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Harm T, Schwarz FJ, Zdanyte M, Goldschmied A, Baas L, Aidery P, Shcherbyna S, Toskas I, Keller T, Kast I, Schreieck J, Geisler T, Gawaz MP, Mueller KAL. Novel 3-dimensional effective regurgitation orifice area quantification serves as a reliable tool to identify severe mitral valve regurgitation. Sci Rep 2024; 14:22067. [PMID: 39333219 PMCID: PMC11437129 DOI: 10.1038/s41598-024-73264-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 09/16/2024] [Indexed: 09/29/2024] Open
Abstract
A precise quantification of mitral regurgitation (MR) severity is essential for treatment and outcome of patients with MR. 3D echocardiography facilitates estimation of MR but selection of patients with necessity of invasive treatment remains challenging. We investigate effective regurgitation orifice area (EROA) quantification by 3D compared to 2D echocardiography in patients with MR and highlight the improved discrimination of MR severity. We consecutively enrolled fifty patients with primary or secondary and at least moderate MR undergoing 2D and 3D colour Doppler echocardiography prior to transcatheter edge-to-edge repair (TEER). Improved accuracy of MR grading using 3D vena contracta area (VCA) as an estimate of EROA was compared to 2D proximal isovelocity surface area (PISA) quantification method and a multiparameter reference standard. Quantification of EROA remarkably varies between 2D and 3D echocardiography and the discrimination between moderate and severe MR was significantly (p = 0.001) different using 2D PISA or 3D VCA, respectively. 3D VCA correlated significantly (r = 0.501, p < 0.001) better with the pre-defined MR severity. We detected crucial differences in the correct identification of severe MR between 2D and 3D techniques, thus 2D PISA significantly (p < 0.0001) underestimates EROA due to clinical and morphological parameters. The assessment of 3D VCA resulted in improved diagnostic accuracy.
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Affiliation(s)
- Tobias Harm
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Frederic-Joaquim Schwarz
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Monika Zdanyte
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Andreas Goldschmied
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Livia Baas
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Parwez Aidery
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Serhii Shcherbyna
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Ioannis Toskas
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Timea Keller
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Isabela Kast
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Juergen Schreieck
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Tobias Geisler
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Meinrad Paul Gawaz
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Karin Anne Lydia Mueller
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany.
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Badau Riebel CI, Agoston-Coldea L. Left Ventricular Fibrosis by Cardiac Magnetic Resonance Tissue Characterization in Chronic Mitral Regurgitation Patients. J Clin Med 2024; 13:3877. [PMID: 38999443 PMCID: PMC11242255 DOI: 10.3390/jcm13133877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 06/20/2024] [Accepted: 06/26/2024] [Indexed: 07/14/2024] Open
Abstract
Background: Left ventricular remodeling in chronic mitral regurgitation (MR) encompasses two types of myocardial fibrosis: replacement fibrosis, identified by late gadolinium enhancement (LGE), and diffuse interstitial fibrosis, assessed by pre- and postcontrast T1 mapping techniques. These may explain irreversible LV dysfunction after MR correction. We aimed to assess the presence of myocardial fibrosis in patients with moderate and severe MR with no criteria for surgery versus mild MR controls. Methods: We enrolled 137 patients with chronic primary MR and 130 controls; all underwent cardiac magnetic resonance, and were followed up in a median of 2.9 years to assess mortality and the need for mitral valve replacement. Results: Patients in the study group displayed significantly higher degrees of LGE (28.4% vs 7.69%, p < 0.05), higher native T1 values (1167 ± 58.5 versus 971 ± 51.4 (p < 0.05)), and higher extracellular volumes compared to controls (32.3% ± 3.5 versus 23.9 ± 2.2, (p < 0.05)). The composite outcome occurred in 28 patients in the study group (20.4%), and significantly higher with LGE+ (78.5%). Replacement fibrosis (HR = 1.83, 95% CI, p < 0.01) and interstitial fibrosis (HR = 1.61, 95% CI, p < 0.01) were independent predictors for the composite outcome. Conclusions: Patients with moderate and severe MR with no criteria for surgery still exhibit a significant degree of both replacement and interstitial fibrosis, with prognostic implications.
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Affiliation(s)
| | - Lucia Agoston-Coldea
- Department of Cardiology, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400347 Cluj Napoca, Romania;
- Department of Internal Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400347 Cluj Napoca, Romania
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Verbeke J, Kamoen V, De Buyzere M, Claessens T, Timmermans F. The Pixel Variation Score: An Echocardiographic Index to Assess Temporal Variation of Mitral Regurgitant Flow. J Am Soc Echocardiogr 2024; 37:316-324. [PMID: 37913997 DOI: 10.1016/j.echo.2023.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 10/16/2023] [Accepted: 10/21/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND In mitral regurgitation (MR), temporal variation of MR flow has been considered an important reason for inaccurate MR grading. Current echocardiographic methods for assessing temporal MR flow variation are complex, and their clinical relevance has not been investigated. In this study, we investigated whether assessing MR flow variation using a dimensionless index with echocardiography is feasible, clinically meaningful, and related to patient outcomes. METHODS Consecutive patients with mitral valve prolapse (MVP, n = 244) and functional MR (FMR, n = 396) underwent comprehensive echocardiography. Mitral regurgitation severity was assessed using an integrated approach advocated by current guidelines. The MR continuous-wave Doppler envelope was divided into 3 segments of equal duration. Each segment's pixel intensity was assessed to calculate the pixel variation score (PVS). RESULTS The PVS was lower in FMR patients than in MVP patients. Lower PVS was associated with worse MR, larger left atrial and left ventricular dimensions, lower ejection fraction, and higher pulmonary artery pressures. In MVP, PVS was significantly associated with postoperative left ventricular reverse remodeling and was able to reclassify most patients in whom single-frame measures overestimated MR severity. Finally, PVS had incremental prognostic value on top of clinical and echocardiographic predictors of outcome. CONCLUSIONS Temporal variation in MR flow can reliably be assessed with echocardiography through analysis of the continuous-wave Doppler signal. A high PVS value may alert the echocardiographer to defer from single-frame MR grading and also suggests that the MR is probably not severe.
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Affiliation(s)
- Jonas Verbeke
- Department of Cardiology, University Hospital Ghent, Ghent University, Ghent, Belgium.
| | - Victor Kamoen
- Department of Cardiology, University Hospital Ghent, Ghent University, Ghent, Belgium
| | - Marc De Buyzere
- Department of Cardiology, University Hospital Ghent, Ghent University, Ghent, Belgium
| | - Tom Claessens
- Department of Materials, Textiles and Chemical Engineering, Ghent University, Ghent, Belgium
| | - Frank Timmermans
- Department of Cardiology, University Hospital Ghent, Ghent University, Ghent, Belgium
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Zoghbi WA, Jone PN, Chamsi-Pasha MA, Chen T, Collins KA, Desai MY, Grayburn P, Groves DW, Hahn RT, Little SH, Kruse E, Sanborn D, Shah SB, Sugeng L, Swaminathan M, Thaden J, Thavendiranathan P, Tsang W, Weir-McCall JR, Gill E. Guidelines for the Evaluation of Prosthetic Valve Function With Cardiovascular Imaging: A Report From the American Society of Echocardiography Developed in Collaboration With the Society for Cardiovascular Magnetic Resonance and the Society of Cardiovascular Computed Tomography. J Am Soc Echocardiogr 2024; 37:2-63. [PMID: 38182282 DOI: 10.1016/j.echo.2023.10.004] [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] [Indexed: 01/07/2024]
Abstract
In patients with significant cardiac valvular disease, intervention with either valve repair or valve replacement may be inevitable. Although valve repair is frequently performed, especially for mitral and tricuspid regurgitation, valve replacement remains common, particularly in adults. Diagnostic methods are often needed to assess the function of the prosthesis. Echocardiography is the first-line method for noninvasive evaluation of prosthetic valve function. The transthoracic approach is complemented with two-dimensional and three-dimensional transesophageal echocardiography for further refinement of valve morphology and function when needed. More recently, advances in computed tomography and cardiac magnetic resonance have enhanced their roles in evaluating valvular heart disease. This document offers a review of the echocardiographic techniques used and provides recommendations and general guidelines for evaluation of prosthetic valve function on the basis of the scientific literature and consensus of a panel of experts. This guideline discusses the role of advanced imaging with transesophageal echocardiography, cardiac computed tomography, and cardiac magnetic resonance in evaluating prosthetic valve structure, function, and regurgitation. It replaces the 2009 American Society of Echocardiography guideline on prosthetic valves and complements the 2019 guideline on the evaluation of valvular regurgitation after percutaneous valve repair or replacement.
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Affiliation(s)
- William A Zoghbi
- Houston Methodist Hospital, DeBakey Heart & Vascular Center, Houston, Texas.
| | - Pei-Ni Jone
- Lurie Children's Hospital, Northwestern University, Chicago, Illinois
| | | | - Tiffany Chen
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Milind Y Desai
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Paul Grayburn
- Baylor Scott & White Health, University of Texas Southwestern, Dallas, Texas
| | - Daniel W Groves
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Rebecca T Hahn
- Columbia University Irving Medical Center, New York, New York
| | - Stephen H Little
- Houston Methodist Hospital, DeBakey Heart & Vascular Center, Houston, Texas
| | - Eric Kruse
- University of Chicago Medical Center, Chicago, Illinois
| | | | - Sangeeta B Shah
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia
| | - Lissa Sugeng
- North Shore University Hospital, Manhasset, New York
| | - Madhav Swaminathan
- Cardiothoracic Anesthesiology and Critical Care Medicine, Duke University, Durham, North Carolina
| | | | | | - Wendy Tsang
- University of Toronto, Toronto, Ontario, Canada
| | | | - Edward Gill
- University of Colorado School of Medicine, Aurora, Colorado
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Ambrožič J, Rauber M, Berlot B, Škofic N, Toplišek J, Bervar M, Cvijić M. Challenges and pitfalls in classification of disproportionate mitral regurgitation. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2023:10.1007/s10554-023-03043-1. [PMID: 38159132 DOI: 10.1007/s10554-023-03043-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 12/25/2023] [Indexed: 01/03/2024]
Abstract
The concept of disproportionate mitral regurgitation (dispropMR) has been introduced to identify patients with functional mitral regurgitation (MR) who benefit from percutaneous treatment. We aimed to examine echocardiographic characteristics behind this entity. We retrospectively included 172 consecutive patients with reduced left ventricular ejection fraction (LVEF), and more than mild MR referred to clinically indicated echocardiography. According to the proportionality ratio (effective regurgitant orifice area (EROA)/left ventricular end-diastolic volume (LVEDV)) patients were divided into dispropMR and proportionate MR (propMR) group. Potential factors which might affect proportionality definition were analyzed. 55 patients (32%) had dispropMR. Discrepant grading of MR severity was observed when using regurgitant volume (RegVol) by proximal isovelocity surface area (PISA) method or volumetric method, with significant discordance only in dispropMR (p < 0.001). Patients with dispropMR had more frequently left ventricular foreshortened images for LVEDV calculation than patients with propMR (p = 0.003), resulting in smaller LVEDV in dispropMR group. DispropMR group had more substantial dynamic variation of regurgitant flow compared to propMR. Accordingly, EROA was consistently overestimated by standard single-point PISA method compared to serial PISA method. This was more pronounced in dispropMR (bias:10.5 ± 28.3 mm2) compared to propMR group (bias:6.4 ± 12.8 mm2). DispropMR may be found in roughly one third of clinically indicated echocardiographic studies in patients with reduced LVEF and more than mild MR. EROA overestimation due to dynamic variation of regurgitant flow and LVEDV underestimation due to LV foreshortening were more frequently found in dispropMR. Our results indicate that methodological limitations of echocardiographic MR grading could not be neglected in classifying the proportionality of MR.
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Affiliation(s)
- Jana Ambrožič
- Department of Cardiology, University Medical Centre Ljubljana, Zaloska 7, Ljubljana, 1000, Slovenia
| | - Martin Rauber
- Department of Cardiology, University Medical Centre Ljubljana, Zaloska 7, Ljubljana, 1000, Slovenia
| | - Boštjan Berlot
- Department of Cardiology, University Medical Centre Ljubljana, Zaloska 7, Ljubljana, 1000, Slovenia
| | - Nataša Škofic
- Department of Surgery, University Medical Centre Ljubljana, Zaloska 7, Ljubljana, 1000, Slovenia
| | - Janez Toplišek
- Department of Cardiology, University Medical Centre Ljubljana, Zaloska 7, Ljubljana, 1000, Slovenia
| | - Mojca Bervar
- Department of Cardiology, University Medical Centre Ljubljana, Zaloska 7, Ljubljana, 1000, Slovenia
| | - Marta Cvijić
- Department of Cardiology, University Medical Centre Ljubljana, Zaloska 7, Ljubljana, 1000, Slovenia.
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, Ljubljana, 1000, Slovenia.
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Altes A, Vermes E, Levy F, Vancraeynest D, Pasquet A, Vincentelli A, Gerber BL, Tribouilloy C, Maréchaux S. Quantification of primary mitral regurgitation by echocardiography: A practical appraisal. Front Cardiovasc Med 2023; 10:1107724. [PMID: 36970355 PMCID: PMC10036770 DOI: 10.3389/fcvm.2023.1107724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 02/20/2023] [Indexed: 03/12/2023] Open
Abstract
The accurate quantification of primary mitral regurgitation (MR) and its consequences on cardiac remodeling is of paramount importance to determine the best timing for surgery in these patients. The recommended echocardiographic grading of primary MR severity relies on an integrated multiparametric approach. It is expected that the large number of echocardiographic parameters collected would offer the possibility to check the measured values regarding their congruence in order to conclude reliably on MR severity. However, the use of multiple parameters to grade MR can result in potential discrepancies between one or more of them. Importantly, many factors beyond MR severity impact the values obtained for these parameters including technical settings, anatomic and hemodynamic considerations, patient's characteristics and echocardiographer' skills. Hence, clinicians involved in valvular diseases should be well aware of the respective strengths and pitfalls of each of MR grading methods by echocardiography. Recent literature highlighted the need for a reappraisal of the severity of primary MR from a hemodynamic perspective. The estimation of MR regurgitation fraction by indirect quantitative methods, whenever possible, should be central when grading the severity of these patients. The assessment of the MR effective regurgitant orifice area by the proximal flow convergence method should be used in a semi-quantitative manner. Furthermore, it is crucial to acknowledge specific clinical situations in MR at risk of misevaluation when grading severity such as late-systolic MR, bi-leaflet prolapse with multiple jets or extensive leak, wall-constrained eccentric jet or in older patients with complex MR mechanism. Finally, it is debatable whether the 4-grades classification of MR severity would be still relevant nowadays, since the indication for mitral valve (MV) surgery is discussed in clinical practice for patients with 3+ and 4+ primary MR based on symptoms, specific markers of adverse outcome and MV repair probability. Primary MR grading should be seen as a continuum integrating both quantification of MR and its consequences, even for patients with presumed "moderate" MR.
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Affiliation(s)
- Alexandre Altes
- GCS-Groupement des Hôpitaux de l’Institut Catholique de Lille/Lille Catholic Hospitals, Heart Valve Center, Cardiology Department, ETHICS EA 7446, Lille Catholic University, Lille, France
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium
| | | | - Franck Levy
- Department of Cardiology, Center Cardio-Thoracique de Monaco, Monaco, Monaco
| | - David Vancraeynest
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium
| | - Agnès Pasquet
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium
| | - André Vincentelli
- Cardiac Surgery Department, Centre Hospitalier Régional et Universitaire de Lille, Lille, France
| | - Bernhard L. Gerber
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium
| | | | - Sylvestre Maréchaux
- GCS-Groupement des Hôpitaux de l’Institut Catholique de Lille/Lille Catholic Hospitals, Heart Valve Center, Cardiology Department, ETHICS EA 7446, Lille Catholic University, Lille, France
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Lozano-Edo S, Jover-Pastor P, Osa-Saez A, Buendia-Fuentes F, Rodriguez-Serrano M, Arnau-Vives MA, Rueda-Soriano J, Calvillo-Batlles P, Fonfria-Esparcia C, Martinez-Dolz L, Agüero J. Spatiotemporal Complexity of Vena Contracta and Mitral Regurgitation Grading Using Three-Dimensional Echocardiographic Analysis. J Am Soc Echocardiogr 2023; 36:77-86.e7. [PMID: 36208654 DOI: 10.1016/j.echo.2022.09.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 09/27/2022] [Accepted: 09/29/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Spatiotemporal complexity of the color Doppler vena contracta challenging the assumption of a circular and constant orifice may lead to mitral regurgitation (MR) grading inconsistencies. Using 3D transesophageal echocardiography, we characterized spatiotemporal vena contracta complexity and its impact on MR severity grading. METHODS In 192 patients with suspected moderate or severe MR (100 primary MR [PMR]; 92 secondary MR [SMR]), we performed three-dimensional vena contracta area (VCA) quantification using single-frame (midsystolic or VCAmid, maximum or VCAmax) and multiframe (VCAmean) methods, as well as measures of orifice shape (shape index) and systolic variation of VCA. Vena contracta complexity and intermethod discrepancies were analyzed and correlated with functional class and pulmonary vein flow (PVF) patterns and with cardiac magnetic resonance (CMR) in a subset of cases (n = 20). RESULTS The vena contracta was noncircular (shape index > 1.5) in 90% of patients. Severe noncircularity (shape index > 3) was more prevalent in SMR than in PMR (32.4% vs 14.6%). Variations of the VCA were more prominent in SMR than in PMR. VCAmid showed a low grading agreement with VCAmax (62%) and high grading agreement with VCAmean (83.3%). Pulmonary vein flow systolic reversal was associated with MR severity by VCA in SMR but not in PMR. VCAmid and VCAmean showed a stronger association with systolic flow reversal than VCAmax (area under the curve, 0.88, 0.86, and 0.79, respectively). In the subset of patients with CMR quantification, severe MR by VCAmax was graded as nonsevere by CMR more frequently compared with VCAmid and VCAmean. CONCLUSIONS Highly prevalent spatiotemporal vena contracta complexity features in MR challenge the assumption of a circular and constant orifice. VCAmid seems the best single-frame approximation to multiframe quantification, and VCAmax may lead to severity overestimation.
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Affiliation(s)
| | | | - Ana Osa-Saez
- Hospital Universitari i Politecnic La Fe, Valencia, Spain; Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Francisco Buendia-Fuentes
- Hospital Universitari i Politecnic La Fe, Valencia, Spain; Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Maria Rodriguez-Serrano
- Hospital Universitari i Politecnic La Fe, Valencia, Spain; Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Miguel Angel Arnau-Vives
- Hospital Universitari i Politecnic La Fe, Valencia, Spain; Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Joaquin Rueda-Soriano
- Hospital Universitari i Politecnic La Fe, Valencia, Spain; Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | | | | | - Luis Martinez-Dolz
- Hospital Universitari i Politecnic La Fe, Valencia, Spain; Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Jaume Agüero
- Hospital Universitari i Politecnic La Fe, Valencia, Spain; Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.
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8
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Zoghbi WA, Levine RA, Flachskampf F, Grayburn P, Gillam L, Leipsic J, Thomas JD, Kwong RY, Vandervoort P, Chandrashekhar Y. Atrial Functional Mitral Regurgitation: A JACC: Cardiovascular Imaging Expert Panel Viewpoint. JACC Cardiovasc Imaging 2022; 15:1870-1882. [PMID: 36357130 DOI: 10.1016/j.jcmg.2022.08.016] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 08/03/2022] [Accepted: 08/11/2022] [Indexed: 11/09/2022]
Abstract
Functional or secondary mitral regurgitation (MR) is associated with increased cardiovascular morbidity and mortality. Mechanistically, secondary MR is attributable to an imbalance between mitral leaflet tethering and closure forces, leading to poor coaptation. The pathophysiology of functional MR is most often the result of abnormalities in left ventricular function and remodeling, seen in ischemic or nonischemic conditions. Less commonly and more recently recognized is the scenario in which left ventricular geometry and function are preserved, the culprit being mitral annular enlargement associated with left atrial dilatation, termed atrial functional mitral regurgitation (AFMR). This most commonly occurs in the setting of chronic atrial fibrillation or heart failure with preserved ejection fraction. There is variability in the published reports and in current investigations as to the definition of AFMR. This paper reviews the pathophysiology of AFMR and focus on the need for a collective definition of AFMR to facilitate consistency in reported data and enhance much-needed research into outcomes and treatment strategies in AFMR.
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Affiliation(s)
| | | | | | | | - Linda Gillam
- Morristown Medical Center, Morristown, New Jersey, USA
| | - Jonathon Leipsic
- Providence Health Care, Vancouver Coastal Health, Vancouver, Canada
| | - James D Thomas
- Northwestern Medicine, Feinberg School of Medicine, Chicago, Illinois, USA
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Kochav JD, Kim J, Judd R, Tak KA, Janjua E, Maciejewski AJ, Kim HW, Klem I, Heitner J, Shah D, Zoghbi WA, Shenoy C, Farzaneh-Far A, Polsani V, Villar-Calle P, Parker M, Judd KM, Khalique OK, Leon MB, Devereux RB, Levine RA, Kim RJ, Weinsaft JW. Myocardial Contractile Mechanics in Ischemic Mitral Regurgitation: Multicenter Data Using Stress Perfusion Cardiovascular Magnetic Resonance. JACC Cardiovasc Imaging 2022; 15:1212-1226. [PMID: 35798397 PMCID: PMC9273017 DOI: 10.1016/j.jcmg.2022.03.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 02/24/2022] [Accepted: 03/04/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Left ventricular (LV) ischemia has been variably associated with functional mitral regurgitation (FMR). Determinants of FMR in patients with ischemia are poorly understood. OBJECTIVES This study sought to test whether contractile mechanics in ischemic myocardium underlying the mitral valve have an impact on likelihood of FMR. METHODS Vasodilator stress perfusion cardiac magnetic resonance was performed in patients with coronary artery disease (CAD) at multiple centers. FMR severity was confirmed quantitatively via core lab analysis. To test relationship of contractile mechanics with ischemic FMR, regional wall motion and strain were assessed in patients with inducible ischemia and minimal (≤5% LV myocardium, nontransmural) infarction. RESULTS A total of 2,647 patients with CAD were studied; 34% had FMR (7% moderate or greater). FMR severity increased with presence (P < 0.001) and extent (P = 0.01) of subpapillary ischemia: patients with moderate or greater FMR had more subpapillary ischemia (odds ratio [OR]: 1.13 per 10% LV; 95% CI: 1.05-1.21; P = 0.001) independent of ischemia in remote regions (P = NS); moderate or greater FMR prevalence increased stepwise with extent of ischemia and infarction in subpapillary myocardium (P < 0.001); stronger associations between FMR and infarction paralleled greater wall motion scores in infarct-affected territories. Among patients with inducible ischemia and minimal infarction (n = 532), wall motion and radial strain analysis showed impaired subpapillary contractile mechanics to associate with moderate or greater FMR (P < 0.05) independent of remote regions (P = NS). Conversely, subpapillary ischemia without contractile dysfunction did not augment FMR likelihood. Mitral and interpapillary dimensions increased with subpapillary radial strain impairment; each remodeling parameter associated with impaired subpapillary strain (P < 0.05) independent of remote strain (P = NS). Subpapillary radial strain (OR: 1.13 per 5% [95% CI: 1.02-1.25]; P = 0.02) and mitral tenting area (OR: 1.05 per 10 mm2 [95% CI: 1.00-1.10]; P = 0.04) were associated with moderate or greater FMR controlling for global remodeling represented by LV end-systolic volume (P = NS): when substituting sphericity for LV volume, moderate or greater FMR remained independently associated with subpapillary radial strain impairment (OR: 1.22 per 5% [95% CI: 1.02-1.47]; P = 0.03). CONCLUSIONS Among patients with CAD and ischemia, FMR severity and adverse mitral apparatus remodeling increase in proportion to contractile dysfunction underlying the mitral valve.
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Affiliation(s)
- Jonathan D Kochav
- Division of Cardiology, Weill Cornell Medicine, New York, New York, USA; Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA.
| | - Jiwon Kim
- Division of Cardiology, Weill Cornell Medicine, New York, New York, USA
| | - Robert Judd
- Duke Cardiovascular Magnetic Resonance Center, Duke University Medical Center, Durham, North Carolina, USA
| | - Katherine A Tak
- Division of Cardiology, Weill Cornell Medicine, New York, New York, USA
| | - Emmad Janjua
- Division of Cardiology, Weill Cornell Medicine, New York, New York, USA; Weill Cornell Medicine-Qatar, Doha, Qatar
| | | | - Han W Kim
- Duke Cardiovascular Magnetic Resonance Center, Duke University Medical Center, Durham, North Carolina, USA
| | - Igor Klem
- Duke Cardiovascular Magnetic Resonance Center, Duke University Medical Center, Durham, North Carolina, USA
| | - John Heitner
- Division of Cardiology, New York Presbyterian Brooklyn Methodist Hospital, New York, New York, USA
| | - Dipan Shah
- Division of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - William A Zoghbi
- Division of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Chetan Shenoy
- Division of Cardiology, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Afshin Farzaneh-Far
- Division of Cardiology, University of Illinois at Chicago, Chicago, Illinois, USA
| | | | | | - Michele Parker
- Duke Cardiovascular Magnetic Resonance Center, Duke University Medical Center, Durham, North Carolina, USA
| | - Kevin M Judd
- Heart Imaging Technologies, Durham, North Carolina, USA
| | - Omar K Khalique
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Martin B Leon
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | | | - Robert A Levine
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Raymond J Kim
- Duke Cardiovascular Magnetic Resonance Center, Duke University Medical Center, Durham, North Carolina, USA
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Singh A, Su J, This A, Allaire S, Rouet JM, Laghi A, Kebed K, Addetia K, Schreckenberg M, Lang RM, Bonnefous O. A Novel Approach for Semi Automated 3D Quantification of Mitral Regurgitant Volume Reflects a More Physiologic Approach to MR. J Am Soc Echocardiogr 2022; 35:940-946. [PMID: 35605896 DOI: 10.1016/j.echo.2022.05.005] [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: 11/30/2021] [Revised: 03/12/2022] [Accepted: 05/10/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Quantification of mitral regurgitation (MR) by echocardiography is an integral to assessing lesion severity, and entails integration of multiple Doppler-based parameters. These methods are primarily founded upon the principle of PISA (proximal isovelocity surface area), a 2D method known to employ several assumptions regarding MR jet characteristics. We analyzed the results of a semi-automated method of 3D-based RV estimation which accounts for jet behavior throughout the cardiac cycle, and compared it to conventional 2D PISA methods for MR. METHODS A total of 50 patients referred for transesophageal echocardiogram (TEE) for evaluation of primary (n= 25) and secondary MR (n=25) were included for analysis. 3D full volume color data sets were acquired, along with standard 2D methods for PISA calculation. 3D semi-automated MR flow quantification algorithm was applied offline to calculate 3D regurgitant volume (RVol), with simultaneous temporal curves generated from the 3D dataset. 3DRvol was compared to 2DRVol. 3D vena contracta area was also performed in all cases. RESULTS There was a modest correlation between 2DRVol and 3DRVol (r = 0.60). The semi-automated 3D approach resulted in significantly lower RV values compared to 2D PISA. Real-time and dynamic flow curve patterns were used for integral estimates of 3DRVol over the cardiac cycle, with a distinct bimodal pattern in functional MR, and brief and solitary peak in primary. CONCLUSIONS Using a semi-automated 3D software for quantification of mitral regurgitation allows for simultaneous calculation of 3D RVol with an automated generation of dynamic flow curves characteristic of the underlying MR mechanism. Our flow curve pattern results highlight well-known differences between MR flow dynamics in degenerative MR compared to functional MR.
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Affiliation(s)
- Amita Singh
- University of Chicago Medical Center (Chicago, IL).
| | - Jimmy Su
- Philips Healthcare (Cambridge, MA)
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11
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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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12
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Computational Analysis of Virtual Echocardiographic Assessment of Functional Mitral Regurgitation for Validation of Proximal Isovelocity Surface Area Methods. J Am Soc Echocardiogr 2021; 34:1211-1223. [PMID: 34214636 DOI: 10.1016/j.echo.2021.06.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 06/14/2021] [Accepted: 06/16/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Mitral regurgitation (MR) quantification by the proximal isovelocity surface area (PISA) method remains challenging. Using computer models, the authors evaluated the accuracy of different PISA methods and quantified their errors. METHODS Five functional MR computer models of different geometric and tethering abnormalities were created, validated, and treated as phantom models, from which the reference values were directly obtained. Virtual two-dimensional (2D) PISA and three-dimensional (3D) PISA (both peak and integrated values) were performed on these phantom models. By comparing virtual PISA results with reference values, the accuracy of different PISA methods was evaluated, and their sources of errors were quantified. RESULTS Compared with reference values of regurgitant flow rate, excellent correlations were found for true PISA (r = 0.99, bias = 32.3 ± 35.3 mL/sec), 3D PISA (r = 0.97, bias = -24.4 ± 55.5 mL/sec), followed by multiplane 2D hemicylindrical PISA (r = 0.88, bias = -24.1 ± 85.4 mL/sec) and hemiellipsoidal PISA (r = 0.91, bias = -55.7 ± 96.6 mL/sec). Weaker correlations were found for single-plane 2D hemispherical PISA (parasternal long-axis: r = 0.71, bias = -77.6 ± 124.5 mL/sec; apical two-chamber: r = 0.69, bias = -52.0 ± 122.0 mL/sec; apical four-chamber: r = 0.82, bias = -65.5 ± 107.3 mL/sec). For regurgitant volume quantification, integrated PISA was more accurate than peak PISA. The bias of 3D PISA improved from -12.7 ± 7.8 mL (peak PISA) to -2.1 ± 5.3 mL (integrated PISA). CONCLUSIONS For functional MR quantification, 2D hemispherical PISA had significant underestimation, multiplane 2D hemiellipsoidal and hemicylindrical PISA showed improved accuracy, and 3D PISA was the most accurate. The PISA method is subject to both systematic underestimation due to the Doppler angle effect and systematic overestimation when regurgitant flow is not perpendicular to PISA contour. Integrated PISA is able to capture dynamic MR and is therefore more accurate than peak PISA. The sum of regurgitant flow rates is the most feasible way to perform integrated PISA.
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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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14
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Hadjadj S, Marsit O, Paradis JM, Beaudoin J. Pathophysiology, Diagnosis, and New Therapeutic Approaches for Ischemic Mitral Regurgitation. Can J Cardiol 2020; 37:968-979. [PMID: 33347977 DOI: 10.1016/j.cjca.2020.12.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 12/10/2020] [Accepted: 12/12/2020] [Indexed: 01/22/2023] Open
Abstract
Ischemic mitral regurgitation (MR) is a valvular complication frequently seen in patients with coronary artery disease and is associated with increased mortality and morbidity. Ischemic mitral regurgitation has a complex, heterogeneous, and still incompletely understood pathophysiology involving both the mitral valve and the left ventricle. The occurrence of valve regurgitation in patients with ischemic cardiomyopathy in return accelerates left ventricular remodelling and dysfunction, ultimately leading to irreversible heart failure. Diagnostic evaluation of ischemic MR is unique and different from the other causes of MR. The severity thresholds associated with outcomes are different from primary MR, and specific imaging characteristics are potentially useful to guide therapy. The use of imaging modalities such as 3-dimensional echocardiography and cardiac magnetic resonance imaging can refine the diagnostic evaluation and help in choosing the correct management. Although multiple treatments are available to improve ischemic MR, each therapeutic option is associated with limitations and incomplete success. Therapy has therefore to be individualised for each patient. Current options include optimal medical therapy, cardiac resynchronisation therapy, percutaneous or surgical revascularisation, surgical mitral repair or replacement, and new percutaneous interventions. This review aims to discuss the latest insights regarding the pathophysiology, diagnosis, and treatment of ischemic MR.
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Affiliation(s)
- Sandra Hadjadj
- Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Ons Marsit
- Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Jean-Michel Paradis
- Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Jonathan Beaudoin
- Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada.
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15
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Kamoen V, El Haddad M, De Backer T, De Buyzere M, Timmermans F. Outcome of degenerative nonprolapse mitral regurgitation using the average pixel intensity method. Echocardiography 2020; 37:1329-1335. [PMID: 32777144 DOI: 10.1111/echo.14695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 04/27/2020] [Accepted: 04/27/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Primary mitral valve regurgitation (MR) is a comprehensive term that mostly comprises mitral valve prolapse (MVP), while other causes of degenerative MR are often not considered. We describe the echocardiographic characteristics of degenerative nonprolapse mitral regurgitation (DMR) and assess the outcome at medium-term follow-up using the novel average pixel intensity (API) method. METHODS Of 126 patients with any nonprolapse DMR were consecutively included. MR was graded according to all guideline-recommended parameters and with the API method. MR flow dynamics in DMR were compared to MVP-MR and functional MR (FMR). RESULTS DMR is associated with moderate-to-severe calcifications of the mitral valve apparatus, and a low event rate was observed at a mean follow-up of 27 months. The API grading method had a higher feasibility (94%) compared to proximal isovelocity surface area (PISA) (60%) method and vena contracta width (VCW) (71%) for assessing MR. The API method was predictive for events. The API method also provides insights into DMR flow dynamics: A triphasic pattern was observed with a midsystolic nadir for both API and PISA-EROA, which is similar to the dynamic flow pattern described in FMR, but distinct from holosystolic MVP-MR. Compared to FMR and MVP-MR patients, DMR is less severe and patients with DMR are generally older than MVP-MR patients. CONCLUSIONS DMR is a distinct MR pathology and conveys a relatively low event rate. MR grading was feasible with the API method, and flow dynamics demonstrated a similar triphasic pattern compared to FMR but distinct from holosystolic MVP-MR.
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Affiliation(s)
- Victor Kamoen
- Department of Cardiology, Heart Center, Ghent University Hospital, Ghent, Belgium
| | - Milad El Haddad
- Department of Cardiology, Heart Center, Ghent University Hospital, Ghent, Belgium
| | - Tine De Backer
- Department of Cardiology, Heart Center, Ghent University Hospital, Ghent, Belgium
| | - Marc De Buyzere
- Department of Cardiology, Heart Center, Ghent University Hospital, Ghent, Belgium
| | - Frank Timmermans
- Department of Cardiology, Heart Center, Ghent University Hospital, Ghent, Belgium
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Drake DH, Zimmerman KG, Sidebotham DA. Past, current and future management of secondary mitral valve disease: the importance of anatomic staging. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:968. [PMID: 32953768 PMCID: PMC7475447 DOI: 10.21037/atm.2020.03.82] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Daniel H Drake
- Department of Surgery, Munson Medical Center, Traverse City, MI, USA
| | - Karen G Zimmerman
- Department of Cardiology, Henry Ford Health System, Detroit, MI, USA
| | - David A Sidebotham
- Department of Cardiothoracic Anesthesia and Cardiothoracic Intensive Care Unit, Auckland City Hospital, Grafton, Auckland, New Zealand
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17
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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 2020; 41:2799-2810. [PMID: 32350503 PMCID: PMC8453270 DOI: 10.1093/eurheartj/ehaa129] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [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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18
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Gavazzoni M, Taramasso M, Zuber M, Pozzoli A, Miura M, Oliveira D, Maisano F. Functional mitral regurgitation and cardiac resynchronization therapy in the "era" of trans-catheter interventions: Is it time to move from a staged strategy to a tailored therapy? Int J Cardiol 2020; 315:15-21. [PMID: 32456957 DOI: 10.1016/j.ijcard.2020.03.071] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 02/19/2020] [Accepted: 03/27/2020] [Indexed: 01/15/2023]
Abstract
Cardiac resynchronization therapy (CRT) has been associated to left ventricle (LV) remodelling, reduction of functional mitral regurgitation (FMR) and clinical improvement in patients with heart failure and reduced ejection fraction (HFrEF). The prevalence of significant FMR in patients with LV dyssynchrony that are candidate to CRT is up to 40%. Current approach in patients with FMR undergoing CRT consists of re-evaluation of the amount of FMR following a waiting period of at least 3 months after the implant. In case of persistent significant FMR despite CRT and guideline directed medical therapy, trancatheter Mitral Valve repair (TMVR) is an important option to improve quality of life and prognosis. This stepwise approach does not take into account the probability of the individual response to CRT and the availability of TMVR solutions that are safe and effective in high risk patients. We reviewed the effects of CRT on FMR, the prognostic role of persistence of FMR after CRT treatment and the impact of treatment of FMR in patients CRT non responders. We aimed to point out the limits of current step-wised approach in light on more recent evidence regarding FMR treatment. A new, "tailored" approached is proposed.
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Affiliation(s)
- Mara Gavazzoni
- Heart Valve Clinic, University Hospital of Zurich, Ramistrasse 100, 8091 Zurich, Switzerland.
| | - Maurizio Taramasso
- Heart Valve Clinic, University Hospital of Zurich, Ramistrasse 100, 8091 Zurich, Switzerland
| | - Michel Zuber
- Heart Valve Clinic, University Hospital of Zurich, Ramistrasse 100, 8091 Zurich, Switzerland
| | - Alberto Pozzoli
- Heart Valve Clinic, University Hospital of Zurich, Ramistrasse 100, 8091 Zurich, Switzerland
| | - Mizuki Miura
- Heart Valve Clinic, University Hospital of Zurich, Ramistrasse 100, 8091 Zurich, Switzerland
| | | | - Francesco Maisano
- Heart Valve Clinic, University Hospital of Zurich, Ramistrasse 100, 8091 Zurich, Switzerland
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Zoghbi W, Adams D, Bonow R, Enriquez-Sarano M, Foster E, Grayburn P, Hahn R, Han Y, Hung J, Lang R, Little S, Shah D, Shernan S, Thavendiranathan P, Thomas J, Weissman N. Recommendations for noninvasive evaluation of native valvular regurgitation
A report from the american society of echocardiography developed in collaboration with the society for cardiovascular magnetic resonance. JOURNAL OF THE INDIAN ACADEMY OF ECHOCARDIOGRAPHY & CARDIOVASCULAR IMAGING 2020. [DOI: 10.4103/2543-1463.282191] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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20
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Uretsky S, Aldaia L, Marcoff L, Koulogiannis K, Hiramatsu S, Argulian E, Rosenthal M, Gillam LD, Wolff SD. The Effect of Systolic Variation of Mitral Regurgitation on Discordance Between Noninvasive Imaging Modalities. JACC Cardiovasc Imaging 2019; 12:2431-2442. [DOI: 10.1016/j.jcmg.2019.02.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 01/17/2019] [Accepted: 02/01/2019] [Indexed: 01/08/2023]
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21
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Adamyan KG, Chilingaryan AL, Tunyan LG, Mkrtchyan NG, Minasyan AM. [Clinical Course and Predictors of Ischemic Mitral Regurgitation in Patients with Myocardial Infarctions of Different Localizations]. ACTA ACUST UNITED AC 2019; 59:25-38. [PMID: 31397227 DOI: 10.18087/cardio.2019.8.10268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 08/08/2019] [Indexed: 11/18/2022]
Abstract
PURPOSE to assess the clinical course of ischemic mitral regurgitation (IMR) in patients with myocardial infarction of different localizations and reveal its mechanisms and predictors. MATERIALS AND METHODS We enrolled in this study patients with first inferoposterior myocardial infarction (IPMI) (n=77), and anteroseptal MI (ASMI) (n=79) revascularized within 12 hours after symptoms onset, as well as age, sex and weight matched healthy control subjects (n=50). Parameters of mitral structures and mitral annulus areas (MAA), left ventricular (LV) volumes (LVV) and sphericity index (SI), global (G) and segmental (S) longitudinal LV strain (GLS, SLS), papillary muscles (PM) LS (PMLS) and PM systolic dyssynchrony (PMSD) were measured by echocardiography on the 7th and 180th days of follow up. RESULTS On the 7th day of follow up IMR was diagnosed more frequently in IPMI vs. ASMI (42 vs. 28%, р<0.001). In both groups patients with TIMI 0 flow before angioplasty had highest, while those with TIMI 3 flow - lowest incidence of IMR. Presence of IMR depended on collateral flow availability in vascular bed of infarct related artery. Wall motion abnormalities (WMA) of infarcted segments, MAA, posteromedial PM posterior displacement (PPMPD), SLS, PMLS, PMSD correlated with IMR in patients with IPMI on the 7th day of follow up. VLV, GLS and MAA correlated with IMR in patients with ASMI on the 7th day follow up. Patients with IPMI without IMR in 7th day did not develop IMR for 180 days of follow up while IMR developed in 19.3% of patients with ASMI without IMR at initial examination. Among patients with IPMI and ASMI 37.5% and 45.5%, respectively, of those with IMR at initial examination had no IMR after 180 days of follow up. Patients with IPMI more frequently had eccentric IMR than patients with ASMI (78 and 24%, respectively, p<0.002). At examination after 6 months WMA, MAA, PMSD, PPMPD, SLS, PMLS, PMSD correlated with IMR in patients with IPMI, while VLV, AMA, PM apical displacement (PMAD), GLS and PMSD correlated with IMR in patients with ASMI. AMA, PMAD and PMSD were predictors of IMR in patients with MI of both localizations. In addition, in patients with ASMI VLV and SI were also predictors of IMR.
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Affiliation(s)
- K G Adamyan
- Science Research Institute of Cardiology; Yerevan State Medical University after M. Heratsi
| | - A L Chilingaryan
- Science Research Institute of Cardiology; Yerevan State Medical University after M. Heratsi
| | - L G Tunyan
- Science Research Institute of Cardiology; Yerevan State Medical University after M. Heratsi
| | | | - A M Minasyan
- Yerevan State Medical University after M. Heratsi; Medical Center St. Gregory
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Kammerlander AA, Wiesinger M, Duca F, Aschauer S, Binder C, Zotter Tufaro C, Nitsche C, Badre-Eslam R, Schönbauer R, Bartko P, Beitzke D, Loewe C, Hengstenberg C, Bonderman D, Mascherbauer J. Diagnostic and Prognostic Utility of Cardiac Magnetic Resonance Imaging in Aortic Regurgitation. JACC Cardiovasc Imaging 2019; 12:1474-1483. [DOI: 10.1016/j.jcmg.2018.08.036] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 08/17/2018] [Accepted: 08/21/2018] [Indexed: 10/27/2022]
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24
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Kim DH, Dal-Bianco JP, Aikawa E, Bischoff J, Levine RA. Mitral Valve Adaptation: Can We Win the Race? Circ Cardiovasc Imaging 2019; 11:e007642. [PMID: 29626080 DOI: 10.1161/circimaging.118.007642] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Dae-Hee Kim
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA (D.-H.K., J.P.D.-B., R.A.L.); Center for Excellence in Vascular Biology, Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (E.A.); Vascular Biology Program and Department of Surgery, Boston Children's Hospital and Harvard Medical School, MA (J.B.); and Division of Cardiology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea (D.-H.K.)
| | - Jacob P Dal-Bianco
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA (D.-H.K., J.P.D.-B., R.A.L.); Center for Excellence in Vascular Biology, Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (E.A.); Vascular Biology Program and Department of Surgery, Boston Children's Hospital and Harvard Medical School, MA (J.B.); and Division of Cardiology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea (D.-H.K.)
| | - Elena Aikawa
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA (D.-H.K., J.P.D.-B., R.A.L.); Center for Excellence in Vascular Biology, Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (E.A.); Vascular Biology Program and Department of Surgery, Boston Children's Hospital and Harvard Medical School, MA (J.B.); and Division of Cardiology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea (D.-H.K.)
| | - Joyce Bischoff
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA (D.-H.K., J.P.D.-B., R.A.L.); Center for Excellence in Vascular Biology, Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (E.A.); Vascular Biology Program and Department of Surgery, Boston Children's Hospital and Harvard Medical School, MA (J.B.); and Division of Cardiology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea (D.-H.K.)
| | - Robert A Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA (D.-H.K., J.P.D.-B., R.A.L.); Center for Excellence in Vascular Biology, Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (E.A.); Vascular Biology Program and Department of Surgery, Boston Children's Hospital and Harvard Medical School, MA (J.B.); and Division of Cardiology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea (D.-H.K.).
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25
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Penicka M. Mitral Regurgitation Flow Variation: The End of a Single Time-Point Assessment? JACC Cardiovasc Imaging 2019; 12:2443-2444. [PMID: 31005528 DOI: 10.1016/j.jcmg.2019.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 02/27/2019] [Indexed: 12/30/2022]
Affiliation(s)
- Martin Penicka
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium.
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26
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Levine RA, Nagata Y, Dal-Bianco JP. Left Ventricular Dyssynchrony and the Mitral Valve Apparatus: An Orchestra That Needs to Play in Sync. JACC Cardiovasc Imaging 2019; 12:1738-1740. [PMID: 30660517 DOI: 10.1016/j.jcmg.2018.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 07/23/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Robert A Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Yasufumi Nagata
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Cardiology, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Jacob P Dal-Bianco
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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27
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Insights into functional mitral regurgitation using the average pixel intensity method. Int J Cardiovasc Imaging 2018; 35:761-769. [DOI: 10.1007/s10554-018-1509-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 11/24/2018] [Indexed: 02/06/2023]
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28
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Kamoen V, El Haddad M, De Buyzere M, De Backer T, Timmermans F. Grading of mitral regurgitation in mitral valve prolapse using the average pixel intensity method. Int J Cardiol 2018; 258:305-312. [DOI: 10.1016/j.ijcard.2018.01.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 11/28/2017] [Accepted: 01/02/2018] [Indexed: 12/12/2022]
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29
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Gosling A, Lyvers J, Warner K, Cobey FC. The Value of Dynamic Three-Dimensional Proximal Isovelocity Surface Area: Preventing Unnecessary Mitral Valve Replacement in a High-Risk Patient. J Cardiothorac Vasc Anesth 2018; 33:566-572. [PMID: 29548903 DOI: 10.1053/j.jvca.2018.01.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Andre Gosling
- Tufts Medical Center, Department of Anesthesiology and Perioperitive Medicine, Boston, MA
| | - Jeffrey Lyvers
- Duke Medical Center, Department of Anesthesiology, Durham, NC
| | - Kenneth Warner
- Tufts Medical Center, Division of Cardiac Surgery, Boston, MA
| | - Frederick C Cobey
- Tufts Medical Center, Department of Anesthesiology and Perioperitive Medicine, Boston, MA.
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Uretsky S, Argulian E, Narula J, Wolff SD. Use of Cardiac Magnetic Resonance Imaging in Assessing Mitral Regurgitation. J Am Coll Cardiol 2018; 71:547-563. [DOI: 10.1016/j.jacc.2017.12.009] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 11/16/2017] [Accepted: 12/07/2017] [Indexed: 02/04/2023]
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Carbone A, D'Andrea A, Scognamiglio G, Scarafile R, Tocci G, Sperlongano S, Martone F, Radmilovic J, D'Amato M, Liccardo B, Scherillo M, Galderisi M, Golino P. Mitral Prolapse: An Old Mysterious Entity - The Incremental Role of Multimodality Imaging in Sports Eligibility. J Cardiovasc Echogr 2018; 28:207-217. [PMID: 30746324 PMCID: PMC6341849 DOI: 10.4103/jcecho.jcecho_42_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Mitral valve prolapse is generally a benign condition characterized by fibromyxomatous changes of the mitral leaflet with displacement into the left atrium and late-systolic regurgitation. Although it is an old clinical entity, it still arouses perplexity in diagnosis and clinical management. Complications, such as mitral regurgitation (MR), atrial fibrillation, congestive heart failure, endocarditis, ventricular arrhythmias, and sudden cardiac death (SCD), have been reported. A large proportion of the overall causes of SCD in young competitive athletes is explained by mitral valve prolapse. Recent studies have shown the fibrosis of the papillary muscles and inferobasal left ventricular wall in mitral valve prolapse, suggesting a possible origin of ventricular fatal arrhythmias. Athletes with mitral valve prolapse and MR should undergo annual evaluations including physical examination, echocardiogram, and exercise stress testing to evaluate the cardiovascular risks of competitive sports and obtain the eligibility. In this setting, multimodality imaging techniques – echocardiography, cardiac magnetic resonance, and cardiac computed tomography – should provide a broad spectrum of information, from diagnosis to clinical management of the major clinical profiles of the disease.
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Affiliation(s)
- Andreina Carbone
- Luigi Vanvitelli University, Monaldi Hospital, AORN Ospedali Dei Colli, Naples, Italy
| | - Antonello D'Andrea
- Luigi Vanvitelli University, Monaldi Hospital, AORN Ospedali Dei Colli, Naples, Italy
| | | | - Raffaella Scarafile
- Luigi Vanvitelli University, Monaldi Hospital, AORN Ospedali Dei Colli, Naples, Italy
| | - Gianpaolo Tocci
- Luigi Vanvitelli University, Monaldi Hospital, AORN Ospedali Dei Colli, Naples, Italy
| | - Simona Sperlongano
- Luigi Vanvitelli University, Monaldi Hospital, AORN Ospedali Dei Colli, Naples, Italy
| | - Francesca Martone
- Luigi Vanvitelli University, Monaldi Hospital, AORN Ospedali Dei Colli, Naples, Italy
| | - Juri Radmilovic
- Luigi Vanvitelli University, Monaldi Hospital, AORN Ospedali Dei Colli, Naples, Italy
| | - Marianna D'Amato
- Luigi Vanvitelli University, Monaldi Hospital, AORN Ospedali Dei Colli, Naples, Italy
| | - Biagio Liccardo
- Luigi Vanvitelli University, Monaldi Hospital, AORN Ospedali Dei Colli, Naples, Italy
| | | | - Maurizio Galderisi
- Department of Advanced Biomedical Sciences, Federico Ii University of Naples, Naples, Italy
| | - Paolo Golino
- Luigi Vanvitelli University, Monaldi Hospital, AORN Ospedali Dei Colli, Naples, Italy
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El-Tallawi KC, Messika-Zeitoun D, Zoghbi WA. Assessment of the severity of native mitral valve regurgitation. Prog Cardiovasc Dis 2017; 60:322-333. [PMID: 29174559 DOI: 10.1016/j.pcad.2017.11.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 11/13/2017] [Indexed: 01/04/2023]
Abstract
Mitral regurgitation (MR) is a major cause of cardiovascular morbidity and mortality. MR is classified as primary (organic) if it is due to an intrinsic valve abnormality, or secondary (functional) if the etiology is because of remodeling of left ventricular geometry and/or valve annulus. Transthoracic echocardiography (TTE) is the initial modality for MR evaluation. Parameters used for the assessment of MR include valve structure, cardiac remodeling, and color and spectral Doppler. Quantitative measurements include effective regurgitant orifice area, regurgitant volume, and regurgitant fraction. Knowledge of advantages and limitations of echo-Doppler parameters is essential for accurate results. An integrative approach is recommended in overall grading of MR as mild, moderate, or severe since singular parameters may be affected by several factors. When the mechanism and/or grade of MR is unclear from the TTE or is discrepant with the clinical scenario, further evaluation with transesophageal echocardiography or cardiac magnetic resonance imaging is recommended, the latter emerging as a powerful MR quantitation tool.
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Affiliation(s)
- Kinan Carlos El-Tallawi
- Houston Methodist DeBakey Heart and Vascular Center, Cardiovascular Imaging Center, Houston, TX, United States
| | - David Messika-Zeitoun
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France; University Paris VII, France
| | - William A Zoghbi
- Houston Methodist DeBakey Heart and Vascular Center, Cardiovascular Imaging Center, Houston, TX, United States.
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Abstract
Ischemic mitral regurgitation (IMR) is a frequent complication of left ventricular (LV) global or regional pathological remodeling due to chronic coronary artery disease. It is not a valve disease but represents the valvular consequences of increased tethering forces and reduced closing forces. IMR is defined as mitral regurgitation caused by chronic changes of LV structure and function due to ischemic heart disease and it worsens the prognosis. In this review, we discuss on etiology, pathophysiology, and mechanisms of IMR, its classification, evaluation, and therapeutic corrective methods of IMR.
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Affiliation(s)
- Praveen Kerala Varma
- Division of Cardiac Surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham (Amrita University), Kochi, Kerala, India
| | - Neethu Krishna
- Division of Cardiac Surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham (Amrita University), Kochi, Kerala, India
| | - Reshmi Liza Jose
- Division of Anesthesiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham (Amrita University), Kochi, Kerala, India
| | - Ashish Narayan Madkaiker
- Division of Cardiac Surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham (Amrita University), Kochi, Kerala, India
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34
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Sündermann SH, Falk V. Chirurgische Behandlung der sekundären Mitralklappeninsuffizienz. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2017. [DOI: 10.1007/s00398-017-0147-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abudiab MM, Chao CJ, Liu S, Naqvi TZ. Quantitation of valve regurgitation severity by three-dimensional vena contracta area is superior to flow convergence method of quantitation on transesophageal echocardiography. Echocardiography 2017; 34:992-1001. [DOI: 10.1111/echo.13549] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Muaz M. Abudiab
- Echocardiography Laboratory; Department of Cardiovascular Diseases; Mayo Clinic; Scottsdale AZ USA
| | - Chieh-Ju Chao
- Echocardiography Laboratory; Department of Cardiovascular Diseases; Mayo Clinic; Scottsdale AZ USA
| | - Shuang Liu
- Echocardiography Laboratory; Department of Cardiovascular Diseases; Mayo Clinic; Scottsdale AZ USA
| | - Tasneem Z. Naqvi
- Echocardiography Laboratory; Department of Cardiovascular Diseases; Mayo Clinic; Scottsdale AZ USA
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Bertrand PB, Schwammenthal E, Levine RA, Vandervoort PM. Exercise Dynamics in Secondary Mitral Regurgitation: Pathophysiology and Therapeutic Implications. Circulation 2017; 135:297-314. [PMID: 28093494 DOI: 10.1161/circulationaha.116.025260] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Secondary mitral valve regurgitation (MR) remains a challenging problem in the diagnostic workup and treatment of patients with heart failure. Although secondary MR is characteristically dynamic in nature and sensitive to changes in ventricular geometry and loading, current therapy is mainly focused on resting conditions. An exercise-induced increase in secondary MR, however, is associated with impaired exercise capacity and increased mortality. In an era where a multitude of percutaneous solutions are emerging for the treatment of patients with heart failure, it becomes important to address the dynamic component of secondary MR during exercise as well. A critical reappraisal of the underlying disease mechanisms, in particular the dynamic component during exercise, is of timely importance. This review summarizes the pathophysiological mechanisms involved in the dynamic deterioration of secondary MR during exercise, its functional and prognostic impact, and the way current treatment options affect the dynamic lesion and exercise hemodynamics in general.
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Affiliation(s)
- Philippe B Bertrand
- From Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium (P.B.B., P.M.V.); Faculty of Medicine and Life Sciences, Hasselt University, Belgium (P.B.B., P.M.V.); Heart Center, Sheba Medical Center, Tel Hashomer, Israel (E.S.); and Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston (R.A.L.).
| | - Ehud Schwammenthal
- From Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium (P.B.B., P.M.V.); Faculty of Medicine and Life Sciences, Hasselt University, Belgium (P.B.B., P.M.V.); Heart Center, Sheba Medical Center, Tel Hashomer, Israel (E.S.); and Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston (R.A.L.)
| | - Robert A Levine
- From Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium (P.B.B., P.M.V.); Faculty of Medicine and Life Sciences, Hasselt University, Belgium (P.B.B., P.M.V.); Heart Center, Sheba Medical Center, Tel Hashomer, Israel (E.S.); and Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston (R.A.L.)
| | - Pieter M Vandervoort
- From Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium (P.B.B., P.M.V.); Faculty of Medicine and Life Sciences, Hasselt University, Belgium (P.B.B., P.M.V.); Heart Center, Sheba Medical Center, Tel Hashomer, Israel (E.S.); and Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston (R.A.L.)
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Buck T, Bösche L, Plicht B. [Real-time 3D echocardiography for estimation of severity in valvular heart disease : Impact on current guidelines]. Herz 2017; 42:241-254. [PMID: 28229203 DOI: 10.1007/s00059-017-4540-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Besides providing spatial anatomic information on heart valves, real-time three-dimensional echocardiography (3DE) combined with color Doppler has the potential to overcome the limitations of flow quantification inherent to conventional 2D color Doppler methods. Recent studies validated the application of color Doppler 3DE (cD-3DE) for the quantification of regurgitation flow based on the vena contracta area (VCA) and the proximal isovelocity surface area (PISA) methods. Particularly the assessment of VCA by cD-3DE led to a change of paradigm by understanding of the VCA as being strongly asymmetric in the majority of patients and etiologies. This review provides a comprehensive description of the different concepts of cD-3DE-based flow quantification in the setting of different valvular heart diseases and their presentation in recent guidelines.
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Affiliation(s)
- T Buck
- Medizinische Klinik III, Klinik für Kardiologie, Klinikum Westfalen, Am Knappschaftskrankenhaus 1, 44309, Dortmund, Deutschland.
| | - L Bösche
- Medizinische Universitätsklinik II - Kardiologie und Angiologie, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum, Deutschland
| | - B Plicht
- Medizinische Klinik III, Klinik für Kardiologie, Klinikum Westfalen, Am Knappschaftskrankenhaus 1, 44309, Dortmund, Deutschland
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Heo R, Son JW, ó Hartaigh B, Chang HJ, Kim YJ, Datta S, Cho IJ, Shim CY, Hong GR, Ha JW, Chung N. Clinical Implications of Three-Dimensional Real-Time Color Doppler Transthoracic Echocardiography in Quantifying Mitral Regurgitation: A Comparison with Conventional Two-Dimensional Methods. J Am Soc Echocardiogr 2017; 30:393-403.e7. [DOI: 10.1016/j.echo.2016.12.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Indexed: 10/20/2022]
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Ayoub S, Ferrari G, Gorman RC, Gorman JH, Schoen FJ, Sacks MS. Heart Valve Biomechanics and Underlying Mechanobiology. Compr Physiol 2016; 6:1743-1780. [PMID: 27783858 PMCID: PMC5537387 DOI: 10.1002/cphy.c150048] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Heart valves control unidirectional blood flow within the heart during the cardiac cycle. They have a remarkable ability to withstand the demanding mechanical environment of the heart, achieving lifetime durability by processes involving the ongoing remodeling of the extracellular matrix. The focus of this review is on heart valve functional physiology, with insights into the link between disease-induced alterations in valve geometry, tissue stress, and the subsequent cell mechanobiological responses and tissue remodeling. We begin with an overview of the fundamentals of heart valve physiology and the characteristics and functions of valve interstitial cells (VICs). We then provide an overview of current experimental and computational approaches that connect VIC mechanobiological response to organ- and tissue-level deformations and improve our understanding of the underlying functional physiology of heart valves. We conclude with a summary of future trends and offer an outlook for the future of heart valve mechanobiology, specifically, multiscale modeling approaches, and the potential directions and possible challenges of research development. © 2016 American Physiological Society. Compr Physiol 6:1743-1780, 2016.
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Affiliation(s)
- Salma Ayoub
- Center for Cardiovascular Simulation, Institute for Computational Engineering and Sciences, Department of Biomedical Engineering, The University of Texas at Austin, Austin, USA
| | - Giovanni Ferrari
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, USA
| | - Robert C. Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, USA
| | - Joseph H. Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, USA
| | - Frederick J. Schoen
- Department of Pathology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Michael S. Sacks
- Center for Cardiovascular Simulation, Institute for Computational Engineering and Sciences, Department of Biomedical Engineering, The University of Texas at Austin, Austin, USA
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Hung J, Levine RA. Pixels or Pixie Dust? Grading of mitral regurgitation using intensity analysis of continuous wave Doppler. Heart 2016; 103:177-178. [DOI: 10.1136/heartjnl-2016-310293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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El Haddad M, De Backer T, De Buyzere M, Devos D, Swillens A, Segers P, Timmermans F. Grading of mitral regurgitation based on intensity analysis of the continuous wave Doppler signal. Heart 2016; 103:190-197. [DOI: 10.1136/heartjnl-2016-309510] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 07/15/2016] [Accepted: 07/19/2016] [Indexed: 12/24/2022] Open
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Tan TC, Zeng X, Jiao Y, Wang L, Wei Q, Thiele K, Salgo I, Mehta V, Andrawes M, Picard MH, Hung J. Three-Dimensional Field Optimization Method: Clinical Validation of a Novel Color Doppler Method for Quantifying Mitral Regurgitation. J Am Soc Echocardiogr 2016; 29:926-934. [PMID: 27405591 DOI: 10.1016/j.echo.2016.05.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Assessment of mitral regurgitation (MR) severity by echocardiography is important for clinical decision making, but MR severity can be challenging to quantitate accurately and reproducibly. The accuracy of effective regurgitant orifice area (EROA) and regurgitant volume (RVol) calculated using two-dimensional (2D) proximal isovelocity surface area is limited by the geometric assumptions of proximal isovelocity surface area shape, and both variables demonstrate interobserver variability. The aim of this study was to compare a novel automated three-dimensional (3D) echocardiographic method for calculating MR regurgitant flow using standard 2D techniques. METHODS A sheep model of ischemic MR and patients with MR were prospectively examined. Patients with a range of severity of MR were examined. EROA and RVol were calculated from 3D color Doppler acquisitions using a novel computer-automated algorithm based on the field optimization method to measure EROA and RVol. For an independent comparison group, the 3D field optimization method was compared with 2D methods for grading MR in an experimental ovine model of MR. RESULTS Fifteen 3D data sets from nine sheep (open-chest transthoracic echocardiographic data sets) and 33 transesophageal data sets from patients with MR were prospectively examined. For sheep data sets, mean 2D EROA was 0.16 ± 0.05 cm2, and mean 2D RVol was 21.84 ± 8.03 mL. Mean 3D EROA was 0.09 ± 0.04 cm2, and mean 3D RVol was 14.40 ± 5.79 cm3. There was good correlation between 2D and 3D EROA (R = 0.70) and RVol (R = 0.80). For patient data sets, mean 2D EROA was 0.35 ± 0.35 cm2, and mean 2D RVol was 58.9 ± 52.9 mL. Mean 3D EROA was 0.34 ± 0.29 cm2, and mean 3D RVol was 54.6 ± 36.5 mL. There was excellent correlation between 2D and 3D EROA (R = 0.94) and RVol (R = 0.84). Bland-Altman analysis revealed greater interobserver variability for 2D RVol measurements compared with 3D RVol using the 3D field optimization method measurements, but variability was statistically significant only for RVol. CONCLUSIONS Direct automated measurement of proximal isovelocity surface area region for EROA calculation using real-time 3D color Doppler echocardiography is feasible, with a high correlation to current 2D EROA methods but less variability. This novel automated method provides an accurate and highly reproducible method for calculating EROA.
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Affiliation(s)
- Timothy C Tan
- Cardiac Ultrasound Laboratory, Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Xin Zeng
- Cardiac Ultrasound Laboratory, Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Yuan Jiao
- Cardiac Ultrasound Laboratory, Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lin Wang
- St. Francis Hospital, Roslyn, New York
| | - Qifeng Wei
- Philips Healthcare, Andover, Massachusetts
| | | | - Ivan Salgo
- Philips Healthcare, Andover, Massachusetts
| | - Vipin Mehta
- Department of Anesthesiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael Andrawes
- Department of Anesthesiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael H Picard
- Cardiac Ultrasound Laboratory, Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Judy Hung
- Cardiac Ultrasound Laboratory, Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
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Naser N, Dzubur A, Kusljugic Z, Kovacevic K, Kulic M, Sokolovic S, Terzic I, Haxihibeqiri-Karabdic I, Hondo Z, Brdzanovic S, Miseljic S. Echocardiographic Assessment of Ischaemic Mitral Regurgitation, Mechanism, Severity, Impact on Treatment Strategy and Long Term Outcome. Acta Inform Med 2016; 24:172-7. [PMID: 27482130 PMCID: PMC4949051 DOI: 10.5455/aim.2016.24.172-177] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 04/15/2016] [Indexed: 12/28/2022] Open
Abstract
Introduction: The commonest mitral regurgitation etiologies are degenerative (60%), rheumatic post-inflammatory, 12%) and functional (25%). Due to the large number of patients with acute MI, the incidence of ischaemic MR is also high. Ischaemic mitral regurgitation is a complex multifactorial disease that involves left ventricular geometry, the mitral annulus, and the valvular/subvalvular apparatus. Ischaemic mitral regurgitation is an important consequence of LV remodeling after myocardial infarction. Research Objectives: The objective of this study is to determine the role of echocardiography in detecting and assessment of mitral regurgitation mechanism, severity, impact on treatment strategy and long term outcome in patients with myocardial infarction during the follow up period of 5 years. Also one of objectives to determine if the absence or presence of ischaemic MR is associated with increased morbidity and mortality in patients with myocardial infarction. Patients and methods: The study covered 138 adult patients. All patients were subjected to echocardiography evaluation after acute myocardial infarction during the period of follow up for 5 years. The patients were examined on an ultrasound machine Philips iE 33 xMatrix, Philips HD 11 XE, and GE Vivid 7 equipped with all cardiologic probes for adults and multi-plan TEE probes. We evaluated mechanisms and severity of mitral regurgitation which includes the regurgitant volume (RV), effective regurgitant orifice area (EROA), the regurgitant fraction (RF), Jet/LA area, also we measured the of vena contracta width (VC width cm) for assessment of IMR severity, papillary muscles anatomy and displacement, LV systolic function ± dilation, LV regional wall motion abnormality WMA, LV WMI, Left ventricle LV remodeling, impact on treatment strategy and long term mortality. Results: We analyzed and follow up 138 patients with previous (>16 days) Q-wave myocardial infarction by ECG who underwent TTE and TEE echocardiography for detection and assessment of ischaemic mitral regurgitation (IMR) with baseline age (62 ± 9), ejection fraction (EF 41±12%), the regurgitant volume (RV) were 42±21 mL/beat, and effective regurgitant orifice area (EROA) 20±16 mm2, the regurgitant fraction (RF) were 48±10%, Jet/LA area 47±12%. Also we measured the of vena contracta width (VC width cm) 0,4±0,6 for assessment of IMR severity. During 5 years follow up, total mortality for patients with moderate/severe IMR–grade II-IV (54.2±1.8%) were higher than for those with mild IMR–grade I (30.4±2.9%) (P<0.05), the total mortality for patients with EROA ≥20 mm2(54±1.9%) were higher than for those with EROA <20 mm2(27.2±2.7%) (P<0.05), and the total mortality for patients with RVol ≥30 mL (56.8±1.7%) were higher than for those with RVol<30ml (29.4±2.9%) (P<0.05). After assessment of IMR and during follow up period 64 patients (46%) underwent CABG alone or combined CABG with mitral valve repair or replacement. In this study, the procedure of concomitant down-sized ring annuloplasty at the time if CABG surgery has a failure rate around 24% in terms of high late recurrence rate of IMR during the follow period especially after 18–42 months. Conclusion: The presence of ischaemic MR is associated with increased morbidity and mortality. Chronic IMR, an independent predictor of mortality with a reported survival of 40–60% at 5 years. Ischaemic mitral regurgitation has important prognosis implications in patients with coronary heart disease. Recognizing the mechanism of valve incompetence is an essential point for the surgical planning and for a good result of the mitral repair. It is important that echocardiographers understand the complex nature of the condition. Despite remarkable progress in reparative surgery, further investigation is still necessary to find the best approach to treat ischaemic mitral regurgitation.
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Affiliation(s)
- Nabil Naser
- Polyclinic "Dr. Nabil", Sarajevo, Bosnia and Herzegovina
| | - Alen Dzubur
- Institute for heart diseases, University Clinical Center Sarajevo, Bosnia and Herzegovina
| | - Zumreta Kusljugic
- Department of Cardiology, University Clinical Center Tuzla, Bosnia and Herzegovina
| | - Katarina Kovacevic
- Department of Cardiology, University Clinical Center Tuzla, Bosnia and Herzegovina
| | - Mehmed Kulic
- Institute for heart diseases, University Clinical Center Sarajevo, Bosnia and Herzegovina
| | - Sekib Sokolovic
- Institute for heart diseases, University Clinical Center Sarajevo, Bosnia and Herzegovina
| | | | | | - Zorica Hondo
- Institute for heart diseases, University Clinical Center Sarajevo, Bosnia and Herzegovina
| | - Snjezana Brdzanovic
- Institute for heart diseases, University Clinical Center Sarajevo, Bosnia and Herzegovina
| | - Sanja Miseljic
- Institute for heart diseases, University Clinical Center Sarajevo, Bosnia and Herzegovina
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Cobey FC, Ashihkmina E, Edrich T, Fox J, Shook D, Bollen B, Breeze JL, Sanouri Ursprung WW, Shernan SK. The Mechanism of Mitral Regurgitation Influences the Temporal Dynamics of the Vena Contracta Area as Measured with Color Flow Doppler. Anesth Analg 2016; 122:321-9. [DOI: 10.1213/ane.0000000000001056] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Obase K, Weinert L, Hollatz A, Farooqui F, Roberts JD, Minhaj MM, Tung A, Chaney M, Ota T, Jeevanandam V, Yoshida K, Mor-Avi V, Lang RM. Elongation of chordae tendineae as an adaptive process to reduce mitral regurgitation in functional mitral regurgitation. Eur Heart J Cardiovasc Imaging 2015; 17:500-9. [PMID: 26710820 DOI: 10.1093/ehjci/jev314] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 11/08/2015] [Indexed: 11/13/2022] Open
Abstract
AIMS In functional mitral regurgitation (FMR), increased leaflet area has been described as a remodelling compensatory mechanism. We hypothesized that chordae tendineae elongation would also occur as part of this remodelling. In this study, the lengths of primary chords and measurements of mitral leaflets and annulus were compared with varying degrees of mitral regurgitation (MR). METHODS AND RESULTS We studied 58 patients who underwent three-dimensional (3D) transoesophageal echocardiography, including 38 with FMR and 20 with normal mitral valves (NL). The FMR group was divided into two subgroups according to two-dimensional vena contracta width (VCW). Three-dimensional datasets from transgastric or mid-oesophageal approach were used to measure primary chordal length, coaptation length, inter-papillary muscle distances, and quantitative 3D measurements of the annulus and leaflets. Leaflet surface area was increased and coaptation length was decreased in FMR compared with NL. While no difference in other 3D measurement of annulus/leaflets was noted between the FMR subgroups, averaged chordal length was shorter in patients with more severe FMR. Chords of the anterior leaflet in FMR with larger VCW were shorter compared with both NL and FMR with smaller VCW. In contrast, the chords of the posterior leaflet were longer in FMR with smaller VCW compared with the other two groups. CONCLUSION Our results suggest the posterior leaflet chords possibly remodel by elongating and contribute to reduced MR and that in a subgroup of FMR patients, the primary chords may remodel by shortening, resulting in augmented MR. This information could be useful in choosing strategy for FMR correction.
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Affiliation(s)
- Kikuko Obase
- Noninvasive Cardiac Imaging Laboratory, Section of Cardiology, Department of Medicine, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL 60637, USA Department of Cardiology, Kawasaki Medical School, Kurashiki, Japan
| | - Lynn Weinert
- Noninvasive Cardiac Imaging Laboratory, Section of Cardiology, Department of Medicine, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL 60637, USA
| | - Andrew Hollatz
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL, USA
| | - Farhan Farooqui
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL, USA
| | - Joseph D Roberts
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL, USA
| | - Mohammed M Minhaj
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL, USA
| | - Avery Tung
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL, USA
| | - Mark Chaney
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL, USA
| | - Takeyoshi Ota
- Cardiovascular Surgery, University of Chicago, Chicago, IL, USA
| | | | - Kiyoshi Yoshida
- Department of Cardiology, Kawasaki Medical School, Kurashiki, Japan
| | - Victor Mor-Avi
- Noninvasive Cardiac Imaging Laboratory, Section of Cardiology, Department of Medicine, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL 60637, USA
| | - Roberto M Lang
- Noninvasive Cardiac Imaging Laboratory, Section of Cardiology, Department of Medicine, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL 60637, USA
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Levine RA, Hagége AA, Judge DP, Padala M, Dal-Bianco JP, Aikawa E, Beaudoin J, Bischoff J, Bouatia-Naji N, Bruneval P, Butcher JT, Carpentier A, Chaput M, Chester AH, Clusel C, Delling FN, Dietz HC, Dina C, Durst R, Fernandez-Friera L, Handschumacher MD, Jensen MO, Jeunemaitre XP, Le Marec H, Le Tourneau T, Markwald RR, Mérot J, Messas E, Milan DP, Neri T, Norris RA, Peal D, Perrocheau M, Probst V, Pucéat M, Rosenthal N, Solis J, Schott JJ, Schwammenthal E, Slaugenhaupt SA, Song JK, Yacoub MH. Mitral valve disease--morphology and mechanisms. Nat Rev Cardiol 2015; 12:689-710. [PMID: 26483167 DOI: 10.1038/nrcardio.2015.161] [Citation(s) in RCA: 231] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Mitral valve disease is a frequent cause of heart failure and death. Emerging evidence indicates that the mitral valve is not a passive structure, but--even in adult life--remains dynamic and accessible for treatment. This concept motivates efforts to reduce the clinical progression of mitral valve disease through early detection and modification of underlying mechanisms. Discoveries of genetic mutations causing mitral valve elongation and prolapse have revealed that growth factor signalling and cell migration pathways are regulated by structural molecules in ways that can be modified to limit progression from developmental defects to valve degeneration with clinical complications. Mitral valve enlargement can determine left ventricular outflow tract obstruction in hypertrophic cardiomyopathy, and might be stimulated by potentially modifiable biological valvular-ventricular interactions. Mitral valve plasticity also allows adaptive growth in response to ventricular remodelling. However, adverse cellular and mechanobiological processes create relative leaflet deficiency in the ischaemic setting, leading to mitral regurgitation with increased heart failure and mortality. Our approach, which bridges clinicians and basic scientists, enables the correlation of observed disease with cellular and molecular mechanisms, leading to the discovery of new opportunities for improving the natural history of mitral valve disease.
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Affiliation(s)
- Robert A Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Yawkey 5E, Boston, MA 02114, USA
| | - Albert A Hagége
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | | | | | - Jacob P Dal-Bianco
- Massachusetts General Hospital, Cardiac Ultrasound Laboratory, Harvard Medical School, Boston, MA, USA
| | | | | | | | - Nabila Bouatia-Naji
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | - Patrick Bruneval
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | | | - Alain Carpentier
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | | | | | | | - Francesca N Delling
- Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | | | - Christian Dina
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | - Ronen Durst
- Hadassah-Hebrew University Medical Centre, Jerusalem, Israel
| | - Leticia Fernandez-Friera
- Hospital Universitario HM Monteprincipe and the Centro Nacional de Investigaciones Cardiovasculares, Carlos III (CNIC), Madrid, Spain
| | - Mark D Handschumacher
- Massachusetts General Hospital, Cardiac Ultrasound Laboratory, Harvard Medical School, Boston, MA, USA
| | | | - Xavier P Jeunemaitre
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | - Hervé Le Marec
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | - Thierry Le Tourneau
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | | | - Jean Mérot
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | - Emmanuel Messas
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | - David P Milan
- Cardiovascular Research Center, Harvard Medical School, Boston, MA, USA
| | - Tui Neri
- Aix-Marseille University, INSERM UMR 910, Marseille, France
| | | | - David Peal
- Cardiovascular Research Center, Harvard Medical School, Boston, MA, USA
| | - Maelle Perrocheau
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | - Vincent Probst
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | - Michael Pucéat
- Aix-Marseille University, INSERM UMR 910, Marseille, France
| | | | - Jorge Solis
- Hospital Universitario HM Monteprincipe and the Centro Nacional de Investigaciones Cardiovasculares, Carlos III (CNIC), Madrid, Spain
| | - Jean-Jacques Schott
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | | | - Susan A Slaugenhaupt
- Center for Human Genetic Research, MGH Research Institute, Harvard Medical School, Boston, MA, USA
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Buck T, Plicht B. Real-Time Three-Dimensional Echocardiographic Assessment of Severity of Mitral Regurgitation Using Proximal Isovelocity Surface Area and Vena Contracta Area Method. Lessons We Learned and Clinical Implications. CURRENT CARDIOVASCULAR IMAGING REPORTS 2015; 8:38. [PMID: 26322152 PMCID: PMC4548007 DOI: 10.1007/s12410-015-9356-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Mitral regurgitation (MR) is considered the most common valve disease with a prevalence of 2-3 % of significant regurgitation (moderate to severe and severe) in the general population. Accurate assessment of the severity of regurgitation was demonstrated to be of significant importance for patient management and prognosis and consequently has been widely recognized in recent guidelines. However, evaluation of severity of valvular regurgitation can be potentially difficult with the largest challenges presenting in cases of mitral regurgitation. Real-time three-dimensional echocardiography (RT3DE) by the use of color Doppler has the potential to overcome the limitations of conventional flow quantification using 2D color Doppler methods. Recent studies validated the application of color Doppler RT3DE for the assessment of flow based on vena contracta area (VCA) and proximal isovelocity surface area (PISA). Particularly, the assessment of VCA by color Doppler RT3DE led to a change of paradigm by understanding the VCA as being strongly asymmetric in the majority of patients and etiologies. In this review, we provide a discussion of the current state of clinical evaluation, limitations, and future perspectives of the two methods and their presentation in recent literature and guidelines.
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Affiliation(s)
- Thomas Buck
- Medical Clinic III, Department of Cardiology, Klinikum Westfalen, Am Knappschaftskrankenhaus 1, 44309 Dortmund, Germany
| | - Björn Plicht
- Medical Clinic III, Department of Cardiology, Klinikum Westfalen, Am Knappschaftskrankenhaus 1, 44309 Dortmund, Germany
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Effects of the Mueller maneuver on functional mitral regurgitation and implications for obstructive sleep apnea. Am J Cardiol 2015; 115:1563-7. [PMID: 25846766 DOI: 10.1016/j.amjcard.2015.02.061] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Revised: 02/26/2015] [Accepted: 02/26/2015] [Indexed: 11/24/2022]
Abstract
Obstructive sleep apnea is prevalent and adversely affects cardiovascular health. However, little is known of the acute effects of an obstructive apnea on cardiovascular physiology. We hypothesized that pre-existing functional mitral regurgitation (MR) would worsen during performance of a Mueller maneuver (MM) used to simulate an obstructive apnea; 15 subjects with an ejection fraction ≤35% and pre-existing functional MR were studied with Doppler echocardiography. The radius of the proximal flow convergence was used as a measure of mitral regurgitant flow. Measurements were made at baseline, during the MM, and post-MM. Areas of all 4 chambers were also measured at these time points, both in systole and diastole. Mean flow convergence radius for the group decreased significantly during the transition from the late-MM to post-MM (0.65 → 0.57 mm, p = 0.001), implying increased MR during the MM. In addition, in 3 subjects, duration of MR increased during the MM. Right atrial (RA) areas, both systolic and diastolic, increased during the maneuver, whereas RA fractional area change decreased, indicating reduced RA emptying. Left ventricular emptying decreased early in the maneuver, probably because of the increased afterload burden, and then recovered. In conclusion, high negative intrathoracic pressure produces changes that, repeated hundreds of times per night in patients with obstructive sleep apnea, have the potential to worsen heart failure and predispose affected subjects to atrial fibrillation.
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