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Liu H, Sacks MS, Simonian NT, Gorman JH, Gorman RC. Simulated Effects of Acute Left Ventricular Myocardial Infarction on Mitral Regurgitation in an Ovine Model. J Biomech Eng 2024; 146:101009. [PMID: 38652602 DOI: 10.1115/1.4065376] [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: 04/30/2023] [Accepted: 04/18/2024] [Indexed: 04/25/2024]
Abstract
Ischemic mitral regurgitation (IMR) occurs from incomplete coaptation of the mitral valve (MV) after myocardial infarction (MI), typically worsened by continued remodeling of the left ventricular (LV). The importance of LV remodeling is clear as IMR is induced by the post-MI dual mechanisms of mitral annular dilation and leaflet tethering from papillary muscle (PM) distension via the MV chordae tendineae (MVCT). However, the detailed etiology of IMR remains poorly understood, in large part due to the complex interactions of the MV and the post-MI LV remodeling processes. Given the patient-specific anatomical complexities of the IMR disease processes, simulation-based approaches represent an ideal approach to improve our understanding of this deadly disease. However, development of patient-specific models of left ventricle-mitral valve (LV-MV) interactions in IMR are complicated by the substantial variability and complexity of the MR etiology itself, making it difficult to extract underlying mechanisms from clinical data alone. To address these shortcomings, we developed a detailed ovine LV-MV finite element (FE) model based on extant comprehensive ovine experimental data. First, an extant ovine LV FE model (Sci. Rep. 2021 Jun 29;11(1):13466) was extended to incorporate the MV using a high fidelity ovine in vivo derived MV leaflet geometry. As it is not currently possible to image the MVCT in vivo, a functionally equivalent MVCT network was developed to create the final LV-MV model. Interestingly, in pilot studies, the MV leaflet strains did not agree well with known in vivo MV leaflet strain fields. We then incorporated previously reported MV leaflet prestrains (J. Biomech. Eng. 2023 Nov 1;145(11):111002) in the simulations. The resulting LV-MV model produced excellent agreement with the known in vivo ovine MV leaflet strains and deformed shapes in the normal state. We then simulated the effects of regional acute infarctions of varying sizes and anatomical locations by shutting down the local myocardial contractility. The remaining healthy (noninfarcted) myocardium mechanical behaviors were maintained, but allowed to adjust their active contractile patterns to maintain the prescribed pressure-volume loop behaviors in the acute post-MI state. For all cases studied, the LV-MV simulation demonstrated excellent agreement with known LV and MV in vivo strains and MV regurgitation orifice areas. Infarct location was shown to play a critical role in resultant MV leaflet strain fields. Specifically, extensional deformations of the posterior leaflets occurred in the posterobasal and laterobasal infarcts, while compressive deformations of the anterior leaflet were observed in the anterobasal infarct. Moreover, the simulated posterobasal infarct induced the largest MV regurgitation orifice area, consistent with experimental observations. The present study is the first detailed LV-MV simulation that reveals the important role of MV leaflet prestrain and functionally equivalent MVCT for accurate predictions of LV-MV interactions. Importantly, the current study further underscored simulation-based methods in understanding MV function as an integral part of the LV.
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Affiliation(s)
- Hao Liu
- James T. Willerson Center for Cardiovascular Modeling and Simulation, The Oden Institute for Computational Engineering and Sciences, The Department of Biomedical Engineering, The University of Texas at Austin, Austin, TX 78712
| | - Michael S Sacks
- James T. Willerson Center for Cardiovascular Modeling and Simulation, The Oden Institute for Computational Engineering and Sciences, The Department of Biomedical Engineering, The University of Texas at Austin, Austin, TX 78712
| | - Natalie T Simonian
- James T. Willerson Center for Cardiovascular Modeling and Simulation, The Oden Institute for Computational Engineering and Sciences, The Department of Biomedical Engineering, The University of Texas at Austin, Austin, TX 78712
| | - Joseph H Gorman
- Gorman Cardiovascular Research Group, Smilow Center for Translational Research, University of Pennsylvania, Philadelphia, PA 19146-2701
| | - Robert C Gorman
- Gorman Cardiovascular Research Group, Smilow Center for Translational Research, University of Pennsylvania, Philadelphia, PA 19146-2701
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Karl R, Romano G, Marx J, Eden M, Schlegel P, Stroh L, Fischer S, Hehl M, Kühle R, Mohl L, Karck M, Frey N, De Simone R, Engelhardt S. An ex-vivo and in-vitro dynamic simulator for surgical and transcatheter mitral valve interventions. Int J Comput Assist Radiol Surg 2024; 19:411-421. [PMID: 38064021 PMCID: PMC10881771 DOI: 10.1007/s11548-023-03036-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 11/06/2023] [Indexed: 02/22/2024]
Abstract
PURPOSE Minimally invasive mitral valve surgery (MIMVS) and transcatheter edge-to-edge repair (TEER) are complex procedures used to treat mitral valve (MV) pathologies, but with limited training opportunities available. To enable training, a realistic hemodynamic environment is needed. In this work we aimed to develop and validate a simulator that enables investigation of MV pathologies and their repair by MIMVS and TEER in a hemodynamic setting. METHODS Different MVs were installed in the simulator, and pressure, flow, and transesophageal echocardiographic measurements were obtained. To confirm the simulator's physiological range, we first installed a biological prosthetic, a mechanical prosthetic, and a competent excised porcine MV. Subsequently, we inserted two porcine MVs-one with induced chordae tendineae rupture and the other with a dilated annulus, along with a patient-specific silicone valve extracted from echocardiography with bi-leaflet prolapse. Finally, TEER and MIMVS procedures were conducted by experts to repair the MVs. RESULTS Systolic pressures, cardiac outputs, and regurgitations volumes (RVol) with competent MVs were 119 ± 1 mmHg, 4.78 ± 0.16 l min-1, and 5 ± 3 ml respectively, and thus within the physiological range. In contrast, the pathological MVs displayed increased RVols. MIMVS and TEER resulted in a decrease in RVols and mitigated the severity of mitral regurgitation. CONCLUSION Ex-vivo modelling of MV pathologies and repair procedures using the described simulator realistically replicated physiological in-vivo conditions. Furthermore, we showed the feasibility of performing MIMVS and TEER at the simulator, also at patient-specific level, thus providing new clinical perspectives in terms of training modalities and personalized planning.
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Affiliation(s)
- Roger Karl
- Ruprecht-Karls University of Heidelberg, Heidelberg, Germany.
- Department of Cardiac Surgery, Heidelberg University Hospital, Heidelberg, Germany.
- Department of Internal Medicine III, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
- German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Heidelberg, Germany.
| | - Gabriele Romano
- Department of Cardiac Surgery, Heidelberg University Hospital, Heidelberg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Josephin Marx
- Department of Cardiac Surgery, Heidelberg University Hospital, Heidelberg, Germany
- Department of Internal Medicine III, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Matthias Eden
- Department of Internal Medicine III, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Philipp Schlegel
- Department of Internal Medicine III, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Lubov Stroh
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Samantha Fischer
- Department of Cardiac Surgery, Heidelberg University Hospital, Heidelberg, Germany
- Department of Internal Medicine III, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Maximilian Hehl
- Department of Cardiac Surgery, Heidelberg University Hospital, Heidelberg, Germany
- Department of Internal Medicine III, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Reinald Kühle
- Clinic and Polyclinic for Oral and Maxillofacial Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Lukas Mohl
- Department of Cardiac Surgery, Heidelberg University Hospital, Heidelberg, Germany
- Department of Internal Medicine III, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Matthias Karck
- Department of Cardiac Surgery, Heidelberg University Hospital, Heidelberg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Norbert Frey
- Department of Internal Medicine III, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Raffaele De Simone
- Department of Cardiac Surgery, Heidelberg University Hospital, Heidelberg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Sandy Engelhardt
- Department of Cardiac Surgery, Heidelberg University Hospital, Heidelberg, Germany
- Department of Internal Medicine III, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
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3
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Wang J, Liu X, Pu Z, Chen M, Fang Z, Jin J, Dong J, Guo Y, Cheng B, Xiu J, Luo J, Tang Y, Wang Y, Chen X, Zhang G, Shao Y, Song G, Hong L, Jiang H, Wu Y, Yuan Y, Chen L, He B, Wang J, Xu K, Yang Y, Zhou D, Zhang Q, Li Y, Ma K, Lam YY, Han Y, Ge J, Lim DS, Pivotal Trial Investigators FTD. Safety and efficacy of the DragonFly system for transcatheter valve repair of degenerative mitral regurgitation: one-year results of the DRAGONFLY-DMR trial. EUROINTERVENTION 2024; 20:e239-e249. [PMID: 38389469 PMCID: PMC10870008 DOI: 10.4244/eij-d-23-00361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 10/20/2023] [Indexed: 02/24/2024]
Abstract
BACKGROUND Severe degenerative mitral regurgitation (DMR) can cause a poor prognosis if left untreated. For patients considered at prohibitive surgical risk, transcatheter edge-to-edge repair (TEER) has become an accepted alternative therapy. The DragonFly transcatheter valve repair system is an innovative evolution of the mitral TEER device family to treat DMR. AIMS Herein we report on the DRAGONFLY-DMR trial (ClinicalTrials.gov: NCT04734756), which was a prospective, single-arm, multicentre study on the safety and effectiveness of the DragonFly system. METHODS A total of 120 eligible patients with prohibitive surgical risk and DMR ≥3+ were screened by a central eligibility committee for enrolment. The study utilised an independent echocardiography core laboratory and clinical event committee. The primary endpoint was the clinical success rate, which measured freedom from all-cause mortality, mitral valve reintervention, and mitral regurgitation (MR) >2+ at 1-year follow-up. RESULTS At 1 year, the trial successfully achieved its prespecified primary efficacy endpoint, with a clinical success rate of 87.5% (95% confidence interval: 80.1-92.3%). The rates of major adverse events, all-cause mortality, mitral valve reintervention, and heart failure hospitalisation were 9.0%, 5.0%, 0.8%, and 3.4%, respectively. MR ≤2+ was 90.4% at 1 month and 92.0% at 1 year. Over time, left ventricular reverse remodelling was observed (p<0.05), along with significant improvements in the patients' functional and quality-of-life outcomes, shown by an increase in the New York Heart Association Class I/II from 32.4% at baseline to 93.6% at 12 months (p<0.001) and increased Kansas City Cardiomyopathy Questionnaire (KCCQ) score of 31.1±18.2 from baseline to 12 months (p<0.001). CONCLUSIONS The DRAGONFLY-DMR trial contributes to increasing evidence supporting the safety and efficacy of TEER therapy, specifically the DragonFly system, for treating patients with chronic symptomatic DMR 3+ to 4+ at prohibitive surgical risk.
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Affiliation(s)
- Jian'an Wang
- Department of Cardiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xianbao Liu
- Department of Cardiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhaoxia Pu
- Department of Cardiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Mao Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Zhenfei Fang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Jun Jin
- Department of Cardiology, The Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Jianzhen Dong
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yansong Guo
- Department of Cardiology, Fujian Provincial Hospital, Fuzhou, China
| | - Biao Cheng
- Department of Cardiology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China
| | - Jiancheng Xiu
- Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jianfang Luo
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangzhou, China and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yida Tang
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, China
| | - Yan Wang
- Department of Medicine, Xiamen University Cardiovascular Hospital, Xiamen, China
| | - Xiaomen Chen
- Cardiology Center, Ningbo First Hospital, Ningbo, China
| | - Gejun Zhang
- Department of Cardiology, Fuwai Cardiovascular Hospital of Yunnan Province, Kunming, China
| | - Yibing Shao
- Department of Cardiology, Qingdao Municipal Hospital, Qingdao, China
| | - Guangyuan Song
- Interventional Center of Valvular Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Lang Hong
- Department of Cardiology, Jiangxi Provincial People's Hospital, Nanchang, China and The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| | - Hong Jiang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yangqin Wu
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yiqiang Yuan
- Department of Cardiology, Henan Chest Hospital, Zhengzhou, China
| | - Lianglong Chen
- Department of Cardiology, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Ben He
- Department of Cardiology, Shanghai Chest Hospital, Shanghai, China and Shanghai Jiao Tong University, Shanghai, China
| | - Jingfeng Wang
- Department of Cardiology, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Kai Xu
- Department of Cardiology, General Hospital of the Northern Theater of the Chinese People's Liberation Army, Shenyang, China
| | - Yining Yang
- Department of Cardiology, The First Affiliated Hospital, Xinjiang Medical University, Urumqi, China
| | - Daxin Zhou
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qi Zhang
- Department of Cardiology, Shanghai East Hospital, Shanghai, China and Tongji University, Shanghai, China
| | - Yi Li
- The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | | | - Yat-Yin Lam
- Hong Kong Asia Heart Centre, Canossa Hospital, Hong Kong, China
| | - Yaling Han
- Department of Cardiology, General Hospital of the Northern Theater of the Chinese People's Liberation Army, Shenyang, China
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - D Scott Lim
- Department of Medicine, University of Virginia Health System Hospital, Charlottesville, VA, USA
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Abadie BQ, Cremer PC, Vakamudi S, Gillinov AM, Svensson LG, Cho L. Sex-Specific Prognosis of Left Ventricular Size and Function Following Repair of Degenerative Mitral Regurgitation. J Am Coll Cardiol 2024; 83:303-312. [PMID: 38199708 DOI: 10.1016/j.jacc.2023.10.033] [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: 08/30/2023] [Revised: 09/29/2023] [Accepted: 10/13/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND Prior studies have demonstrated worse long-term outcomes for women after surgery for severe mitral regurgitation (MR). The current Class I indications for surgery for severe degenerative MR use cutoffs of left ventricular end-systolic dimension (LVESD) and left ventricular ejection fraction (EF) that do not account for known sex-related differences. OBJECTIVES The primary objective of this study was to assess long-term mortality following mitral valve repair in women compared with men on the basis of preoperative left ventricular systolic dimensions and EF. METHODS Consecutive patients who underwent isolated mitral valve repair for degenerative MR at a single institution between 1994 and 2016 were screened. Adjusted HRs for all-cause mortality were compared according to baseline LVESD, LVESD indexed to body surface area (LVESDi), and EF for men and women. RESULTS Among 4,589 patients, 1,825 were women (40%), and after a median follow-up period of 7.2 years, 344 patients (7.5%) had died. The risk for mortality for women increased from the baseline hazard at an LVESD of 3.6 cm, whereas an inflection point for increased risk with LVESD was not evident in men. Regarding LVESDi, the risk for women increased at 1.8 cm/m2 compared with 2.1 cm/m2 in men. For EF, women and men had a similar inflection point (58%); however, mortality was higher for women as EF decreased. CONCLUSIONS After mitral valve repair, women have a higher risk for all-cause mortality at lower LVESD and LVESDi and higher EF. These results support consideration of sex-specific thresholds for LVESDi in surgical decision making for patients with severe MR.
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Affiliation(s)
- Bryan Q Abadie
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Paul C Cremer
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sneha Vakamudi
- Ascension Texas Cardiovascular and the University of Texas at Austin Dell Medical School, Austin, Texas, USA
| | - A Marc Gillinov
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lars G Svensson
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Leslie Cho
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA.
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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] [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
- Correspondence: Sylvestre Maréchaux
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Secondary Mitral Regurgitation: Cardiac Remodeling, Diagnosis, and Management. STRUCTURAL HEART 2022. [DOI: 10.1016/j.shj.2022.100129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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7
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Altes A, Levy F, Iacuzio L, Dumortier H, Toledano M, Tartar J, Tribouilloy C, Maréchaux S. Comparison of mitral regurgitant volume assessment between proximal flow convergence and volumetric methods in patients with significant primary mitral regurgitation: an echocardiographic and CMR study. J Am Soc Echocardiogr 2022; 35:671-681. [DOI: 10.1016/j.echo.2022.03.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 03/04/2022] [Accepted: 03/04/2022] [Indexed: 11/25/2022]
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Percutaneous Edge-to-Edge Mitral Valve Repair for Functional Mitral Regurgitation. INTERNATIONAL JOURNAL OF HEART FAILURE 2022; 4:55-74. [PMID: 36263104 PMCID: PMC9383345 DOI: 10.36628/ijhf.2021.0041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/30/2021] [Accepted: 01/04/2022] [Indexed: 11/18/2022]
Abstract
The presence and severity of functional mitral regurgitation (FMR) is associated with worse outcomes in patients with heart failure and reduced ejection fraction. Prior to the availability of percutaneous mitral valve repair, management for FMR has been limited to medical therapy, cardiac resynchronization therapy for a specific subset of patients and surgery which has yet to demonstrate mortality benefits. Transcatheter edge-to-edge repair (TEER) of the mitral valve has emerged in the past decade as an invaluable member of the armamentarium against FMR with the 2 landmark randomized controlled trials providing deep insights on patient selection. In addition, TEER has spurred the rapid advancement in our understanding of FMR. This article seeks to provide an overview as well as our current understanding on the role of TEER in FMR.
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House CM, Xi M, Moriarty KA, Nelson WB. Gender differences in primary mitral regurgitant volumes at specific regurgitant fractions as assessed by magnetic resonance imaging. Int J Cardiovasc Imaging 2021; 38:663-671. [PMID: 34669058 DOI: 10.1007/s10554-021-02449-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/12/2021] [Indexed: 10/20/2022]
Abstract
Guidelines suggest using a regurgitant fraction of 50% and regurgitant volume of 60 ml for determination of severe mitral insufficiency. Recent MRI data has suggested that a regurgitant fraction of 40% defines severe primary mitral insufficiency. We sought to determine whether there were gender differences in primary mitral regurgitant volumes for regurgitant fractions of 40% and 50%. A database search identified 394 patients that had MRI with a mitral regurgitant volume ≥ 10 ml or a study indication of mitral insufficiency. Chart review identified 97 patients with primary mitral insufficiency. Of these patients, 53 (54%) were women. Men had significantly larger left ventricular volumes, myocardial mass, stroke volumes and mitral regurgitant volumes (37 ± 25 ml vs. 24 ± 12 ml). The difference in regurgitant fraction between genders was not significant (27 ± 14% vs. 24 ± 11%; p-value = 0.24). Regurgitant fraction and regurgitant volume had a strong linear correlation in both men (r = .95) and women (r = .92). Despite similar linear correlations, the slope-intercept equations differed significantly between men and women (p < .001). A regurgitant fraction of 40% correlated with a regurgitant volume of 59 ml in men and 39.5 ml in women, while a regurgitant fraction of 50% correlated with a regurgitant volume of 76.2 ml in men and 49.6 ml in women. Regurgitant fraction, determined by cardiac MRI, provides a gender independent assessment of primary mitral insufficiency, and suggests that regurgitant volume thresholds for severe primary mitral insufficiency may be lower in women.
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Affiliation(s)
- Chad M House
- Regions Hospital Heart Center, 640 Jackson Street, Mail Stop 11102M, St. Paul, MN, 55101, USA. .,HealthPartners Medical Group, Bloomington, MN, USA.
| | - Min Xi
- HealthPartners Institute for Education and Research, Bloomington, MN, USA
| | - Katie A Moriarty
- Regions Hospital Heart Center, 640 Jackson Street, Mail Stop 11102M, St. Paul, MN, 55101, USA.,HealthPartners Medical Group, Bloomington, MN, USA.,University of Minnesota Medical School, Minneapolis, MN, USA
| | - William B Nelson
- Regions Hospital Heart Center, 640 Jackson Street, Mail Stop 11102M, St. Paul, MN, 55101, USA.,HealthPartners Medical Group, Bloomington, MN, USA.,University of Minnesota Medical School, Minneapolis, MN, USA
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Grayburn PA, Sannino A, Lancellotti P. Redefining Severe Functional Mitral Regurgitation: Can We Reconcile Guideline Differences? JACC Cardiovasc Imaging 2021; 14:2316-2318. [PMID: 34274277 DOI: 10.1016/j.jcmg.2021.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 06/10/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Paul A Grayburn
- Department of Cardiology, Baylor Scott & White Heart and Vascular Hospital at Plano, Plano, Texas, USA.
| | - Anna Sannino
- Department of Cardiology, Baylor Scott & White Heart and Vascular Hospital at Plano, Plano, Texas, USA; Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Patrizio Lancellotti
- University of Liège Hospital, GIGA Cardiovascular Sciences, Centre Hospitalier Universitaire Sart Tilman, Liège, Belgium
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Hatoum H, Askegaard G, Iyer R, Prasad Dasi L. Atrial and ventricular flows across a transcatheter mitral valve. Interact Cardiovasc Thorac Surg 2021; 33:1-9. [PMID: 33674829 DOI: 10.1093/icvts/ivab032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 11/20/2020] [Accepted: 01/10/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The objective of this study was to evaluate the haemodynamic performance of transcatheter mitral valve replacement (TMVR) Implant with a focus on turbulence and washout adjacent to the ventricular surface of the leaflets. TMVR holds the promise of treating a large spectrum of mitral valve diseases. However, the haemodynamic performance and flow dynamics of such replacements are not fully understood. METHODS A tri-leaflet biopsrosthetic TMVR represented by Caisson implant of size 36A was implanted in the mitral position of a left heart simulator pulse duplicating system under physiological conditions. The 36A implant covers an anterior-posterior range of 26-32 mm and a commissure-to-commissure range of 30-36 mm. Transmitral pressure gradient, effective orifice area and regurgitant fraction were calculated. Particle image velocimetry was performed to evaluate turbulence in 2 perpendicular planes (Reynolds and viscous shear stresses, respectively). Additionally, dye experiments were performed to visualize washout. RESULTS Transmitral pressure gradient was 1.29 ± 0.27 mmHg and effective orifice area was 2.96 ± 0.28 cm2. Regurgitant fraction was 14.13 ± 0.08%. Total washout was 4.27 cardiac cycles. Largest viscous shear stress reaches 3.7 Pa and 2.4 Pa in ventricle and atrium, respectively. Reynolds shear stress in the atrial side was <10 Pa. In the ventricular side, the largest Reynolds shear stress reached ∼35 Pa. CONCLUSIONS TMVR leads to favourable haemodynamics with low degree of turbulence combined with fast washout around the leaflets indicating promising potential for freedom from blood damage potential and thrombosis corroborated by initial clinical studies as part of the valves's Early Feasibility Study.
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Affiliation(s)
- Hoda Hatoum
- Department of Biomedical Engineering, Michigan Technological University, Houghton, MI, USA
| | | | - Ramji Iyer
- R&D Department, LivaNova PLC, Maple Grove, MN, USA
| | - Lakshmi Prasad Dasi
- Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, USA
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Lopes PM, Albuquerque F, Freitas P, Gama F, Horta E, Reis C, Abecasis J, Trabulo M, Ferreira AM, Aguiar C, Canada M, Ribeiras R, Mendes M, Andrade MJ. Assessing proportionate and disproportionate functional mitral regurgitation with individualized thresholds. Eur Heart J Cardiovasc Imaging 2021; 23:431-440. [PMID: 33637993 DOI: 10.1093/ehjci/jeab023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 02/02/2021] [Indexed: 11/12/2022] Open
Abstract
AIMS The concept of proportionate/disproportionate functional mitral regurgitation (FMR) has been limited by the lack of a simple way to assess it and by the paucity of data showing its prognostic superiority. The aim of this study was to evaluate the prognostic value of an individualized method of assessing FMR proportionality. METHODS AND RESULTS We retrospectively identified 572 patients with at least mild FMR and reduced left ventricular ejection fraction (<50%) under medical therapy. To determine FMR proportionality status, we used an approach where a simple equation determined the individualized theoretical regurgitant volume (or effective regurgitant orifice area) threshold associated with haemodynamically significant FMR. Then, we compared the measured with the theoretical value to categorize the population into non-severe, proportionate, and disproportionate FMR. The primary endpoint was all-cause mortality. During a median follow-up of 3.8 years (interquartile range: 1.8-6.2), 254 patients died. The unadjusted mortality incidence per 100 persons-year rose as the degree of FMR disproportionality worsened. On multivariable analysis, disproportionate FMR remained independently associated with all-cause mortality [adjusted hazard ratio: 1.785; 95% confidence interval (CI): 1.249-2.550; P = 0.001]. The FMR proportionality concept showed greater discriminative power (C-statistic 0.639; 95% CI: 0.597-0.680) than the American (C-statistic 0.583; 95% CI: 0.546-0.621; P for comparison <0.001) and European guidelines (C-statistic 0.584; 95% CI: 0.547-0.620; P for comparison <0.001). When added to any of the before-mentioned guidelines, FMR proportionality also improved risk stratification by reclassifying patients into lower and higher risk subsets. CONCLUSION Disproportionate FMR is independently associated with all-cause mortality and improves the risk stratification of current guidelines.
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Affiliation(s)
- Pedro M Lopes
- Department of Cardiology, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo dos Santos, 2790-134 Carnaxide, Lisbon, Portugal
| | - Francisco Albuquerque
- Department of Cardiology, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo dos Santos, 2790-134 Carnaxide, Lisbon, Portugal
| | - Pedro Freitas
- Department of Cardiology, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo dos Santos, 2790-134 Carnaxide, Lisbon, Portugal
| | - Francisco Gama
- Department of Cardiology, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo dos Santos, 2790-134 Carnaxide, Lisbon, Portugal
| | - Eduarda Horta
- Department of Cardiology, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo dos Santos, 2790-134 Carnaxide, Lisbon, Portugal
| | - Carla Reis
- Department of Cardiology, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo dos Santos, 2790-134 Carnaxide, Lisbon, Portugal
| | - João Abecasis
- Department of Cardiology, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo dos Santos, 2790-134 Carnaxide, Lisbon, Portugal
| | - Marisa Trabulo
- Department of Cardiology, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo dos Santos, 2790-134 Carnaxide, Lisbon, Portugal
| | - António M Ferreira
- Department of Cardiology, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo dos Santos, 2790-134 Carnaxide, Lisbon, Portugal
| | - Carlos Aguiar
- Department of Cardiology, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo dos Santos, 2790-134 Carnaxide, Lisbon, Portugal
| | - Manuel Canada
- Department of Cardiology, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo dos Santos, 2790-134 Carnaxide, Lisbon, Portugal
| | - Regina Ribeiras
- Department of Cardiology, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo dos Santos, 2790-134 Carnaxide, Lisbon, Portugal
| | - Miguel Mendes
- Department of Cardiology, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo dos Santos, 2790-134 Carnaxide, Lisbon, Portugal
| | - Maria J Andrade
- Department of Cardiology, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo dos Santos, 2790-134 Carnaxide, Lisbon, Portugal
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Abstract
PURPOSE OF REVIEW Degenerative mitral regurgitation (DMR) continues to be an important cause of morbidity and mortality with surgical mitral valve repair remaining the gold standard for the treatment of severe disease. The purpose of this review is to summarize recent advances in the understanding of DMR as well as the progress made in its assessment with a focus on imaging techniques. RECENT FINDINGS Recent insights into the anatomy and physiology of DMR challenge the assumption that fibroelastic deficiency and Barlow disease are part of a single DMR spectrum. Advances in echocardiography and cardiovascular MRI have the potential to improve quantification of mitral regurgitation, provide unique information on prognosis and impact of DMR, further the association between DMR and arrhythmic risk and aide in decision-making for DMR treatment. SUMMARY With growing interest in the use of noninvasive transcatheter therapies in the mitral valve space, comprehensive assessment of the mitral valve is critical to instruct decision-making and guide therapeutic strategy.
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Mitral valve regurgitation: a disease with a wide spectrum of therapeutic options. Nat Rev Cardiol 2020; 17:807-827. [DOI: 10.1038/s41569-020-0395-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/12/2020] [Indexed: 12/30/2022]
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15
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Bartko PE, Arfsten H, Heitzinger G, Pavo N, Toma A, Strunk G, Hengstenberg C, Hülsmann M, Goliasch G. A Unifying Concept for the Quantitative Assessment of Secondary Mitral Regurgitation. J Am Coll Cardiol 2020; 73:2506-2517. [PMID: 31118144 DOI: 10.1016/j.jacc.2019.02.075] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 02/18/2019] [Accepted: 02/26/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Diverging guideline definitions for the quantitative assessment of severe secondary mitral regurgitation (sMR) reflect the lacking link of the sMR spectrum to mortality and has introduced a source of uncertainty and continuing debate. OBJECTIVES The current study aimed to define improved risk-thresholds specifically tailored to the complex nature of sMR that provide a unifying solution to the ongoing guideline-controversy. METHODS This study enrolled 423 heart failure patients under guideline-directed medical therapy and assessed sMR by effective regurgitant orifice area (EROA), regurgitant volume (RegVol), and regurgitant fraction (RegFrac). RESULTS Measures of sMR severity were consistently associated with 5-year mortality with a hazard ratio of 1.42 for a 1-SD increase (95% confidence interval [CI]: 1.25 to 1.63; p < 0.001) for EROA, 1.37 (95% CI: 1.20 to 1.56; p < 0.001) for RegVol, and 1.50 (95% CI: 1.30 to 1.73; p < 0.001) for RegFrac. Results remained statistically significant after bootstrap- or clinical confounder-based adjustment. Spline-curve analyses showed a linearly increasing risk enabling the ability to stratify into low-risk (EROA <20 mm2 and RegVol <30 ml), intermediate-risk (EROA 20 to 29 mm2 and RegVol 30 to 44 ml), and high-risk (EROA ≥30 mm2 and RegVol ≥45 ml) groups. In the intermediate-risk group, a RegFrac ≥50% as indicator for hemodynamic severe sMR was associated with poor outcome (p = 0.017). A unifying concept based on combined assessment of the EROA, the RegVol, and the RegFrac showed a significantly better discrimination compared with the currently established algorithms. CONCLUSIONS Risk-based thresholds tailored to the pathophysiological concept of sMR provide a unifying solution to the ongoing guideline controversy. An algorithm based on the combined assessment of the unifying cutoffs for EROA, RegVol, and RegFrac improves risk prediction compared with currently established grading.
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Affiliation(s)
- Philipp E Bartko
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | | | - Gregor Heitzinger
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Noemi Pavo
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Aurel Toma
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Guido Strunk
- FH Campus Vienna and Complexity Research, Vienna, Austria
| | | | - Martin Hülsmann
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Georg Goliasch
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria.
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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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Kreidel F, Ruf T, Tamm A, Geyer M, Emrich T, von Bardeleben RS. [Evaluation of mitral regurgitation : How much quantification do we need?]. Herz 2019; 44:574-585. [PMID: 31555893 DOI: 10.1007/s00059-019-04857-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Severe mitral regurgitation (MR) is associated with increased morbidity and mortality. Thus, the correct evaluation of the underlying etiology, pathomechanism and severity is crucial for optimal treatment. Echocardiography is the predominant diagnostic modality in the clinical routine as it enables grading of mitral regurgitation, which can frequently be achieved by readily available qualitative parameters. Additionally, echocardiography provides several methods to quantify the hemodynamic significance of MR. The effective regurgitation orifice area (EROA) is the quantitative parameter best correlated with clinical events. American and European imaging guidelines both recommend the use of quantitative parameters even though they disagree on the cut-off values for secondary MR. The evaluation of MR should always include an assessment of the adjacent heart chambers in order to be able to assess the impact of volume overload on size and function of the left ventricle and left atrium. The final interpretation of the quantitative parameters requires knowledge of left ventricular volume and ejection fraction. Newer 3D-echocardiographic approaches to quantify MR are less dependent on mathematical assumptions and have shown convincing results in several studies but still lack sufficient clinical validation. As an alternative to echocardiography, for specific indications cardiac magnetic resonance imaging (MRI) has proven to be a systematic and observer-independent method for quantification of MR.
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Affiliation(s)
- F Kreidel
- Department of Cardiology, Universitätsmedizin Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland.
| | - T Ruf
- Department of Cardiology, Universitätsmedizin Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland
| | - A Tamm
- Department of Cardiology, Universitätsmedizin Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland
| | - M Geyer
- Department of Cardiology, Universitätsmedizin Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland
| | - T Emrich
- Klinik für Radiologie der Universitätsmedizin Main, Mainz, Deutschland
| | - R S von Bardeleben
- Department of Cardiology, Universitätsmedizin Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland
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18
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Lee K, Om SY, Lee SH, Oh JK, Park HK, Choi YS, Lee SA, Lee S, Kim DH, Song JM, Kang DH, Song JK. Clinical Situations Associated with Inappropriately Large Regurgitant Volumes in the Assessment of Mitral Regurgitation Severity Using the Proximal Flow Convergence Method in Patients with Chordae Rupture. J Am Soc Echocardiogr 2019; 33:64-71. [PMID: 31668504 DOI: 10.1016/j.echo.2019.08.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 08/24/2019] [Accepted: 08/27/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Regurgitant volume (RVol) calculated using the proximal flow convergence method (proximal isovelocity surface area [PISA]) has been accepted as a key quantitative parameter for the diagnosis of and clinical decision-making with regard to severe mitral regurgitation (MR). However, a recent prospective study showed a significant overestimation of RVol by the echocardiographic PISA method compared with the MR volume measured using magnetic resonance imaging. We aimed to evaluate the frequency of overestimation of RVol by the PISA method and the clinical conditions that require a different quantitative method to correct the overestimation. METHODS We retrospectively enrolled 166 consecutive patients with degenerative MR and chordae rupture, in whom RVol was measured using both the PISA and two-dimensional Doppler volumetric methods. The volumetric method was used to measure total stroke volume using the two-dimensional Simpson biplane method, and forward stroke volume was measured using pulsed Doppler tracing at the left ventricular (LV) outflow tract. RVol by the volumetric method was calculated using total stroke volume - forward stroke volume. Severe MR was defined as an RVol >60 mL. RESULTS All patients had severe MR based on RVol by the PISA method, but 68 (41.1%) showed RVol by the volumetric method values of <60 mL, resulting in discordant results. The patients with discordant results were characterized by a higher prevalence of female sex, lower body surface area, smaller LV diastolic and systolic dimensions and volumes, smaller left atrial volume, smaller PISA angle, and lower frequency of flail leaflets (39.7% vs 62.2%, P = .004). Multivariate analysis revealed that LV end-diastolic volume (LVEDV) and PISA angle were independent factors, with the best cutoff LVEDV and PISA angle being 173 mL and 103°, respectively. During follow-up (median, 3.4 years; interquartile range, 2.0-4.8 years), mitral valve repair and replacement were performed in 103 and six patients, respectively. The 2-year mitral valve surgery-free survival rate was higher in the discordant group (51.8% ± 0.06% vs 31.2% ± 0.05%, P < .001). CONCLUSIONS Even in the patients with documented chordae rupture, the PISA method alone resulted in inappropriate overestimation of MR severity in a significant proportion of patients. Thus, an additive quantitative method is absolutely necessary in patients with a small LVEDV or narrow PISA angle.
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Affiliation(s)
- Kyusup Lee
- Division of Cardiology, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang Yong Om
- Division of Cardiology, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sun Hack Lee
- Division of Cardiology, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jin Kyung Oh
- Division of Cardiology, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hong-Kyung Park
- Division of Cardiology, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yoon-Sil Choi
- Division of Cardiology, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seung-Ah Lee
- Division of Cardiology, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sahmin Lee
- Division of Cardiology, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dae-Hee Kim
- Division of Cardiology, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jong-Min Song
- Division of Cardiology, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Duk-Hyun Kang
- Division of Cardiology, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae-Kwan Song
- Division of Cardiology, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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Gebhardt BR. Knowing the Limits: Pitfalls of Echocardiography in Mitral Regurgitation. J Cardiothorac Vasc Anesth 2019; 34:294-296. [PMID: 31500979 DOI: 10.1053/j.jvca.2019.07.133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 07/16/2019] [Indexed: 11/11/2022]
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Kagiyama N, Shrestha S. Echocardiographic assessment of mitral regurgitation. J Med Ultrason (2001) 2019; 47:59-70. [PMID: 31446501 DOI: 10.1007/s10396-019-00971-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 07/24/2019] [Indexed: 12/13/2022]
Abstract
Mitral regurgitation (MR) is one of the most frequent indications for valve surgery in developed countries, and echocardiographic assessment is an essential tool to evaluate its etiologies, severity, and therapeutic indications. The mitral valve apparatus is a complex structure composed of several parts: apart from the mitral valve leaflets and annulus, it also includes the chordae tendineae, papillary muscles, and left ventricular (LV) wall. MR can be caused not only by organic changes of the mitral valve leaflets or chordae (primary MR) but also by extreme mitral annular enlargement or mitral leaflet tethering due to displacement and malfunction of papillary muscles and LV wall (secondary MR). In secondary MR with LV dysfunction, a milder degree of MR can be associated with adverse outcomes compared with primary MR. Grading the severity is the first step in evaluation of indication for surgical/transcatheter interventions. As such, there are several techniques to assess the severity of MR using echocardiography. However, none of the techniques is reliable enough by itself, and it is always recommended to integrate multiple methods. In cases where echocardiographic assessment of MR severity is inconclusive, magnetic resonance may be helpful. In addition to the severity, anatomical information, such as localization in primary MR due to mitral valve prolapse and LV size in secondary MR due to LV dilatation/dysfunction, is an important concern in presurgical echocardiography. Transesophageal echocardiography and three-dimensional echocardiography are key techniques for anatomical evaluation including mitral valve and LV volumes. In transcatheter intervention for MR, echocardiography plays a pivotal role as a guide for procedures and endpoints. In this review article, the authors provide a comprehensive summary of current standards of echocardiographic assessment of MR.
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Affiliation(s)
- Nobuyuki Kagiyama
- West Virginia University Heart and Vascular Institute, 1 Medical Center Drive, Morgantown, WV, 26505, USA.
| | - Sirish Shrestha
- West Virginia University Heart and Vascular Institute, 1 Medical Center Drive, Morgantown, WV, 26505, USA
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Hagendorff A, Doenst T, Falk V. Echocardiographic assessment of functional mitral regurgitation: opening Pandora's box? ESC Heart Fail 2019; 6:678-685. [PMID: 31347297 PMCID: PMC6676284 DOI: 10.1002/ehf2.12491] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 06/11/2019] [Indexed: 12/26/2022] Open
Abstract
Two recent trials of transcatheter mitral-valve repair in patients with functional mitral regurgitation (FMR) presented opposing results for the MitraClip® compared to medical therapy alone. The conflicting results gave rise to intensive discussions about assessment of mitral valve regurgitation (MR). A recent editorial viewpoint provided a potential explanation presenting a new pathophysiologic concept. However, the echocardiographic characterization of both trials' patients is inconsistent and the discussed concepts appear to suffer from plausibility weaknesses. It is well conceivable that limitations in the echocardiographic assessment of the trial patients introduced a bias regarding the selection of patients with severe (or less severe) MR that may be a more plausible explanation for the differences in outcome. We here illustrate our viewpoint regarding the two MitraClip trials and also illustrate the difficulties in assessing functional MR properly. It may indeed be "opening Pandora's box", but we will also make an attempt to provide a solution.
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Affiliation(s)
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Volkmar Falk
- Department of Cardiac Surgery, German Heart Center, Berlin, Germany
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23
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Grayburn PA, Sannino A, Packer M. Proportionate and Disproportionate Functional Mitral Regurgitation. JACC Cardiovasc Imaging 2019; 12:353-362. [DOI: 10.1016/j.jcmg.2018.11.006] [Citation(s) in RCA: 290] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 11/12/2018] [Accepted: 11/19/2018] [Indexed: 10/27/2022]
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Abstract
PURPOSE OF REVIEW This article will review the current techniques in cardiac magnetic resonance imaging (CMR) for diagnosing and assessing primary valvular heart disease. RECENT FINDINGS The recent advancements in CMR have led to an increased role of this modality for qualifying and quantifying various native valve diseases. Phase-contrast velocity encoded imaging is a well-established technique that can be used to quantify aortic and pulmonic flow. This technique, combined with the improved ability for CMR to obtain accurate left and right ventricular volumetrics, has allowed for increased accuracy and reproducibility in assessing valvular dysfunction. Advancements in CMR technology also allows for improved spatial and temporal resolution imaging of various valves and their regurgitant or stenotic jets. Therefore, CMR can be a powerful tool in evaluation of native valvular heart disease. The role of CMR in assessing valvular heart disease is growing and being recognized in recent guidelines. CMR has the ability to assess valve morphology along with qualifying and quantifying valvular disease. In addition, the ability to obtain accurate volumetric measurements may improve more precise management strategies and may lead to improvements in mortality and morbidity.
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Evaluation of the Integrative Algorithm for Grading Chronic Aortic and Mitral Regurgitation Severity Using the Current American Society of Echocardiography Recommendations: To Discriminate Severe from Moderate Regurgitation. J Am Soc Echocardiogr 2018; 31:1002-1012.e2. [DOI: 10.1016/j.echo.2018.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Indexed: 11/21/2022]
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A Comparative Assessment of Echocardiographic Parameters for Determining Primary Mitral Regurgitation Severity Using Magnetic Resonance Imaging as a Reference Standard. J Am Soc Echocardiogr 2018; 31:992-999. [PMID: 29921479 DOI: 10.1016/j.echo.2018.04.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND The American Society of Echocardiography (ASE) guidelines suggest the use of several echocardiographic methods to assess mitral regurgitation severity using an integrated approach, without guidance as to the weighting of each parameter. The purpose of this multicenter prospective study was to evaluate the recommended echocardiographic parameters against a reference modality and develop and validate a weighting for each echocardiographic measure of mitral regurgitation severity. METHODS This study included 112 patients who underwent evaluation with echocardiography and magnetic resonance imaging (MRI). Echocardiographic parameters recommended by the ASE were included and compared with MRI-derived regurgitant volume (MRI-RV). RESULTS Echocardiographic parameters that correlated best with MRI-RV were proximal isovelocity surface area (PISA) radius (r = 0.65, P < .0001), PISA-derived effective regurgitant orifice area (r = 0.65, P < .0001), left ventricular end-diastolic volume (r = 0.56, P < .0001), and PISA-derived regurgitant volume (r = 0.52, P < .0001). In the linear regression models PISA-derived effective regurgitant orifice area, PISA-derived regurgitant volume, left ventricular end-diastolic volume, and the presence of a flail leaflet independently predicted MRI-RV. CONCLUSION Echocardiographic parameters of mitral regurgitation as recommended by the ASE had moderate correlations with MRI-RV. The best predictors of MRI-RV were PISA-derived effective regurgitant orifice area, PISA-derived regurgitant volume, left ventricular end-diastolic volume, and the presence of a flail leaflet, suggesting that these parameters should be weighted more heavily than other echocardiographic parameters in the application of the ASE-recommended integrated approach.
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Zürcher F, Brugger N, Jahren SE, de Marchi SF, Seiler C. Quantification of Multiple Mitral Regurgitant Jets: An In Vitro Validation Study Comparing Two- and Three-Dimensional Proximal Isovelocity Surface Area Methods. J Am Soc Echocardiogr 2018; 30:511-521. [PMID: 28274714 DOI: 10.1016/j.echo.2016.12.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Indexed: 10/19/2022]
Abstract
BACKGROUND The accuracy of the proximal isovelocity surface area (PISA) method for the quantification of mitral regurgitation (MR), in the case of multiple jets, is unknown. The aim of this study was to evaluate different two-dimensional (2D) and three-dimensional (3D) PISA methods using 3D color Doppler data sets. METHODS Several regurgitant volumes (Rvols) were simulated using a pulsatile pump connected to a phantom equipped with single and double regurgitant orifices of different sizes and interspaces. A flowmeter served as the reference method. Transthoracic (TTE) and transoesophageal echocardiography (TEE) were used to acquire the 3D data sets. Offline, Rvols were calculated by 2D PISA methods based on hemispheric and hemicylindric assumptions and by 3D integrated PISA. RESULTS A fusion of the PISA was observed in the setting of narrow-spaced regurgitant orifices; compared with flowmeter, Rvol was underestimated using the single hemispheric PISA model (TTE: Bland-Altman bias ± limit of agreement, -17.5 ± 8.9 mL; TEE: -15.9 ± 7.3 mL) and overestimated using the double hemispheric PISA model (TTE: +7.1 ± 14.6 mL; TEE: +10.4 ± 11.9 mL). The combined approach (hemisphere for single orifice, hemicylinder with two bases for nonfused PISAs, and hemicylinder with one base for fused PISAs) was more precise (TTE: -3.4 ± 6.3 mL; TEE: -1.9 ± 5.6 mL). Three-dimensional integrated PISA was the most accurate method to quantify Rvol (TTE: -2.1 ± 6.5 mL; TEE -3.2 ± 4.8 mL). CONCLUSIONS In the setting of double MR orifices, the 2D combined approach and integrated 3D PISA appear to be superior as compared with the conventional hemispheric method, thus providing tools for the challenging quantification of MR with multiple jets.
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Affiliation(s)
- Fabian Zürcher
- Department of Cardiology, University Hospital, Bern, Switzerland
| | - Nicolas Brugger
- Department of Cardiology, Hôpital Fribourgeois, Fribourg, Switzerland
| | | | | | - Christian Seiler
- Department of Cardiology, University Hospital, Bern, Switzerland.
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Inciardi RM, Rossi A, Benfari G, Cicoira M. Fill in the Gaps of Secondary Mitral Regurgitation: a Continuum Challenge From Pathophysiology to Prognosis. Curr Heart Fail Rep 2018; 15:106-115. [DOI: 10.1007/s11897-018-0379-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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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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Roche-Campo F, Bedet A, Vivier E, Brochard L, Mekontso Dessap A. Cardiac function during weaning failure: the role of diastolic dysfunction. Ann Intensive Care 2018; 8:2. [PMID: 29330683 PMCID: PMC5768586 DOI: 10.1186/s13613-017-0348-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 12/26/2017] [Indexed: 12/16/2022] Open
Abstract
Background Cardiac dysfunction is a common cause of weaning failure. Weaning shares some similarities with a cardiac stress test and may challenge active phases of the cardiac cycle-like ventricular contractility and relaxation. This study aimed at assessing systolic and diastolic function during the weaning process and scrutinizing their dynamics during weaning trials. Methods Echocardiography was performed during baseline ventilator settings to assess cardiac function at the initiation of the weaning process and at the start and the end of consecutive weaning trials (performed at day-1, day-2, and before extubation if applicable) to explore the evolution of left ventricle contractility and relaxation in a subset of patients. Results Among 67 patients included, weaning was prolonged (≥ 7 days) in 18 (27%) patients and short (< 7 days) in 49 (73%). Prevalence of systolic dysfunction and isolated diastolic dysfunction before the initiation of weaning process were 37 and 17%, respectively. Isolated diastolic dysfunction was more frequent in patients with prolonged weaning as compared to their counterparts. Thirty-one patients were explored by echocardiography during consecutive weaning trials. An increase in filling pressures with an alteration of ventricular relaxation (as assessed by a decrease in tissue Doppler early mitral diastolic wave velocity) was found during failed weaning trials. Conclusions Isolated diastolic dysfunction was associated with a prolongation of weaning. Increased filling pressures with left ventricle relaxation impairment may be a key mechanism of weaning trial failure. Electronic supplementary material The online version of this article (10.1186/s13613-017-0348-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ferran Roche-Campo
- Service de Réanimation Médicale, DHU A-TVB, Hôpitaux Universitaires Henri Mondor, Assistance Publique - Hôpitaux de Paris, 51 Avenue du Maréchal de Lattre de Tassigny, 94010, Créteil Cedex, France.,Servei de Medicina Intensiva, Hospital Verge de la Cinta, Tortosa, Tarragona, Spain
| | - Alexandre Bedet
- Service de Réanimation Médicale, DHU A-TVB, Hôpitaux Universitaires Henri Mondor, Assistance Publique - Hôpitaux de Paris, 51 Avenue du Maréchal de Lattre de Tassigny, 94010, Créteil Cedex, France. .,Groupe de Recherche Clinique CARMAS, Institut Mondor de Recherche Biomédicale, Faculté de Médecine de Créteil, Université Paris Est Créteil, 94010, Créteil, France.
| | - Emmanuel Vivier
- Service de Réanimation Médicale, DHU A-TVB, Hôpitaux Universitaires Henri Mondor, Assistance Publique - Hôpitaux de Paris, 51 Avenue du Maréchal de Lattre de Tassigny, 94010, Créteil Cedex, France.,Service de Réanimation Polyvalente, Centre hospitalier Saint-Joseph Saint-Luc, Lyon, France
| | - Laurent Brochard
- Service de Réanimation Médicale, DHU A-TVB, Hôpitaux Universitaires Henri Mondor, Assistance Publique - Hôpitaux de Paris, 51 Avenue du Maréchal de Lattre de Tassigny, 94010, Créteil Cedex, France.,Keenan Research Centre and Critical Care Department, St Michael's Hospital, Toronto, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Armand Mekontso Dessap
- Service de Réanimation Médicale, DHU A-TVB, Hôpitaux Universitaires Henri Mondor, Assistance Publique - Hôpitaux de Paris, 51 Avenue du Maréchal de Lattre de Tassigny, 94010, Créteil Cedex, France.,Groupe de Recherche Clinique CARMAS, Institut Mondor de Recherche Biomédicale, Faculté de Médecine de Créteil, Université Paris Est Créteil, 94010, Créteil, France
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Polte CL, Gao SA, Johnsson ÅA, Lagerstrand KM, Bech-Hanssen O. Characterization of Chronic Aortic and Mitral Regurgitation Undergoing Valve Surgery Using Cardiovascular Magnetic Resonance. Am J Cardiol 2017; 119:2061-2068. [PMID: 28450039 DOI: 10.1016/j.amjcard.2017.03.041] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Revised: 03/06/2017] [Accepted: 03/06/2017] [Indexed: 11/26/2022]
Abstract
Grading of chronic aortic regurgitation (AR) and mitral regurgitation (MR) by cardiovascular magnetic resonance (CMR) is currently based on thresholds, which are neither modality nor quantification method specific. Accordingly, this study sought to identify CMR-specific and quantification method-specific thresholds for regurgitant volumes (RVols), RVol indexes, and regurgitant fractions (RFs), which denote severe chronic AR or MR with an indication for surgery. The study comprised patients with moderate and severe chronic AR (n = 38) and MR (n = 40). Echocardiography and CMR was performed at baseline and in all operated AR/MR patients (n = 23/25) 10 ± 1 months after surgery. CMR quantification of AR: direct (aortic flow) and indirect method (left ventricular stroke volume [LVSV] - pulmonary stroke volume [PuSV]); MR: 2 indirect methods (LVSV - aortic forward flow [AoFF]; mitral inflow [MiIF] - AoFF). All operated patients had severe regurgitation and benefited from surgery, indicated by a significant postsurgical reduction in end-diastolic volume index and improvement or relief of symptoms. The discriminatory ability between moderate and severe AR was strong for RVol >40 ml, RVol index >20 ml/m2, and RF >30% (direct method) and RVol >62 ml, RVol index >31 ml/m2, and RF >36% (LVSV-PuSV) with a negative likelihood ratio ≤ 0.2. In MR, the discriminatory ability was very strong for RVol >64 ml, RVol index >32 ml/m2, and RF >41% (LVSV-AoFF) and RVol >40 ml, RVol index >20 ml/m2, and RF >30% (MiIF-AoFF) with a negative likelihood ratio < 0.1. In conclusion, CMR grading of chronic AR and MR should be based on modality-specific and quantification method-specific thresholds, as they differ largely from recognized guideline criteria, to assure appropriate clinical decision-making and timing of surgery.
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Benfari G, Dandale R, Rossi A, Onorati F, Mugnai G, Ribichini F, Temporelli PL, Vassanelli C. Functional mitral regurgitation. J Cardiovasc Med (Hagerstown) 2016; 17:767-73. [DOI: 10.2459/jcm.0000000000000429] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Bech-Hanssen O, Polte CL, Lagerstrand KM, Johnsson ÅA, Fadel BM, Gao SA. Left ventricular volumes by echocardiography in chronic aortic and mitral regurgitations. SCAND CARDIOVASC J 2016; 50:154-61. [DOI: 10.3109/14017431.2016.1148195] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Odd Bech-Hanssen
- Department of Cardiology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Physiology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska University Hospital, Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Heart Centre, King Faisal Specialist Hospital & Research Centre, Riyadh, Kingdom of Saudi Arabia
| | - Christian Lars Polte
- Department of Cardiology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska University Hospital, Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Kerstin M. Lagerstrand
- Department of Diagnostic Radiation Physics, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Åse A. Johnsson
- Department of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Department of Radiology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Bahaa M. Fadel
- Heart Centre, King Faisal Specialist Hospital & Research Centre, Riyadh, Kingdom of Saudi Arabia
| | - Sinsia A. Gao
- Department of Clinical Physiology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska University Hospital, Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
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Aplin M, Kyhl K, Bjerre J, Ihlemann N, Greenwood JP, Plein S, Uddin A, Tønder N, Høst NB, Ahlström MG, Hove J, Hassager C, Iversen K, Vejlstrup NG, Lav Madsen P. Cardiac remodelling and function with primary mitral valve insufficiency studied by magnetic resonance imaging. Eur Heart J Cardiovasc Imaging 2016; 17:863-70. [DOI: 10.1093/ehjci/jev321] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 11/13/2015] [Indexed: 11/13/2022] Open
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Lange SA, Jung J, Jaeck A, Hitschold T, Ebner B. Subclinical Myocardial Impairment Occurred in Septal and Anterior LV Wall Segments After Anthracycline-Embedded Chemotherapy and did not Worsen During Adjuvant Trastuzumab Treatment in Breast Cancer Patients. Cardiovasc Toxicol 2015; 16:193-206. [DOI: 10.1007/s12012-015-9328-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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38
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Polte CL, Bech-Hanssen O, Johnsson ÅA, Gao SA, Lagerstrand KM. Mitral regurgitation quantification by cardiovascular magnetic resonance: a comparison of indirect quantification methods. Int J Cardiovasc Imaging 2015; 31:1223-31. [DOI: 10.1007/s10554-015-0681-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 05/13/2015] [Indexed: 11/30/2022]
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Brugger N, Wustmann K, Hürzeler M, Wahl A, de Marchi SF, Steck H, Zürcher F, Seiler C. Comparison of three-dimensional proximal isovelocity surface area to cardiac magnetic resonance imaging for quantifying mitral regurgitation. Am J Cardiol 2015; 115:1130-6. [PMID: 25747111 DOI: 10.1016/j.amjcard.2015.01.550] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 01/20/2015] [Accepted: 01/20/2015] [Indexed: 11/18/2022]
Abstract
The aim of our study was to evaluate 3-dimensional (3D) color Doppler proximal isovelocity surface area (PISA) as a tool for quantitative assessment of mitral regurgitation (MR) against in vitro and in vivo reference methods. A customized 3D PISA software was validated in vitro against a flowmeter MR phantom. Sixty consecutive patients, with ≥mild MR of any cause, were recruited and the regurgitant volume (RVol) was measured by 2D PISA, 3D peak PISA, and 3D integrated PISA, using transthoracic (TTE) and transesophageal echocardiography (TEE). Cardiac magnetic resonance imaging (CMR) was used as reference method. Flowmeter RVol was associated with 3D integrated PISA as follows: y = 0.64x + 4.7, r(2) = 0.97, p <0.0001 for TEE and y = 0.88x + 4.07, r(2) = 0.96, p <0.0001 for TTE. The bias and limit of agreement in the Bland-Altman analysis were 6.8 ml [-3.5 to 17.1] for TEE and -0.059 ml [-6.2 to 6.1] for TTE. In vivo, TEE-derived 3D integrated PISA was the most accurate method for MR quantification compared to CMR: r(2) = 0.76, y = 0.95x - 3.95, p <0.0001; 5.1 ml (-14.7 to 26.5). It was superior to TEE 3D peak PISA (r(2) = 0.67, y = 1.00x + 6.20, p <0.0001; -6.3 ml [-33.4 to 21.0]), TEE 2D PISA (r(2) = 0.54, y = 0.76x + 0.18, p <0.0001; 8.4 ml [-20.4 to 37.2]), and TTE-derived measurements. It was also most accurate by receiver operating characteristic analysis (area under the curve 0.99) for the detection of severe MR, RVol cutoff = 48 ml, sensibility 100%, and specificity 96%. RVol and the cutoff to define severe MR were underestimated using the most accurate method. In conclusion, quantitative 3D color Doppler echocardiography of the PISA permits a more accurate MR assessment than conventional techniques and, consequently, should enable an optimized management of patients suffering from MR.
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Affiliation(s)
- Nicolas Brugger
- Department of Cardiology, University Hospital Bern, Bern, Switzerland.
| | - Kerstin Wustmann
- Department of Cardiology, University Hospital Bern, Bern, Switzerland
| | - Michael Hürzeler
- Department of Cardiology, University Hospital Bern, Bern, Switzerland
| | - Andreas Wahl
- Department of Cardiology, University Hospital Bern, Bern, Switzerland
| | | | - Hélène Steck
- Department of Cardiology, University Hospital Bern, Bern, Switzerland
| | - Fabian Zürcher
- Department of Cardiology, University Hospital Bern, Bern, Switzerland
| | - Christian Seiler
- Department of Cardiology, University Hospital Bern, Bern, Switzerland
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Discordance Between Echocardiography and MRI in the Assessment of Mitral Regurgitation Severity. J Am Coll Cardiol 2015; 65:1078-88. [DOI: 10.1016/j.jacc.2014.12.047] [Citation(s) in RCA: 239] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 12/21/2014] [Accepted: 12/22/2014] [Indexed: 11/21/2022]
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41
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Grayburn PA, Carabello B, Hung J, Gillam LD, Liang D, Mack MJ, McCarthy PM, Miller DC, Trento A, Siegel RJ. Defining “Severe” Secondary Mitral Regurgitation. J Am Coll Cardiol 2014; 64:2792-801. [DOI: 10.1016/j.jacc.2014.10.016] [Citation(s) in RCA: 158] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Revised: 10/06/2014] [Accepted: 10/08/2014] [Indexed: 11/15/2022]
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Di Marcello M, Terzo E, Locatelli C, Palermo V, Sala E, Dall'Aglio E, Bussadori C, Spalla I, Brambilla P. Assessment of mitral regurgitation severity by Doppler color flow mapping of the vena contracta in dogs. J Vet Intern Med 2014; 28:1206-13. [PMID: 24934609 PMCID: PMC4857959 DOI: 10.1111/jvim.12380] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 03/07/2014] [Accepted: 04/22/2014] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Quantitative and semiquantitative methods have been proposed for the assessment of MR severity, and though all are associated with limitations. Measurement of vena contracta width (VCW) has been used in clinical practice. OBJECTIVE To measure the VCW in dogs with different levels of MR severity. ANIMALS Two hundred and seventy-nine dogs were classified according to 5 levels of MR severity. METHODS This was a retrospective study. EROA and regurgitant volume calculated by the PISA method, were measured and indexed to BSA. Descriptive statistics were calculated for VCW and VCW index for all categories of MR severity. Spearman's rank correlation coefficients (ρs ) were calculated to compare the results of the different methods (VCW and VCW index vs RV PISA, RV PISA index, EROA, EROA index), and between VCW and VCW index versus MR severity. RESULTS All Spearman's rank correlation coefficients were significant (P < .001). The median values of VCW resulted of 2.9 mm (IQR 3.4-2.5) and of 4.6 mm (IQR 5.4-4.1) in the groups previously classified as mild-to-moderate and moderate-to-severe, respectively. The median values of VCW index resulted of 4.4 mm/m(2) (IQR = 5.5-4.2) in mild-to-moderate MR and of 10.8 mm/m(2) (IQR = 12.8-9.4) in moderate-to-severe MR. CONCLUSION AND CLINICAL IMPORTANCE This is not a validation study against any previously validated invasive gold standard, the VCW method has proved easy to employ and it might be an additional tool in quantifying disease severity that supports, rather than replace, data coming from other techniques in daily clinical practice and research.
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Affiliation(s)
- M. Di Marcello
- Centro Medico Veterinario CellaticaCellaticaBresciaItaly
| | - E. Terzo
- Veterinary Hospital Diagnostic Imaging UnitUniversity College DublinDublinIreland
| | - C. Locatelli
- Department of Veterinary Science and Public HealthSchool of Veterinary MedicineUniversity of MilanMilanItaly
| | - V. Palermo
- Royal (Dick) School of Veterinary StudiesUniversity of EdinburghEdinburghUK
| | - E. Sala
- Busto Arsizio Human HospitalVareseItaly
| | | | | | - I. Spalla
- Department of Veterinary Science and Public HealthSchool of Veterinary MedicineUniversity of MilanMilanItaly
| | - P.G. Brambilla
- Department of Veterinary Science and Public HealthSchool of Veterinary MedicineUniversity of MilanMilanItaly
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Yurdakul S, Yıldirimtürk O, Aytekin S. Left atrial mechanical functions in chronic primary mitral regurgitation patients: a velocity vector imaging-based study. Arch Med Sci 2014; 10:455-63. [PMID: 25097574 PMCID: PMC4107252 DOI: 10.5114/aoms.2014.43740] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2011] [Revised: 01/21/2012] [Accepted: 04/01/2012] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Assessment of the left atrium (LA) mechanical function provides further information on the level of cardiac compensation. We aimed to evaluate LA function using a strain imaging method: velocity vector imaging (VVI) in chronic primary mitral regurgitation (MR). MATERIAL AND METHODS We recruited 48 patients with chronic, isolated, moderate to severe MR (54.70 ±15.35 years and 56% male) and 30 age- and sex-matched healthy controls (56.52 ±15.95 years and 56% male). The LA volumes during reservoir (RV), conduit (CV) and contractile phases (AV) were measured. Global strain (S), systolic strain rate (SRs), early diastolic (ESRd) and late diastolic strain rate (LSRd) were calculated. RESULTS LA RV (50 ±18.7 to 37.9 ±5.9; p = 0.0001), CV (43.1 ±29 to 21 ±2.56; p = 0.0001), and AV (17.9 ±13.5 to 10.9 ±1.9; p = 0.006) were increased in MR patients. The LA reservoir phase strain was 16.2 ±8.1% in the MR group and 51.1 ±5.7% in the control group (p = 0.0001). The LA SRs (1.01 ±0.52 s(-1) for MR and 2.1 ±0.22 s(-1) for controls; p = 0.0001), LA ESRd (0.83 ±0.34 s(-1) for MR and 2.26 ±0.17 s(-1) for controls; p = 0.0001) and LA LSRd (0.76 ±0.24 s(-1) for MR and 2.2 ±0.26 s(-1) for controls; p = 0.0001) were impaired in MR patients. CONCLUSIONS The LA deformation indices may be used as adjunctive parameters to determine LA dysfunction in chronic primary MR.
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Affiliation(s)
- Selen Yurdakul
- Division of Cardiology, Florence Nightingale Hospital, Istanbul, Turkey
| | | | - Saide Aytekin
- Division of Cardiology, Florence Nightingale Hospital, Istanbul, Turkey
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Benjamin MM, Smith RL, Grayburn PA. Ischemic and Functional Mitral Regurgitation in Heart Failure: Natural History and Treatment. Curr Cardiol Rep 2014; 16:517. [DOI: 10.1007/s11886-014-0517-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Maréchaux S, Le Goffic C, Ennezat PV, Semichon M, Castel AL, Delelis F, Lemahieu JM, Menet A, Graux P, Tribouilloy C. Quantitative assessment of primary mitral regurgitation using left ventricular volumes: a three-dimensional transthoracic echocardiographic pilot study. Eur Heart J Cardiovasc Imaging 2014; 15:1133-9. [PMID: 24855214 DOI: 10.1093/ehjci/jeu091] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS To investigate the value of assessment of mitral regurgitant fraction (RF) using left ventricular (LV) volumes obtained by three-dimensional echocardiography (3DE) to quantify primary mitral regurgitation (MR). METHODS AND RESULTS Sixty patients with primary MR in sinus rhythm were prospectively enrolled. RF was calculated using either 2DE or 3DE LV volumes obtained as follows: (LV total stroke volume - LV forward stroke volume by Doppler)/LV total stroke volume. Severity of MR was graded independently by two cardiologists blinded to LV volumetric data using an integrative approach, as recommended by current guidelines. Sixty patients with LV ejection fraction >50% and no MR were also studied. In patients without MR, 3D total LV stroke volume was more strongly correlated with LV forward stroke volume than 2D total LV stroke volume (r = 0.75, P < 0.0001 vs. r = 0.62, P < 0.0001, respectively). The 3D method had a feasibility of 90% in patients with MR. Inter-reader concordance for MR grading (four grades) was excellent with a Kappa-value of 0.90, P < 0.0001. A significant correlation was observed between grade of MR severity and 3D RF (r = 0.83, P < 0.0001) and 2D RF (r = 0.74, P < 0.0001). Comparisons between individual grades for 3D RF were significant (P < 0.05) except for 3+ vs. 4+ MR (P = 0.213). All patients with 3D RF ≥40% had ≥3+ or 4+ MR and those with 3D RF ≤30% had 1+ or 2+ MR with a 'grey' overlap zone between 30 and 40%. CONCLUSIONS RF can be routinely determined using 3D LV volumes with a high feasibility in patients with primary MR and is reliable for identification of Grade 3+ or Grade 4+ MR. The incorporation of this parameter into the currently recommended multiparametric integrative approach might be helpful to discriminate significant MR.
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Affiliation(s)
- Sylvestre Maréchaux
- Cardiology Department, GCS-Groupement des Hôpitaux de L'Institut Catholique de Lille, Université Lille Nord de France, Service de cardiologie et soins intensifs, Faculté Libre de Médecine, Université Catholique de Lille, Rue du Grand But, 59160 Lomme, France INSERM U 1088 Université de Picardie, Amiens, France
| | - Caroline Le Goffic
- Cardiology Department, GCS-Groupement des Hôpitaux de L'Institut Catholique de Lille, Université Lille Nord de France, Service de cardiologie et soins intensifs, Faculté Libre de Médecine, Université Catholique de Lille, Rue du Grand But, 59160 Lomme, France
| | | | - Marc Semichon
- Cardiology Department, GCS-Groupement des Hôpitaux de L'Institut Catholique de Lille, Université Lille Nord de France, Service de cardiologie et soins intensifs, Faculté Libre de Médecine, Université Catholique de Lille, Rue du Grand But, 59160 Lomme, France
| | - Anne-Laure Castel
- Cardiology Department, GCS-Groupement des Hôpitaux de L'Institut Catholique de Lille, Université Lille Nord de France, Service de cardiologie et soins intensifs, Faculté Libre de Médecine, Université Catholique de Lille, Rue du Grand But, 59160 Lomme, France
| | - François Delelis
- Cardiology Department, GCS-Groupement des Hôpitaux de L'Institut Catholique de Lille, Université Lille Nord de France, Service de cardiologie et soins intensifs, Faculté Libre de Médecine, Université Catholique de Lille, Rue du Grand But, 59160 Lomme, France
| | - Jean Michel Lemahieu
- Cardiology Department, GCS-Groupement des Hôpitaux de L'Institut Catholique de Lille, Université Lille Nord de France, Service de cardiologie et soins intensifs, Faculté Libre de Médecine, Université Catholique de Lille, Rue du Grand But, 59160 Lomme, France
| | - Aymeric Menet
- Cardiology Department, GCS-Groupement des Hôpitaux de L'Institut Catholique de Lille, Université Lille Nord de France, Service de cardiologie et soins intensifs, Faculté Libre de Médecine, Université Catholique de Lille, Rue du Grand But, 59160 Lomme, France
| | - Pierre Graux
- Cardiology Department, GCS-Groupement des Hôpitaux de L'Institut Catholique de Lille, Université Lille Nord de France, Service de cardiologie et soins intensifs, Faculté Libre de Médecine, Université Catholique de Lille, Rue du Grand But, 59160 Lomme, France
| | - Christophe Tribouilloy
- INSERM U 1088 Université de Picardie, Amiens, France Centre Hospitalier Universitaire d'Amiens, Amiens, France
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Zamorano JL, Fernández-Golfín C, González-Gómez A. Quantification of mitral regurgitation by echocardiography. Heart 2014; 101:146-54. [PMID: 24780908 DOI: 10.1136/heartjnl-2012-303498] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- José L Zamorano
- Cardiology Department, Ramón y Cajal University Hospital, Madrid, Spain
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47
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Practical and conceptual limitations of tissue Doppler imaging to predict reverse remodelling in cardiac resynchronisation therapy. Eur J Heart Fail 2014; 10:281-90. [DOI: 10.1016/j.ejheart.2008.02.003] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2007] [Revised: 01/02/2008] [Accepted: 02/04/2008] [Indexed: 11/23/2022] Open
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48
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Yeung M, Kerrigan J, Sodhi S, Huang PH, Novak E, Maniar H, Zajarias A. Racial differences in rates of aortic valve replacement in patients with severe aortic stenosis. Am J Cardiol 2013; 112:991-5. [PMID: 23791013 DOI: 10.1016/j.amjcard.2013.05.030] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Revised: 05/14/2013] [Accepted: 05/14/2013] [Indexed: 10/26/2022]
Abstract
Racial disparities exist in the treatment of many cardiovascular diseases. Aortic valve replacement (AVR) is the only treatment for aortic stenosis (AS) that improves patient symptoms and survival. To date, no studies have compared the rate of AVR among different races. The records of patients with an aortic valve area <1 cm(2) by echocardiography diagnosed between January 2004 and May 2010 at Barnes-Jewish Hospital were reviewed retrospectively. Patients were stratified by race. Of the 880 patients analyzed, 10% were African American (AA), and 90% were European American (EA). AA more frequently had hypertension (82% vs 67%, p <0.01), diabetes mellitus (45% vs 32%, p = 0.02), chronic kidney disease (28% vs 17%, p = 0.01), and end stage renal disease (18% vs 2%, p <0.001). AA underwent AVR less frequently than EA (39% vs 53%, p = 0.02) and refused intervention more often (33% vs 20%, p = 0.04). When treated, AA and EA had similar 3-year survival (49% [38 to 60] vs 50% [45 to 54], p = 0.31). Identification of the factors associated with treatment refusal would further our ability to counsel patients on the decision to pursue AVR.
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Mazzone C, Cioffi G, Faganello G, Cherubini A, Tarantini L, Di Lenarda A, Edoardo Russo T, Selmi A, Stefenelli C, Furlanello F. Left Atrial Work in Patients with Stable Chronic Heart Failure: Factors Associated and Prognostic Role. Echocardiography 2013; 31:123-32. [DOI: 10.1111/echo.12325] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
| | - Giovanni Cioffi
- Department of Cardiology; Villa Bianca Hospital; Trento Italy
| | | | | | - Luigi Tarantini
- Department of Cardiology; S. Martino Hospital; Belluno Italy
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50
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Lancellotti P, Tribouilloy C, Hagendorff A, Popescu BA, Edvardsen T, Pierard LA, Badano L, Zamorano JL. Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 2013; 14:611-44. [PMID: 23733442 DOI: 10.1093/ehjci/jet105] [Citation(s) in RCA: 1130] [Impact Index Per Article: 102.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Valvular regurgitation represents an important cause of cardiovascular morbidity and mortality. Echocardiography has become the primary non-invasive imaging method for the evaluation of valvular regurgitation. The echocardiographic assessment of valvular regurgitation should integrate the quantification of the regurgitation, assessment of the valve anatomy and function, as well as the consequences of valvular disease on cardiac chambers. In clinical practice, the management of patients with valvular regurgitation thus largely integrates the results of echocardiography. It is crucial to provide standards that aim at establishing a baseline list of measurements to be performed when assessing regurgitation.
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Affiliation(s)
- Patrizio Lancellotti
- Department of Cardiology, GIGA Cardiovascular Sciences, University of Liège Hospital, Valvular Disease Clinic, CHU Sart Tilman, Liège, Belgium
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