masao Daimon
- Department of Clinical Laboratory/Cardiology, The University of Tokyo Hospital
| | | | | | - Satoshi Nakatani
- Division of Health Sciences, Osaka University Graduate School of Medicine
| | - Hiroshi Ninami
- Department of Cardiac Surgery, Tokyo Women’s Medical University
| | - Hiroyuki Nishi
- Department of Cardiovascular Surgery, Osaka General Medical Center
| | | | - Hitoshi Yaku
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine
| | | | - Kazuhiro Yamamoto
- Division of Cardiovascular Medicine, Endocrinology and Metabolism, Faculty of Medicine, Tottori University
| | | | - Yukio Abe
- Department of Cardiology, Osaka City General Hospital
| | - Makoto Amaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Masashi Amano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kikuko Obase
- Division of Cardiovascular Surgery, Nagasaki University Graduate School of Biomedical Sciences
| | - Minoru Tabata
- Department of Cardiovascular Surgery, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Takashi Miura
- Division of Cardiovascular Surgery, Nagasaki University Graduate School of Biomedical Sciences
| | | | - Mitsushige Murata
- Department of Laboratory Medicine, Tokai University Hachioji Hospital
| | - Nozomi Watanabe
- Department of Cardiology, Miyazaki Medical Association Hospital
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Yutaka Okita
- Department of Cardiovascular Surgery, Takatsuki Hospital
| | - Takeshi Kimura
- Department of Cardiology, Kyoto University Graduate School of Medicine
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Kiyoshi Yoshida
- Department of Cardiology, Sakakibara Heart Institute of Okayama
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von Stumm M, Dudde F, Gasser S, Sequeira-Gross T, Pausch J, Sinning C, Reichenspurner H, Girdauskas E. Prognostic value of mitral valve tenting area in patients with functional mitral regurgitation. Interact Cardiovasc Thorac Surg 2020; 30:431-438. [PMID: 31808513 DOI: 10.1093/icvts/ivz291] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 10/25/2019] [Accepted: 11/01/2019] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES Mitral valve (MV) repair in functional mitral regurgitation is still associated with suboptimal outcomes. Our goal was to determine whether the clinical outcome following MV repair correlates with preoperative tenting parameters. METHODS We retrospectively identified consecutive patients with functional mitral regurgitation who underwent an isolated MV annuloplasty during a 7-year period (2010-2016) from our institutional database. Preoperative tenting parameters (i.e. tenting height, coaptation length, tenting area, posterior mitral leaflet and anterior mitral leaflet angles and interpapillary muscle distance) were systematically measured. The primary end point was the composite of survival and freedom from adverse cardiac events. The follow-up protocol consisted of a structured clinical questionnaire and an analysis of the echocardiographic data. RESULTS A total of 240 patients (mean age 67.8 ± 9.8 years, 57% of men) were analysed. The overall 5-year survival rate for the whole study cohort was 74.7 ± 4.2%, and freedom from adverse cardiac events was 84.8 ± 3.4%. A tenting area ≥2.4 cm2 was identified as a cut-off value, independently predicting the composite primary study end point (hazard ratio 2.0; P = 0.03). Furthermore, a Kaplan-Meier analysis revealed a strong tendency towards worse 5-year outcomes in patients with a tenting area ≥2.4 cm2 (n = 153) versus patients with a tenting area <2.4 cm2 (n = 87) (65.3 ± 5.5% vs 77.1 ± 6.3%; P = 0.06). CONCLUSIONS MV annuloplasty is associated with acceptable clinical and echocardiographic outcomes in patients with functional mitral regurgitation 5 years postoperatively. A preoperative tenting area ≥2.4 cm2 showed a strong trend towards a worse 5-year survival rate and an increased risk of adverse cardiac events after an isolated MV annuloplasty.
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Affiliation(s)
- Maria von Stumm
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Florian Dudde
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Simone Gasser
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tatiana Sequeira-Gross
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jonas Pausch
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Sinning
- Department of Cardiology, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Evaldas Girdauskas
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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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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Marsit O, Clavel MA, Côté-Laroche C, Hadjadj S, Bouchard MA, Handschumacher MD, Clisson M, Drolet MC, Boulanger MC, Kim DH, Guerrero JL, Bartko PE, Couet J, Arsenault M, Mathieu P, Pibarot P, Aïkawa E, Bischoff J, Levine RA, Beaudoin J. Attenuated Mitral Leaflet Enlargement Contributes to Functional Mitral Regurgitation After Myocardial Infarction. J Am Coll Cardiol 2020; 75:395-405. [PMID: 32000951 DOI: 10.1016/j.jacc.2019.11.039] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 11/08/2019] [Accepted: 11/13/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Mitral leaflet enlargement has been identified as an adaptive mechanism to prevent mitral regurgitation in dilated left ventricles (LVs) caused by chronic aortic regurgitation (AR). This enlargement is deficient in patients with functional mitral regurgitation, which remains frequent in the population with ischemic cardiomyopathy. Maladaptive fibrotic changes have been identified in post-myocardial infarction (MI) mitral valves. It is unknown if these changes can interfere with valve growth and whether they are present in other valves. OBJECTIVES This study sought to test the hypothesis that MI impairs leaflet growth, seen in AR, and induces fibrotic changes in mitral and tricuspid valves. METHODS Sheep models of AR, AR + MI, and controls were followed for 90 days. Cardiac magnetic resonance, echocardiography, and computed tomography were performed at baseline and 90 days to assess LV volume, LV function, mitral regurgitation and mitral leaflet size. Histopathology and molecular analyses were performed in excised valves. RESULTS Both experimental groups developed similar LV dilatation and dysfunction. At 90 days, mitral valve leaflet size was smaller in the AR + MI group (12.8 ± 1.3 cm2 vs. 15.1 ± 1.6 cm2, p = 0.03). Mitral regurgitant fraction was 4% ± 7% in the AR group versus 19% ± 10% in the AR + MI group (p = 0.02). AR + MI leaflets were thicker compared with AR and control valves. Increased expression of extracellular matrix remodeling genes was found in both the mitral and tricuspid leaflets in the AR + MI group. CONCLUSIONS In these animal models of AR, the presence of MI was associated with impaired adaptive valve growth and more functional mitral regurgitation, despite similar LV size and function. More pronounced extracellular remodeling was observed in mitral and tricuspid leaflets, suggesting systemic valvular remodeling after MI.
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Affiliation(s)
- Ons Marsit
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec City, Quebec, Canada
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec City, Quebec, Canada
| | - Claudia Côté-Laroche
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec City, Quebec, Canada
| | - Sandra Hadjadj
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec City, Quebec, Canada
| | - Marc-André Bouchard
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec City, Quebec, Canada
| | - Mark D Handschumacher
- Center for Excellence in Vascular Biology, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marine Clisson
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec City, Quebec, Canada
| | - Marie-Claude Drolet
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec City, Quebec, Canada
| | - Marie-Chloé Boulanger
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec City, Quebec, Canada
| | - Dae-Hee Kim
- Division of Cardiology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
| | - J Luis Guerrero
- Cardiac Ultrasound Lab, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Philipp Emanuel Bartko
- Cardiac Ultrasound Lab, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jacques Couet
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec City, Quebec, Canada
| | - Marie Arsenault
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec City, Quebec, Canada
| | - Patrick Mathieu
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec City, Quebec, Canada
| | - Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec City, Quebec, Canada
| | - Elena Aïkawa
- Cardiac Ultrasound Lab, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joyce Bischoff
- Vascular Biology Program and Department of Surgery, Boston Children's Hospital and Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Robert A Levine
- Cardiac Ultrasound Lab, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jonathan Beaudoin
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec City, Quebec, Canada.
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Nagata Y, Iwataki M, Nabeshima Y, Hei S, Onoue T, Hayashi A, Otani K, Tsuda Y, Araki M, Kim DH, Song JK, Hayashida A, Toki M, Yuasa T, Mizukami N, Nishimura Y, Levine RA, Otsuji Y. Potential mechanism of left ventricular spherical remodeling: association of mitral valve complex-myocardium longitudinal tissue remodeling mismatch. Am J Physiol Heart Circ Physiol 2020; 319:H694-H704. [PMID: 32795182 DOI: 10.1152/ajpheart.00279.2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Since mitral valve (MV) complex (MVC) longitudinally bridges left ventricular (LV) base end and its middle, insufficient MVC longitudinal tissue length (TL) elongation relative to whole LV myocardial longitudinal TL elongation could limit LV-base-longitudinal-TL elongation, leading to predominant LV-base-transverse-TL elongation, constituting LV spherical remodeling. In 30 patients with dilated cardiomyopathy (DCM), 30 with aortic regurgitation (AR), and 30 controls, LV sphericity, LV-apex- or base-transverse- and longitudinal-TL, MVC-longitudinal-TL, and whole-LV-longitudinal-TL were measured by three-dimensional (3D) echocardiography. Ratio of each measure versus mean normal value (i.e., LV-apex-transverse-TL ratio) was considered to express the directional and regional tissue elongation. [LV-base-longitudinal-TL ratio/global-LV-TL ratio] and [MVC-longitudinal-TL ratio/whole-LV-longitudinal-TL ratio] were obtained as the degree of LV-base-longitudinal-TL or MVC-longitudinal-TL elongation relative to the whole LV elongation. LV-apex-transverse-, LV-apex-longitudinal-, and LV-base-transverse-TL ratios were significantly increased (1.27 to 1.42, P < 0.01) in both DCM and AR, while the LV-base-longitudinal-TL ratio was not increased in DCM [1.04 ± 0.19, not significant (ns)] and only modestly increased in AR (1.12 ± 0.21, P < 0.01). Whole-LV-longitudinal-TL ratio was significantly increased in both DCM and AR (1.22 ± 0.18 and 1.20 ± 0.16, P < 0.01), while MVC-longitudinal-TL ratio was not or only modestly increased in both groups (1.07 ± 0.15, ns, and 1.12 ± 0.17, P = 0.02, respectively). Multivariable analysis revealed that LV sphericity was independently related to a reduced [LV-base-longitudinal-TL ratio/global-LV-TL ratio] (standard β = -0.42, P < 0.01), which was further related to a reduced [MVC-longitudinal-TL ratio/whole-LV-longitudinal-TL ratio] (standard β = 0.72, P < 0.01). These are consistent with the hypothesis that relatively less MVC-longitudinal-TL elongation in the process of primary LV myocardial tissue elongation may limit LV-base-longitudinal-TL elongation, contributing to LV spherical remodeling.NEW & NOTEWORTHY Left ventricular (LV) spherical remodeling is associated with poor prognosis and less-effective cardiac performance, which commonly develops in dilated cardiomyopathy. However, its mechanism remains unclear. We hypothesized and subsequently clarified that less mitral valve complex (MVC) tissue longitudinal elongation relative to whole LV myocardial tissue longitudinal elongation is related to disproportionately less LV base longitudinal versus transverse myocardial tissue elongation, constituting spherical remodeling. This study suggests modification of MVC tissue elongation could be potential therapeutic targets.
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Affiliation(s)
- Yasufumi Nagata
- Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan.,Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mai Iwataki
- Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan
| | - Yosuke Nabeshima
- Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan
| | - Soshi Hei
- Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan
| | - Takeshi Onoue
- Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan
| | - Atsushi Hayashi
- Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan
| | - Kyoko Otani
- Department of Laboratory and Transfusion Medicine, University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan
| | - Yuki Tsuda
- Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan
| | - Masaru Araki
- Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan
| | - Dae-Hee Kim
- Department of Echocardiography, Asan Medical Center, Seoul, Korea
| | - Jae-Kwan Song
- Department of Echocardiography, Asan Medical Center, Seoul, Korea
| | - Akihiro Hayashida
- Department of Cardiology, the Sakakibara Heart Institution of Okayama, Okayama, Japan
| | - Misako Toki
- Department of Clinical Laboratory, the Sakakibara Heart Institution of Okayama, Okayama, Japan
| | - Toshinori Yuasa
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medicine and Dental Science, Kagoshima University, Kagoshima, Japan
| | - Naoko Mizukami
- Department of Clinical Laboratory, Graduate School of Medicine and Dental Science, Kagoshima University, Kagoshima, Japan
| | - Yosuke Nishimura
- Department of Cardiovascular Surgery, University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan
| | - Robert A Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Yutaka Otsuji
- Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan
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Mihaila Baldea S, Muraru D, Miglioranza MH, Iliceto S, Vinereanu D, Badano LP. Relation of Mitral Annulus and Left Atrial Dysfunction to the Severity of Functional Mitral Regurgitation in Patients with Dilated Cardiomyopathy. Cardiol Res Pract 2020; 2020:3261714. [PMID: 32695502 PMCID: PMC7368231 DOI: 10.1155/2020/3261714] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 05/13/2020] [Indexed: 11/17/2022] Open
Abstract
METHODS 56 patients (58 ± 17 years, 42 men) with DCM and FMR and 52 controls, prospectively enrolled, underwent 3DTTE dedicated for mitral valve (MV), LA, and left ventricle (LV) quantitative analysis. RESULTS Patients with FMR vs. controls presented increased MA size and sphericity during the entire systole, whereas MA fractional area change (MAFAC) and MA displacement were decreased (15 ± 5 vs. 28 ± 5%; and 5 ± 3 vs. 10 ± 2 mm, p < 0.001). In patients with moderate/severe FMR, MA diameters correlated with PISA radius, EROA, and regurgitant volume (Rvol), as also did the MA area (with PISA radius, EROA, and Rvol: r = 0.48, r = 0.58, and r = 0.47, p < 0.05). MAFAC correlated inversely with EROA and Rvol (r = -0.32 and r = -0.35, p < 0.05), with both active and total LA emptying fractions and with LV ejection fraction as well. In a stepwise multivariate regression model, decreased MAFAC and increased LA volume independently predicted patients with severe FMR. CONCLUSIONS Patients with DCM and FMR have MA geometry remodeling and contractile dysfunction, correlated with the severity of FMR. MA contractile dysfunction correlated with both LA and left LV pumps dysfunctions and predicted patients with severe FMR. Our results provide new insights that might help with better selection of patients for MV transcatheter procedures.
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Affiliation(s)
| | - Denisa Muraru
- Istituto Auxologico Italiano IRCCS, Department of Cardiovascular Neural and Metabolic Sciences, San Luca Hospital, Milan, Italy
- University of Milano-Bicocca, Department of Medicine and Surgery, Milan, Italy
| | | | | | - Dragos Vinereanu
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
| | - Luigi Paolo Badano
- Istituto Auxologico Italiano IRCCS, Department of Cardiovascular Neural and Metabolic Sciences, San Luca Hospital, Milan, Italy
- University of Milano-Bicocca, Department of Medicine and Surgery, Milan, Italy
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Fan Y, Wan S, Wong RHL, Lee APW. Atrial functional mitral regurgitation: mechanisms and surgical implications. Asian Cardiovasc Thorac Ann 2020; 28:421-426. [DOI: 10.1177/0218492320941388] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The term atrial functional mitral regurgitation refers to a newly recognized disease entity in which mitral regurgitation occurs secondary to left atrial disease, without left ventricular dilatation and intrinsic mitral valve disease, typically in the setting of long-standing atrial fibrillation. Recent evidence suggests that atrial functional mitral regurgitation is associated with increased risk of death and heart failure re-hospitalization. The etiology, pathophysiology, and mechanism of atrial functional mitral regurgitation is not completely understood but they should not be regarded as the same as for the conventional type of functional mitral regurgitation secondary to left ventricular dilatation and dysfunction. Mitral annular dilatation, atriogenic leaflet distortion, insufficient leaflet remodeling, and subtle left ventricular dysfunction may play a role in the pathogenesis of atrial functional mitral regurgitation. The therapeutic and surgical considerations of atrial functional mitral regurgitation are different from those of ventricular functional mitral regurgitation. In this review, we assess current evidence regarding this new disease entity and propose a new surgical approach based on up-to-date understanding and experience of this condition.
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Affiliation(s)
- Yiting Fan
- Division of Cardiology, Department of Medicine and Therapeutics, Laboratory of Cardiac Imaging and 3D Printing, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong
| | - Song Wan
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Hong Kong
| | - Randolph Hung-Leung Wong
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Hong Kong
| | - Alex Pui-Wai Lee
- Division of Cardiology, Department of Medicine and Therapeutics, Laboratory of Cardiac Imaging and 3D Printing, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong
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Mėlinytė K, Mizarienė V, Jurkevičius R. Long-term ischemic mitral regurgitation: which parameters predict decrease or increase in the degree after five years? Minerva Cardioangiol 2020; 68:237-245. [DOI: 10.23736/s0026-4725.20.05021-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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49
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Gyoten T, Schenk S, Rochor K, Herwig V, Harnath A, Grimmig O, Just S, Fritzsche D, Messroghli D. Outcome comparison of mitral valve surgery and MitraClip therapy in patients with severely reduced left ventricular dysfunction. ESC Heart Fail 2020; 7:1781-1790. [PMID: 32445540 PMCID: PMC7373891 DOI: 10.1002/ehf2.12741] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 04/15/2020] [Accepted: 04/27/2020] [Indexed: 11/11/2022] Open
Abstract
Aims The aim of this study was to compare the outcomes of surgical mitral valve repair or replacement (sMVR) and percutaneous edge‐to‐edge repair using MitraClip (pMVR) in patients with severe left ventricular dysfunction affected by functional mitral regurgitation (FMR). Methods and results We retrospectively identified 132 patients with left ventricular ejection fraction (LVEF) ≦ 30% submitted to sMVR (n = 47) or pMVR (n = 85) for FMR at our centre from January 2013 to December 2017. To adjust for baseline imbalances, we used a propensity score matching by age, logistic EuroSCORE, and left ventricular end‐systolic volume. After being matched, MitraClip therapy showed lower perioperative mortality and rate of complications yet increased residual mitral regurgitation (MR) grade than did surgery (0.2 ± 0.50 in sMVR vs. 1.3 ± 0.88 in pMVR, P < 0.0001). According to stratified multivariate Cox model analysis, residual MR severity was an independent risk factor for cardiac death [hazard ratio (HR), 2.81; 95% confidence interval [CI], 1.44–5.48, P = 0.0025] and re‐hospitalization for heart failure (HR, 3.07; 95% CI, 1.50–6.29, P = 0.0022) at 1 year follow‐up. Stratified multivariable Cox regression analysis at 3 years identified pMVR as risk factor for cardiac death (HR, 0.19; 95% CI, 0.040–0.86, P = 0.031) and re‐hospitalization for heart failure (HR, 0.28; 95% CI, 0.077–0.99, P = 0.048). Conclusions In patients with FMR and LVEF ≤ 30%, MitraClip therapy resulted in lower perioperative complications and mortality than sMVR. However, surgically treated patients who survived the perioperative stage had less residual MR and experienced lower rates of re‐hospitalization for heart failure at 1 year and lower cardiac mortality at 1 and 3 years of follow‐up than did patients undergoing pMVR.
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Affiliation(s)
- Takayuki Gyoten
- Department of Cardiovascular Surgery, Sana-Herzzentrum Cottbus, Leipziger Strasse 50, 03048, Cottbus, Germany
| | - Sören Schenk
- Department of Cardiovascular Surgery, Sana-Herzzentrum Cottbus, Leipziger Strasse 50, 03048, Cottbus, Germany
| | - Kristin Rochor
- Department of Cardiology, Sana-Herzzentrum Cottbus, Leipziger Strasse 50, 03048, Cottbus, Germany
| | - Volker Herwig
- Department of Cardiology, Sana-Herzzentrum Cottbus, Leipziger Strasse 50, 03048, Cottbus, Germany
| | - Axel Harnath
- Department of Cardiology, Sana-Herzzentrum Cottbus, Leipziger Strasse 50, 03048, Cottbus, Germany
| | - Oliver Grimmig
- Department of Cardiovascular Surgery, Sana-Herzzentrum Cottbus, Leipziger Strasse 50, 03048, Cottbus, Germany
| | - Sören Just
- Department of Cardiovascular Surgery, Sana-Herzzentrum Cottbus, Leipziger Strasse 50, 03048, Cottbus, Germany
| | - Dirk Fritzsche
- Department of Cardiovascular Surgery, Sana-Herzzentrum Cottbus, Leipziger Strasse 50, 03048, Cottbus, Germany
| | - Daniel Messroghli
- Department of Internal Medicine-Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany.,Department of Internal Medicine and Cardiology, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), partner site, Berlin, Germany
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50
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Dominici C, Salsano A, Nenna A, Spadaccio C, Barbato R, Mariscalco G, Santini F, Bashir M, El-Dean Z, Chello M. Higher preoperative left atrial volume index predicts lack of mitral regurgitation improvement after transcatheter aortic valve replacement. J Cardiovasc Med (Hagerstown) 2020; 21:383-390. [PMID: 32243341 DOI: 10.2459/jcm.0000000000000968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Moderate-to-severe mitral regurgitation is present in 20-35% of patients undergoing transcatheter aortic valve replacement (TAVR) and the current literature lacks simple echocardiographic parameters, which can predict post-TAVR changes in mitral regurgitation. The aim of this study is to investigate the echocardiographic predictors of improvement or worsening of mitral regurgitation in patients undergoing TAVR with moderate-to-severe mitral regurgitation. METHODS This retrospective study included 113 patients who underwent TAVR with preoperative mitral regurgitation grade at least 2. Patients with concomitant coronary artery disease requiring treatment were excluded. Mitral regurgitation was related to the annular dilatation or tethering mechanism in all patients. Preoperative and postoperative echocardiographies were compared in terms of mitral regurgitation and other commonly measured parameters. RESULTS After TAVR, a reduction in mitral regurgitation was observed in 62.8% of cases. On the basis of the difference between postoperative and preoperative echocardiograms, 71 patients had improved mitral regurgitation, whereas 42 patients had stable or worsened mitral regurgitation. After analyzing preoperative echocardiographic parameters with regard to this group difference, left atrial volume index (LAVI) was the only variable that was different between groups (33.4 ± 4.8 ml/m in improved mitral regurgitation vs. 39.8 ± 3.0 ml/m in not improved mitral regurgitation, P < 0.001). In a multivariable logistic regression model, a LAVI increase was associated with lack of an acute reduction in mitral regurgitation (odds ratio = 1.41, P < 0.001) after adjustment for age and preoperative serum creatinine. CONCLUSION Higher preoperative LAVI is a determinant predictor of lack of an acute reduction in mitral regurgitation after TAVR, and LAVI could be used as a stratifying tool to tailor the treatment strategy and the timing of the procedures. However, validation of these results and long-term outcomes are warranted to support those conclusions.
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Affiliation(s)
- Carmelo Dominici
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome
| | - Antonio Salsano
- Department of Cardiac Surgery, University of Genoa, Genoa, Italy
| | - Antonio Nenna
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome
| | | | - Raffaele Barbato
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome
| | - Giovanni Mariscalco
- Department of Cardiac Surgery, Glenfield Hospital, University Hospitals of Leicester, UK
| | | | - Mohamad Bashir
- Department of Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Zein El-Dean
- Department of Cardiac Surgery, Glenfield Hospital, University Hospitals of Leicester, UK
| | - Massimo Chello
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome
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