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Yuyun MF, Joseph J, Erqou SA, Kinlay S, Echouffo-Tcheugui JB, Peralta AO, Hoffmeister PS, Boden WE, Yarmohammadi H, Martin DT, Singh JP. Evolution and prognosis of tricuspid and mitral regurgitation following cardiac implantable electronic devices: a systematic review and meta-analysis. Europace 2024; 26:euae143. [PMID: 38812433 PMCID: PMC11259857 DOI: 10.1093/europace/euae143] [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: 03/22/2024] [Accepted: 05/23/2024] [Indexed: 05/31/2024] Open
Abstract
AIMS Significant changes in tricuspid regurgitation (TR) and mitral regurgitation (MR) post-cardiac implantable electronic devices (CIEDs) are increasingly recognized. However, uncertainty remains as to whether the risk of CIED-associated TR and MR differs with right ventricular pacing (RVP) via CIED with trans-tricuspid RV leads, compared with cardiac resynchronization therapy (CRT), conduction system pacing (CSP), and leadless pacing (LP). The study aims to synthesize extant data on risk and prognosis of significant post-CIED TR and MR across pacing strategies. METHODS AND RESULTS We searched PubMed, EMBASE, and Cochrane Library databases published until 31 October 2023. Significant post-CIED TR and MR were defined as ≥ moderate. Fifty-seven TR studies (n = 13 723 patients) and 90 MR studies (n = 14 387 patients) were included. For all CIED, the risk of post-CIED TR increased [pooled odds ratio (OR) = 2.46 and 95% CI = 1.88-3.22], while the risk of post-CIED MR reduced (OR = 0.74, 95% CI = 0.58-0.94) after 12 and 6 months of median follow-up, respectively. Right ventricular pacing via CIED with trans-tricuspid RV leads was associated with increased risk of post-CIED TR (OR = 4.54, 95% CI = 3.14-6.57) and post-CIED MR (OR = 2.24, 95% CI = 1.18-4.26). Binarily, CSP did not alter TR risk (OR = 0.37, 95% CI = 0.13-1.02), but significantly reduced MR (OR = 0.15, 95% CI = 0.03-0.62). Cardiac resynchronization therapy did not significantly change TR risk (OR = 1.09, 95% CI = 0.55-2.17), but significantly reduced MR with prevalence pre-CRT of 43%, decreasing post-CRT to 22% (OR = 0.49, 95% CI = 0.40-0.61). There was no significant association of LP with post-CIED TR (OR = 1.15, 95% CI = 0.83-1.59) or MR (OR = 1.31, 95% CI = 0.72-2.39). Cardiac implantable electronic device-associated TR was independently predictive of all-cause mortality [pooled hazard ratio (HR) = 1.64, 95% CI = 1.40-1.90] after median of 53 months. Mitral regurgitation persisting post-CRT independently predicted all-cause mortality (HR = 2.00, 95% CI = 1.57-2.55) after 38 months. CONCLUSION Our findings suggest that, when possible, adoption of pacing strategies that avoid isolated trans-tricuspid RV leads may be beneficial in preventing incident or deteriorating atrioventricular valvular regurgitation and might reduce mortality.
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Affiliation(s)
- Matthew F Yuyun
- Department of Medicine, VA Boston Healthcare System, 1400 VFW Parkway, West Roxbury, MA 02132, USA
- Department of Medicine, Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
- Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, 72 E Concord St, Boston, MA 02118, USA
| | - Jacob Joseph
- Department of Medicine, VA Boston Healthcare System, 1400 VFW Parkway, West Roxbury, MA 02132, USA
- Department of Medicine, VA Providence Healthcare System, 830 Chalkstone Ave, Providence, RI 02908, USA
- Department of Medicine, Brown University, 1 Prospect Street, Providence, RI 02912, USA
| | - Sebhat A Erqou
- Department of Medicine, VA Providence Healthcare System, 830 Chalkstone Ave, Providence, RI 02908, USA
- Department of Medicine, Brown University, 1 Prospect Street, Providence, RI 02912, USA
| | - Scott Kinlay
- Department of Medicine, VA Boston Healthcare System, 1400 VFW Parkway, West Roxbury, MA 02132, USA
- Department of Medicine, Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
- Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, 72 E Concord St, Boston, MA 02118, USA
- Department of Medicine, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Justin B Echouffo-Tcheugui
- Department of Medicine, Johns Hopkins University School of Medicine, 733 N Broadway, Baltimore, MD 21205, USA
| | - Adelqui O Peralta
- Department of Medicine, VA Boston Healthcare System, 1400 VFW Parkway, West Roxbury, MA 02132, USA
- Department of Medicine, Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
- Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, 72 E Concord St, Boston, MA 02118, USA
| | - Peter S Hoffmeister
- Department of Medicine, VA Boston Healthcare System, 1400 VFW Parkway, West Roxbury, MA 02132, USA
- Department of Medicine, Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
- Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, 72 E Concord St, Boston, MA 02118, USA
| | - William E Boden
- Department of Medicine, VA Boston Healthcare System, 1400 VFW Parkway, West Roxbury, MA 02132, USA
- Department of Medicine, Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
- Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, 72 E Concord St, Boston, MA 02118, USA
| | - Hirad Yarmohammadi
- Department of Medicine, Columbia University Irving Medical Center, 177 Fort Washington Avenue, New York, NY 10032, USA
| | - David T Martin
- Department of Medicine, Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
- Department of Medicine, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Jagmeet P Singh
- Department of Medicine, Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
- Department of Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
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Yuyun MF, Joseph J, Erqou SA, Kinlay S, Echouffo-Tcheugui JB, Peralta AO, Hoffmeister PS, Boden WE, Yarmohammadi H, Martin DT, Singh JP. Persistence of significant secondary mitral regurgitation post-cardiac resynchronization therapy and survival: a systematic review and meta-analysis : Mitral regurgitation and mortality post-CRT. Heart Fail Rev 2024; 29:165-178. [PMID: 37855988 DOI: 10.1007/s10741-023-10359-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2023] [Indexed: 10/20/2023]
Abstract
Cardiac resynchronization therapy (CRT) significantly reduces secondary mitral regurgitation (MR) in patients with severe left ventricular systolic dysfunction. However, uncertainty remains as to whether improvement in secondary MR correlates with improvement with mortality seen in CRT. We conducted a meta-analysis to determine the association of persistent unimproved significant secondary MR (defined as moderate or moderate-to-severe or severe MR) compared to improved MR (no MR or mild MR) post-CRT with all-cause mortality, cardiovascular mortality, and heart failure hospitalization. A systematic search of PubMed, EMBASE, and Cochrane Library databases till July 31, 2022 identified studies reporting clinical outcomes by post-CRT secondary MR status. In 12 prospective studies of 4954 patients (weighted mean age 66.8 years, men 77.8%), the median duration of follow-up post-CRT at which patients were re-evaluated for significant secondary MR was 6 months and showed significant relative risk reduction of 30% compared to pre-CRT. The median duration of follow-up post-CRT for ascertainment of main clinical outcomes was 38 months. The random effects pooled hazard ratio (95% confidence interval) of all-cause mortality in patients with unimproved secondary MR compared to improved secondary MR was 2.00 (1.57-2.55); p < 0.001). There was insufficient data to evaluate secondary outcomes in a meta-analysis, but limited data that examined the relationship showed significant association of unimproved secondary MR with increased cardiovascular mortality and heart failure hospitalization. The findings of this meta-analysis suggest that lack of improvement in secondary MR post-CRT is associated with significantly elevated risk of all-cause mortality and possibly cardiovascular mortality and heart failure hospitalization. Future studies may investigate approaches to address persistent secondary MR post-CRT to help improved outcome in this population.
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Affiliation(s)
- Matthew F Yuyun
- Cardiology and Vascular Medicine Service, VA , Boston Healthcare System, 1400 VFW Parkway, West Roxbury, Boston, MA 02132, USA.
- Harvard Medical School, Boston, USA.
- Boston University School of Medicine, Boston, USA.
| | - Jacob Joseph
- Cardiology and Vascular Medicine Service, VA , Boston Healthcare System, 1400 VFW Parkway, West Roxbury, Boston, MA 02132, USA
- VA Providence Healthcare System, Providence, RI, USA
- Brown University, Providence, RI, USA
| | - Sebhat A Erqou
- VA Providence Healthcare System, Providence, RI, USA
- Brown University, Providence, RI, USA
| | - Scott Kinlay
- Cardiology and Vascular Medicine Service, VA , Boston Healthcare System, 1400 VFW Parkway, West Roxbury, Boston, MA 02132, USA
- Harvard Medical School, Boston, USA
- Boston University School of Medicine, Boston, USA
- Brigham and Women's Hospital, Boston, USA
| | - Justin B Echouffo-Tcheugui
- Division of Endocrinology, Diabetes & Metabolism, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Adelqui O Peralta
- Cardiology and Vascular Medicine Service, VA , Boston Healthcare System, 1400 VFW Parkway, West Roxbury, Boston, MA 02132, USA
- Harvard Medical School, Boston, USA
- Boston University School of Medicine, Boston, USA
| | - Peter S Hoffmeister
- Cardiology and Vascular Medicine Service, VA , Boston Healthcare System, 1400 VFW Parkway, West Roxbury, Boston, MA 02132, USA
- Harvard Medical School, Boston, USA
- Boston University School of Medicine, Boston, USA
| | - William E Boden
- Cardiology and Vascular Medicine Service, VA , Boston Healthcare System, 1400 VFW Parkway, West Roxbury, Boston, MA 02132, USA
- Harvard Medical School, Boston, USA
- Boston University School of Medicine, Boston, USA
| | | | - David T Martin
- Harvard Medical School, Boston, USA
- Brigham and Women's Hospital, Boston, USA
| | - Jagmeet P Singh
- Harvard Medical School, Boston, USA
- Massachusetts General Hospital, Boston, USA
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Meyer TE, Chen K, Parker MW, Shih J, Rahban Y. Perspectives on Secondary Mitral Regurgitation in Heart Failure. Curr Heart Fail Rep 2023; 20:417-428. [PMID: 37695505 DOI: 10.1007/s11897-023-00627-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/16/2023] [Indexed: 09/12/2023]
Abstract
PURPOSE OF THE REVIEW This review focuses on broader perspectives of mitral regurgitation (MR) in patients with heart failure. RECENT FINDINGS The ratio of regurgitant volume to end-diastolic volume appears to help identify patients who may benefit from valve interventions. Secondary MR is not only attributed to geometric changes of the LV but also related to the structural changes in the mitral valve that include fibrosis of the mitral leaflets and changes in the extracellular matrix. The transition from mild to severe secondary MR can occur at different rates, from a slow LV remodeling process to a more abrupt process precipitated by an inciting event such as atrial fibrillation. Septal flash and apical rocking, two new visual markers of LV mechanical dyssynchrony, appear to be predictive of MR reduction following cardiac resynchronization therapy. Optimal guideline-directed medical therapy has been shown to decrease the severity of secondary MR effectively. A theoretical framework to characterize secondary MR as it relates to the onset of MR is proposed. Type A: Early onset of MR contemporaneous with myocardial injury. The maladaptive LV remodeling occurs in parallel with MR. Type B: LV remodeling proceeds without significant MR until the LV is moderately dilated, which coincides with or without inciting factors such as atrial fibrillation. Type C: LV remodeling proceeds after myocardial injury without significant MR until the LV is severely dilated. MR is a late manifestation of LV remodeling.
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Affiliation(s)
- Theo E Meyer
- Division of Cardiology, University of Massachusetts Chan Medical School, UMassMemorial Medical Center, Worcester, MA, USA.
| | - Kai Chen
- Division of Cardiology, University of Massachusetts Chan Medical School, UMassMemorial Medical Center, Worcester, MA, USA
| | - Matthew W Parker
- Division of Cardiology, University of Massachusetts Chan Medical School, UMassMemorial Medical Center, Worcester, MA, USA
| | - Jeff Shih
- Division of Cardiology, University of Massachusetts Chan Medical School, UMassMemorial Medical Center, Worcester, MA, USA
| | - Youssef Rahban
- Division of Cardiology, University of Massachusetts Chan Medical School, UMassMemorial Medical Center, Worcester, MA, USA
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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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Abstract
PURPOSE OF THE REVIEW Dyssynchrony occurs when portions of the cardiac chambers contract in an uncoordinated fashion. Ventricular dyssynchrony primarily impacts the left ventricle and may result in heart failure. This entity is recognized as a major contributor to the development and progression of heart failure. A hallmark of dyssynchronous heart failure (HFd) is left ventricular recovery after dyssynchrony is corrected. This review discusses the current understanding of pathophysiology of HFd and provides clinical examples and current techniques for treatment. RECENT FINDINGS Data show that HFd responds poorly to medical therapy. Cardiac resynchronization therapy (CRT) in the form of conventional biventricular pacing (BVP) is of proven benefit in HFd, but is limited by a significant non-responder rate. Recently, conduction system pacing (His bundle or left bundle branch area pacing) has also shown promise in correcting HFd. HFd should be recognized as a distinct etiology of heart failure; HFd responds best to CRT.
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Affiliation(s)
- Sean J Dikdan
- Thomas Jefferson University Hospital, Philadelphia, PA, 19107, USA
| | | | - Behzad B Pavri
- Thomas Jefferson University Hospital, Philadelphia, PA, 19107, USA.
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Russo E, Russo G, Cassese M, Braccio M, Carella M, Compagnucci P, Dello Russo A, Casella M. The Role of Cardiac Resynchronization Therapy for the Management of Functional Mitral Regurgitation. Cells 2022; 11:cells11152407. [PMID: 35954250 PMCID: PMC9367730 DOI: 10.3390/cells11152407] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/31/2022] [Accepted: 08/02/2022] [Indexed: 02/04/2023] Open
Abstract
Valve leaflets and chordae structurally normal characterize functional mitral regurgitation (FMR), which in heart failure (HF) setting results from an imbalance between closing and tethering forces secondary to alterations in the left ventricle (LV) and left atrium geometry. In this context, FMR impacts the quality of life and increases mortality. Despite multiple medical and surgical attempts to treat FMR, to date, there is no univocal treatment for many patients. The pathophysiology of FMR is highly complex and involves several underlying mechanisms. Left ventricle dyssynchrony may contribute to FMR onset and worsening and represents an important target for FMR management. In this article, we discuss the mechanisms of FMR and review the potential therapeutic role of CRT, providing a comprehensive review of the available data coming from clinical studies and trials.
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Affiliation(s)
- Eleonora Russo
- Department of Cardiovascular Disease, IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy
- Correspondence:
| | - Giulio Russo
- Department of Biomedicine and Prevention, Policlinico Tor Vergata, University of Rome, 00133 Rome, Italy
| | - Mauro Cassese
- Department of Cardiac Surgery, Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy
| | - Maurizio Braccio
- Department of Cardiac Surgery, Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy
| | - Massimo Carella
- Scientific Research Department, IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy
| | - Paolo Compagnucci
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti Umberto I-Lancisi-Salesi”, 60126 Ancona, Italy
- Department of Biomedical Sciences and Public Health, University Hospital ”Umberto I-Lancisi-Salesi”, Marche Polytechnic University, 60126 Ancona, Italy
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti Umberto I-Lancisi-Salesi”, 60126 Ancona, Italy
- Department of Biomedical Sciences and Public Health, University Hospital ”Umberto I-Lancisi-Salesi”, Marche Polytechnic University, 60126 Ancona, Italy
| | - Michela Casella
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti Umberto I-Lancisi-Salesi”, 60126 Ancona, Italy
- Department of Clinical, Special and Dental Sciences, University Hospital “Umberto I-Lancisi-Salesi”, Marche Polytechnic University, 60126 Ancona, Italy
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Russo E, Russo G, Braccio M, Cassese M. Predictors of persistence of functional mitral regurgitation after cardiac resynchronization therapy: Review of literature. World J Cardiol 2022; 14:170-176. [PMID: 35432771 PMCID: PMC8968452 DOI: 10.4330/wjc.v14.i3.170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 10/10/2021] [Accepted: 03/07/2022] [Indexed: 02/06/2023] Open
Abstract
Functional mitral regurgitation is a common finding among heart failure patients with ischemic and non-ischemic dilated cardiomyopathies. The presence of moderate or severe mitral regurgitation is associated with higher morbidity and mortality. Heart failure patients meeting electrocardiogram and left ventricle function criteria are good candidates for cardiac resynchronization therapy, which may reduce the degree of functional mitral regurgitation in the short and long term, specifically targeting myocardial dyssynchrony and inducing left ventricle reverse remodeling. In this article, we analyze data from the literature about predictors of mitral regurgitation improvement after cardiac resynchronization therapy implantation.
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Affiliation(s)
- Eleonora Russo
- Department of Cardiovascular Surgery, Casa Sollievo della Sofferenza Hospital, IRCCS, San Giovanni Rotondo 71013, Italy
| | - Giulio Russo
- Institute of Cardiology, Catholic University of the Sacred Heart, Rome 00168, Italy
| | - Maurizio Braccio
- Department of Cardiovascular Surgery, Casa Sollievo della Sofferenza Hospital, IRCCS, San Giovanni Rotondo 71013, Italy
| | - Mauro Cassese
- Department of Cardiovascular Surgery, Casa Sollievo della Sofferenza Hospital, IRCCS, San Giovanni Rotondo 71013, Italy
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Michalski B, Stankovic I, Pagourelias E, Ciarka A, Aarones M, Winter S, Faber L, Aakhus S, Fehske W, Cvijic M, Voigt JU. Relationship of Mechanical Dyssynchrony and LV Remodeling With Improvement of Mitral Regurgitation After CRT. JACC Cardiovasc Imaging 2021; 15:212-220. [PMID: 34656470 DOI: 10.1016/j.jcmg.2021.08.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 08/17/2021] [Accepted: 08/20/2021] [Indexed: 01/14/2023]
Abstract
OBJECTIVES The aim of this study was to explore the association between mechanical dyssynchrony of the left ventricle before cardiac resynchronization therapy (CRT) and improvement of mitral regurgitation (MR) after CRT. BACKGROUND MR is very frequent among patients with dilated cardiomyopathy and conduction delay. METHODS Echocardiograms (pre-CRT and 12 ± 3.8 months thereafter) of 314 patients with dilated cardiomyopathy and any degree of MR, who underwent CRT device implantation according to guidelines, were analyzed. Left ventricular (LV) mechanical dyssynchrony was assessed by apical rocking (ApRock) and septal flash (SF), while MR severity was graded from I to IV on the basis of vena contracta width, regurgitation jet size, and proximal isovelocity surface area. RESULTS At baseline, 30% of patients presented with severe MR (grade III or IV). In 62% of patients, MR decreased after CRT, and these patients more frequently had left bundle branch block, had more severe MR, had more dilated left ventricles, had lower ejection fractions, and more often had ApRock and SF. Reverse remodeling was more frequent among patients with MR reduction (ΔLV end-systolic volume -35.5% ± 27.2% vs -4.1% ± 33.2%; P < 0.001). In a multivariable logistic stepwise regression, only ApRock (odds ratio [OR]: 3.8; 95% CI: 1.7-8.5; P = 0.001), SF (OR: 3.6; 95% CI: 1.6-7.9; P = 0.002), and baseline MR (OR: 1.4; 95% CI: 1.0-1.9; P = 0.046) remained significantly associated with MR reduction. CONCLUSIONS ApRock, SF, and severity of MR at baseline are strongly associated with MR reduction after CRT, while LV reverse remodeling is its underlying mechanism. Therefore, in patients with heart failure with LV dyssynchrony on optimal medical treatment, CRT should be the primary treatment attempt for relevant MR.
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Affiliation(s)
- Blazej Michalski
- Department of Cardiovascular Diseases, University Hospital Gasthuisberg, Catholic University Leuven, Leuven, Belgium; Department of Cardiology, Medical University of Lodz, Lodz, Poland
| | - Ivan Stankovic
- Department of Cardiology, Clinical Hospital Centre Zemun, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Efstathios Pagourelias
- Department of Cardiovascular Diseases, University Hospital Gasthuisberg, Catholic University Leuven, Leuven, Belgium
| | - Agnieszka Ciarka
- Department of Cardiovascular Diseases, University Hospital Gasthuisberg, Catholic University Leuven, Leuven, Belgium; Faculty of Medicine, University of Information Technology and Management, Rzeszow, Poland
| | - Marit Aarones
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Stefan Winter
- Klinik für Innere Medizin und Kardiologie, St. Vinzenz Hospital, Cologne, Germany
| | - Lothar Faber
- Department of Cardiology, Heart and Diabetes Centre of North-Rhine Westphalia, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - Svend Aakhus
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Wolfgang Fehske
- Klinik für Innere Medizin und Kardiologie, St. Vinzenz Hospital, Cologne, Germany
| | - Marta Cvijic
- Department of Cardiology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Jens-Uwe Voigt
- Department of Cardiovascular Diseases, University Hospital Gasthuisberg, Catholic University Leuven, Leuven, Belgium.
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Upadhyay GA, Henry M, Genovese D, Desai P, Lattell J, Wey H, Besser SA, Aziz Z, Beaser AD, Ozcan C, Nayak HM, Lang RM, Tung R. Impact of physiological pacing on functional mitral regurgitation in systolic dysfunction: Initial echocardiographic remodeling findings after His bundle pacing. Heart Rhythm O2 2021; 2:446-454. [PMID: 34667959 PMCID: PMC8505206 DOI: 10.1016/j.hroo.2021.07.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Although His bundle pacing (HBP) has been shown to improve left ventricular ejection fraction (LVEF), its impact on mitral regurgitation (MR) remains uncertain. OBJECTIVES The aim of this study was to evaluate change in functional MR after HBP in patients with left ventricular (LV) systolic dysfunction. METHODS Paired echocardiograms were retrospectively assessed in patients with reduced LVEF (<50%) undergoing HBP for pacing or resynchronization. The primary outcomes assessed were change in MR, LVEF, LV volumes, and valve geometry pre- and post-HBP. MR reduction was characterized as a decline in ≥1 MR grade post-HBP in patients with ≥grade 3 MR at baseline. RESULTS Thirty patients were analyzed: age 68 ± 15 years, 73% male, LVEF 32% ± 10%, 38% coronary artery disease, 33% history of atrial fibrillation. Baseline QRS was 162 ± 31 ms: 33% left bundle branch block, 37% right bundle branch block, 17% paced, and 13% narrow QRS. Significant reductions in LV end-systolic volume (122 mL [73-152 mL] to 89 mL [71-122 mL], P = .006) and increase in LV ejection fraction (31% [25%-37%] to 39% [30%-49%], P < .001) were observed after HBP. Ten patients had grade 3 or 4 MR at baseline, with reduction in MR observed in 7. In patients with at least grade 3 MR at baseline, reduction in LV volumes, improved mitral valve geometry, and greater LV contractility were associated with MR reduction. Greater reduction in paced QRS width was present in MR responders compared to non-MR responders (-40% vs -25%, P = .04). CONCLUSIONS In this initial detailed echocardiographic analysis in patients with LV systolic dysfunction, HBP reduced functional MR through favorable ventricular remodeling.
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Affiliation(s)
- Gaurav A. Upadhyay
- Center for Arrhythmia Care, Section of Cardiology, Department of Medicine, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Michael Henry
- Cardiac Imaging Center, Section of Cardiology, Department of Medicine, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Davide Genovese
- Cardiac Imaging Center, Section of Cardiology, Department of Medicine, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Parth Desai
- Center for Arrhythmia Care, Section of Cardiology, Department of Medicine, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Jonathan Lattell
- Center for Arrhythmia Care, Section of Cardiology, Department of Medicine, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Hannah Wey
- Center for Arrhythmia Care, Section of Cardiology, Department of Medicine, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Stephanie A. Besser
- Center for Arrhythmia Care, Section of Cardiology, Department of Medicine, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Zaid Aziz
- Center for Arrhythmia Care, Section of Cardiology, Department of Medicine, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Andrew D. Beaser
- Center for Arrhythmia Care, Section of Cardiology, Department of Medicine, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Cevher Ozcan
- Center for Arrhythmia Care, Section of Cardiology, Department of Medicine, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Hemal M. Nayak
- Center for Arrhythmia Care, Section of Cardiology, Department of Medicine, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Roberto M. Lang
- Cardiac Imaging Center, Section of Cardiology, Department of Medicine, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Roderick Tung
- Center for Arrhythmia Care, Section of Cardiology, Department of Medicine, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
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Abdelaziz SM, Hussein RRS, El Mokadem M, Mahmoud HB. Clinical and hemodynamic effects of oral sildenafil on biventricular function on patients with left ventricular systolic dysfunction. Int J Clin Pract 2021; 75:e14171. [PMID: 33764636 DOI: 10.1111/ijcp.14171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 03/14/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND We explore the dual benefits of sildenafil on bi-ventricular functions in the form of improvement of ejection fraction, pulmonary vascular resistance and functional capacity of systolic heart failure patients either related to dilated or ischemic cardiomyopathy. AIM OF THE WORK To evaluate the effect of oral sildenafil on biventricular function in patients with left ventricular systolic dysfunction. PATIENTS AND METHODS The prospective randomised case-control study included 80 patients with left ventricular systolic dysfunction resulting from dilated or ischemic cardiomyopathy were equally randomised to one of the treatment groups in (1:1) who were collected from the outpatient clinic of cardiac care unit (CCU) of Beni-Suef University hospital; each group contained 40 patients: The first group (control group): received the guideline-recommended treatment of heart failure with reduced ejection fraction which consists of [angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), beta-blockers, aldosterone receptor antagonist, digoxin]. The second group (sildenafil group): received the previously mentioned guideline-recommended treatment in the control group plus sildenafil 25 mg three times per day. All patients were subjected to detailed history taking, baseline transthorathic echocardiography and exercise ECG using the Naughton protocol. Follow-up transthorathic echocardiography and exercise ECG was conducted after 3 months. RESULTS Sildenafil improves heart failure symptoms such as dyspnea or orthopnea or increasing the functional capacity of myocardium which is measured by estimated metabolic equivalents of task (METS) (P = .017), and exercise duration (P = .013). Sildenafil increased cardiac output (P = .033), which is considered one of the desirable targets in heart failure patients. CONCLUSION In patients with left ventricular systolic dysfunction secondary to dilated or ischemic cardiomyopathy, relatively small doses of sildenafil significantly enhances exercise period and functional ability, with substantial improvement in left ventricular systolic function irrespective of the existence of major pulmonary hypertension.
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Affiliation(s)
- Sarah M Abdelaziz
- Department of Clinical Pharmacy, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Raghda R S Hussein
- Department of Clinical Pharmacy, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Mostafa El Mokadem
- Department of Cardiology, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
| | - Hesham B Mahmoud
- Department of Cardiology, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
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11
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Bartko PE, Hülsmann M, Hung J, Pavo N, Levine RA, Pibarot P, Vahanian A, Stone GW, Goliasch G. Secondary valve regurgitation in patients with heart failure with preserved ejection fraction, heart failure with mid-range ejection fraction, and heart failure with reduced ejection fraction. Eur Heart J 2021; 41:2799-2810. [PMID: 32350503 DOI: 10.1093/eurheartj/ehaa129] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 01/12/2020] [Accepted: 02/12/2020] [Indexed: 12/27/2022] Open
Abstract
Secondary mitral regurgitation and secondary tricuspid regurgitation due to heart failure (HF) remain challenging in almost every aspect: increasing prevalence, poor prognosis, notoriously elusive in diagnosis, and complexity of therapeutic management. Recently, defined HF subgroups according to three ejection fraction (EF) ranges (reduced, mid-range, and preserved) have stimulated a structured understanding of the HF syndrome but the role of secondary valve regurgitation (SVR) across the spectrum of EF remains undefined. This review expands this structured understanding by consolidating the underlying phenotype of myocardial impairment with each type of SVR. Specifically, the current understanding, epidemiological considerations, impact, public health burden, mechanisms, and treatment options of SVR are discussed separately for each lesion across the HF spectrum. Furthermore, this review identifies important gaps in knowledge, future directions for research, and provides potential solutions for diagnosis and treatment. Mastering the challenge of SVR requires a multidisciplinary collaborative effort, both, in clinical practice and scientific approach to optimize patient outcomes.
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Affiliation(s)
- Philipp E Bartko
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Martin Hülsmann
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Judy Hung
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114-2696, USA
| | - Noemi Pavo
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Robert A Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114-2696, USA
| | - Philippe Pibarot
- Laval Hospital, Research Center Québec Heart Institute, Pavillon Ferdinand-Vandry 1050, avenue de la Médecine Local 4211, Laval University, Quebec City, Québec, Canada
| | - Alec Vahanian
- University of Paris, 5 Rue Thomas Mann, 75013 Paris, France
| | - Gregg W Stone
- Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, Cardiovascular Research Foundation, 1700 Broadway, New York, NY 10019, USA
| | - Georg Goliasch
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
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12
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Vinciguerra M, Grigioni F, Romiti S, Benfari G, Rose D, Spadaccio C, Cimino S, De Bellis A, Greco E. Ischemic Mitral Regurgitation: A Multifaceted Syndrome with Evolving Therapies. Biomedicines 2021; 9:biomedicines9050447. [PMID: 33919263 PMCID: PMC8143318 DOI: 10.3390/biomedicines9050447] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/14/2021] [Accepted: 04/19/2021] [Indexed: 12/24/2022] Open
Abstract
Dysfunction of the left ventricle (LV) with impaired contractility following chronic ischemia or acute myocardial infarction (AMI) is the main cause of ischemic mitral regurgitation (IMR), leading to moderate and moderate-to-severe mitral regurgitation (MR). The site of AMI exerts a specific influence determining different patterns of adverse LV remodeling. In general, inferior-posterior AMI is more frequently associated with regional structural changes than the anterolateral one, which is associated with global adverse LV remodeling, ultimately leading to different phenotypes of IMR. In this narrative review, starting from the aforementioned categorization, we proceed to describe current knowledge regarding surgical approaches in the management of IMR.
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Affiliation(s)
- Mattia Vinciguerra
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (S.R.); (S.C.); (E.G.)
- Correspondence:
| | - Francesco Grigioni
- Unit of Cardiovascular Sciences, Department of Medicine Campus Bio-Medico, University of Rome, 00128 Rome, Italy;
| | - Silvia Romiti
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (S.R.); (S.C.); (E.G.)
| | - Giovanni Benfari
- Division of Cardiology, Department of Medicine, University of Verona, 37219 Verona, Italy;
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - David Rose
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool FY3 8NP, UK; (D.R.); (C.S.)
| | - Cristiano Spadaccio
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool FY3 8NP, UK; (D.R.); (C.S.)
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8QQ, UK
| | - Sara Cimino
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (S.R.); (S.C.); (E.G.)
| | - Antonio De Bellis
- Department of Cardiology and Cardiac Surgery, Casa di Cura “S. Michele”, 81024 Maddaloni, Caserta, Italy;
| | - Ernesto Greco
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (S.R.); (S.C.); (E.G.)
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13
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Hadjadj S, Marsit O, Paradis JM, Beaudoin J. Pathophysiology, Diagnosis, and New Therapeutic Approaches for Ischemic Mitral Regurgitation. Can J Cardiol 2020; 37:968-979. [PMID: 33347977 DOI: 10.1016/j.cjca.2020.12.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 12/10/2020] [Accepted: 12/12/2020] [Indexed: 01/22/2023] Open
Abstract
Ischemic mitral regurgitation (MR) is a valvular complication frequently seen in patients with coronary artery disease and is associated with increased mortality and morbidity. Ischemic mitral regurgitation has a complex, heterogeneous, and still incompletely understood pathophysiology involving both the mitral valve and the left ventricle. The occurrence of valve regurgitation in patients with ischemic cardiomyopathy in return accelerates left ventricular remodelling and dysfunction, ultimately leading to irreversible heart failure. Diagnostic evaluation of ischemic MR is unique and different from the other causes of MR. The severity thresholds associated with outcomes are different from primary MR, and specific imaging characteristics are potentially useful to guide therapy. The use of imaging modalities such as 3-dimensional echocardiography and cardiac magnetic resonance imaging can refine the diagnostic evaluation and help in choosing the correct management. Although multiple treatments are available to improve ischemic MR, each therapeutic option is associated with limitations and incomplete success. Therapy has therefore to be individualised for each patient. Current options include optimal medical therapy, cardiac resynchronisation therapy, percutaneous or surgical revascularisation, surgical mitral repair or replacement, and new percutaneous interventions. This review aims to discuss the latest insights regarding the pathophysiology, diagnosis, and treatment of ischemic MR.
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Affiliation(s)
- Sandra Hadjadj
- Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Ons Marsit
- Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Jean-Michel Paradis
- Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Jonathan Beaudoin
- Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada.
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14
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Hübscher A, Schwerg M, Hoffmann S, Baldenhofer G, Heupel C, Jasaityte R, Kruck S, Stangl K, Dreger H, Knebel F. Automated quantification of mitral valve tenting volume in functional mitral regurgitation by three‐dimensional echocardiography. Echocardiography 2020; 37:1043-1048. [DOI: 10.1111/echo.14759] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 05/24/2020] [Indexed: 11/28/2022] Open
Affiliation(s)
- Anne Hübscher
- Medizinische Klinik für Kardiologie und AngiologieCampus Charité MitteCharité – Universitätsmedizin Berlin Berlin Germany
| | - Marius Schwerg
- Medizinische Klinik für Kardiologie und AngiologieCampus Charité MitteCharité – Universitätsmedizin Berlin Berlin Germany
| | - Saskia Hoffmann
- Medizinische Klinik für Kardiologie und AngiologieCampus Charité MitteCharité – Universitätsmedizin Berlin Berlin Germany
| | - Gerd Baldenhofer
- Medizinische Klinik für Kardiologie und AngiologieCampus Charité MitteCharité – Universitätsmedizin Berlin Berlin Germany
- DZHK (German Centre for Cardiovascular Research)Partner Site Berlin Germany
| | - Christian Heupel
- Medizinische Klinik für Kardiologie und AngiologieCampus Charité MitteCharité – Universitätsmedizin Berlin Berlin Germany
| | - Ruta Jasaityte
- Medizinische Klinik für Kardiologie und AngiologieCampus Charité MitteCharité – Universitätsmedizin Berlin Berlin Germany
| | - Sebastian Kruck
- Cardio Centrum Ludwigsburg Bietigheim Bietigheim‐Bissingen Germany
| | - Karl Stangl
- Medizinische Klinik für Kardiologie und AngiologieCampus Charité MitteCharité – Universitätsmedizin Berlin Berlin Germany
- DZHK (German Centre for Cardiovascular Research)Partner Site Berlin Germany
| | - Henryk Dreger
- Medizinische Klinik für Kardiologie und AngiologieCampus Charité MitteCharité – Universitätsmedizin Berlin Berlin Germany
- DZHK (German Centre for Cardiovascular Research)Partner Site Berlin Germany
| | - Fabian Knebel
- Medizinische Klinik für Kardiologie und AngiologieCampus Charité MitteCharité – Universitätsmedizin Berlin Berlin Germany
- DZHK (German Centre for Cardiovascular Research)Partner Site Berlin Germany
- Berlin Institute of Health (BIH) Berlin Germany
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15
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Gavazzoni M, Taramasso M, Zuber M, Pozzoli A, Miura M, Oliveira D, Maisano F. Functional mitral regurgitation and cardiac resynchronization therapy in the "era" of trans-catheter interventions: Is it time to move from a staged strategy to a tailored therapy? Int J Cardiol 2020; 315:15-21. [PMID: 32456957 DOI: 10.1016/j.ijcard.2020.03.071] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 02/19/2020] [Accepted: 03/27/2020] [Indexed: 01/15/2023]
Abstract
Cardiac resynchronization therapy (CRT) has been associated to left ventricle (LV) remodelling, reduction of functional mitral regurgitation (FMR) and clinical improvement in patients with heart failure and reduced ejection fraction (HFrEF). The prevalence of significant FMR in patients with LV dyssynchrony that are candidate to CRT is up to 40%. Current approach in patients with FMR undergoing CRT consists of re-evaluation of the amount of FMR following a waiting period of at least 3 months after the implant. In case of persistent significant FMR despite CRT and guideline directed medical therapy, trancatheter Mitral Valve repair (TMVR) is an important option to improve quality of life and prognosis. This stepwise approach does not take into account the probability of the individual response to CRT and the availability of TMVR solutions that are safe and effective in high risk patients. We reviewed the effects of CRT on FMR, the prognostic role of persistence of FMR after CRT treatment and the impact of treatment of FMR in patients CRT non responders. We aimed to point out the limits of current step-wised approach in light on more recent evidence regarding FMR treatment. A new, "tailored" approached is proposed.
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Affiliation(s)
- Mara Gavazzoni
- Heart Valve Clinic, University Hospital of Zurich, Ramistrasse 100, 8091 Zurich, Switzerland.
| | - Maurizio Taramasso
- Heart Valve Clinic, University Hospital of Zurich, Ramistrasse 100, 8091 Zurich, Switzerland
| | - Michel Zuber
- Heart Valve Clinic, University Hospital of Zurich, Ramistrasse 100, 8091 Zurich, Switzerland
| | - Alberto Pozzoli
- Heart Valve Clinic, University Hospital of Zurich, Ramistrasse 100, 8091 Zurich, Switzerland
| | - Mizuki Miura
- Heart Valve Clinic, University Hospital of Zurich, Ramistrasse 100, 8091 Zurich, Switzerland
| | | | - Francesco Maisano
- Heart Valve Clinic, University Hospital of Zurich, Ramistrasse 100, 8091 Zurich, Switzerland
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16
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Bartko PE, Pavo N, Spinka G, Hülsmann M, Goliasch G. The Authors Reply. JACC Cardiovasc Imaging 2020; 13:891. [PMID: 32139037 DOI: 10.1016/j.jcmg.2019.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 10/16/2019] [Indexed: 11/26/2022]
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17
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Bartko PE, Arfsten H, Heitzinger G, Pavo N, Strunk G, Gwechenberger M, Hengstenberg C, Binder T, Hülsmann M, Goliasch G. Papillary Muscle Dyssynchrony-Mediated Functional Mitral Regurgitation. JACC Cardiovasc Imaging 2019; 12:1728-1737. [DOI: 10.1016/j.jcmg.2018.06.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/01/2018] [Accepted: 06/13/2018] [Indexed: 01/14/2023]
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18
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Packer M. Electrophysiological interventions in the treatment of chronic heart failure: a comparison of the strength of evidence supporting cardiac resynchronization for electrical conduction delay and catheter ablation for atrial fibrillation. Eur J Heart Fail 2019; 21:398-401. [PMID: 30838721 DOI: 10.1002/ejhf.1447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 01/21/2019] [Accepted: 01/30/2019] [Indexed: 11/05/2022] Open
Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA.,Imperial College, London, UK
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19
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Levine RA, Nagata Y, Dal-Bianco JP. Left Ventricular Dyssynchrony and the Mitral Valve Apparatus: An Orchestra That Needs to Play in Sync. JACC Cardiovasc Imaging 2019; 12:1738-1740. [PMID: 30660517 DOI: 10.1016/j.jcmg.2018.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 07/23/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Robert A Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Yasufumi Nagata
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Cardiology, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Jacob P Dal-Bianco
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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20
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Mele D, Bertini M, Malagù M, Nardozza M, Ferrari R. Current role of echocardiography in cardiac resynchronization therapy. Heart Fail Rev 2018; 22:699-722. [PMID: 28714039 DOI: 10.1007/s10741-017-9636-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Cardiac resynchronization therapy (CRT) is an established treatment for patients with heart failure and left ventricular systolic dysfunction. Patients are usually assessed by echocardiography, which provides a number of anatomical and functional information used for cardiac dyssynchrony assessment, prognostic stratification, identification of the optimal site of pacing in the left ventricle, optimization of the CRT device, and patient follow-up. Compared to other cardiac imaging techniques, echocardiography has the advantage to be non-invasive, repeatable, and safe, without exposure to ionizing radiation or nefrotoxic contrast. In this article, we review current evidence about the role of echocardiography before, during, and after the implantation of a CRT device.
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Affiliation(s)
- Donato Mele
- Centro Cardiologico Universitario and LTTA Centre, University of Ferrara, Ferrara, Italy. .,Noninvasive Cardiology Unit, Azienda Ospedaliero-Universitaria, Via Aldo Moro 8, 44124, Ferrara, Cona, Italy.
| | - Matteo Bertini
- Centro Cardiologico Universitario and LTTA Centre, University of Ferrara, Ferrara, Italy
| | - Michele Malagù
- Centro Cardiologico Universitario and LTTA Centre, University of Ferrara, Ferrara, Italy
| | - Marianna Nardozza
- Centro Cardiologico Universitario and LTTA Centre, University of Ferrara, Ferrara, Italy
| | - Roberto Ferrari
- Centro Cardiologico Universitario and LTTA Centre, University of Ferrara, Ferrara, Italy.,Maria Cecilia Hospital, GVM Care & Research, E.S. Health Science Foundation, Cotignola, RA, Italy
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21
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Mele D, Luisi GA, Malagù M, Laterza A, Ferrari R, Bertini M. Echocardiographic evaluation of cardiac dyssynchrony: Does it still matter? Echocardiography 2018; 35:707-715. [PMID: 29719067 DOI: 10.1111/echo.13902] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Cardiac resynchronization therapy (CRT) is an established treatment for patients with heart failure and left ventricular systolic dysfunction. For many years, cardiac mechanical dyssynchrony assessed by echocardiography has been considered as a key evaluation to characterize CRT candidates and predict CRT response. In current guidelines, however, CRT implant indications rely only on electrical dyssynchrony. The aim of this article was to clarify whether and how the evaluation of cardiac mechanical dyssynchrony should be performed today by echocardiography.
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Affiliation(s)
- Donato Mele
- Cardiology Unit and LTTA Center, University of Ferrara, Ferrara, Italy
| | | | - Michele Malagù
- Cardiology Unit and LTTA Center, University of Ferrara, Ferrara, Italy
| | - Anna Laterza
- Cardiology Unit and LTTA Center, University of Ferrara, Ferrara, Italy
| | - Roberto Ferrari
- Cardiology Unit and LTTA Center, University of Ferrara, Ferrara, Italy.,Maria Cecilia Hospital, GVM Care & Research, E.S. Health Science Foundation, Cotignola, Italy
| | - Matteo Bertini
- Cardiology Unit and LTTA Center, University of Ferrara, Ferrara, Italy
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22
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Fernández-Friera L, Salguero R, Vannini L, Argüelles AF, Arribas F, Solís J. Mechanistic insights of the left ventricle structure and fibrosis in the arrhythmogenic mitral valve prolapse. Glob Cardiol Sci Pract 2018; 2018:4. [PMID: 29644231 PMCID: PMC5857061 DOI: 10.21542/gcsp.2018.4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 12/20/2017] [Indexed: 01/03/2023] Open
Abstract
Mitral valve prolapse (MVP) is a common and benign condition. However, some anatomic forms have been recently associated with life-threatening ventricular arrhythmias and sudden cardiac death. Imaging MVP holds the promise of individualized MVP risk assessment. Noninvasive imaging techniques available today are playing an increasingly important role in the diagnosis, prognosis and monitoring of MVP. In this article, we will review the current evidence on arrhythmogenic MVP, with special focus on the utility of echocardiography and CMR for identifying benign and "malignant" forms of MVP. The clinical relevance of this manuscript lies in the value of imaging technology to improve MVP risk prediction, including those arrhythmic-MVP cases with a higher risk of sudden cardiac death.
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Affiliation(s)
- Leticia Fernández-Friera
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain
- HM Hospitales-Centro Integral de Enfermedades Cardiovasculares HM-CIEC, Madrid, Spain
| | | | - Luca Vannini
- Hospital Universitario 12 de Octubre, Madrid, Spain
- Universidad Rey Juan Carlos (PhD Etudent in Epidemiology and Public Health), Madrid
| | - Ana Fidalgo Argüelles
- HM Hospitales-Centro Integral de Enfermedades Cardiovasculares HM-CIEC, Madrid, Spain
| | | | - Jorge Solís
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain
- HM Hospitales-Centro Integral de Enfermedades Cardiovasculares HM-CIEC, Madrid, Spain
- Hospital Universitario 12 de Octubre, Madrid, Spain
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23
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Mihos CG, Yucel E, Capoulade R, Orencole MP, Upadhyay GA, Santana O, Singh JP, Picard MH. Effects of cardiac resynchronization therapy after inferior myocardial infarction on secondary mitral regurgitation and mitral valve geometry. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 41:114-121. [DOI: 10.1111/pace.13255] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 11/06/2017] [Accepted: 11/28/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Christos G. Mihos
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital; Harvard Medical School; Boston MA USA
- Echocardiography Laboratory, Columbia University Division of Cardiology; Mount Sinai Heart Institute; Miami Beach FL USA
| | - Evin Yucel
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital; Harvard Medical School; Boston MA USA
| | - Romain Capoulade
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital; Harvard Medical School; Boston MA USA
| | - Mary P. Orencole
- Cardiac Arrhythmia Service, Massachusetts General Hospital; Harvard Medical School; Boston MA USA
| | | | - Orlando Santana
- Echocardiography Laboratory, Columbia University Division of Cardiology; Mount Sinai Heart Institute; Miami Beach FL USA
| | - Jagmeet P. Singh
- Cardiac Arrhythmia Service, Massachusetts General Hospital; Harvard Medical School; Boston MA USA
| | - Michael H. Picard
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital; Harvard Medical School; Boston MA USA
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24
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Mihos CG, Yucel E, Capoulade R, Orencole MP, Upadhyay GA, Santana O, Singh JP, Picard MH. Impact of cardiac resynchronization therapy on mitral valve apparatus geometry and clinical outcomes in patients with secondary mitral regurgitation. Echocardiography 2017; 34:1561-1567. [DOI: 10.1111/echo.13690] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- Christos G. Mihos
- Cardiac Ultrasound Laboratory; Massachusetts General Hospital; Harvard Medical School; Boston MA USA
| | - Evin Yucel
- Cardiac Ultrasound Laboratory; Massachusetts General Hospital; Harvard Medical School; Boston MA USA
| | - Romain Capoulade
- Cardiac Ultrasound Laboratory; Massachusetts General Hospital; Harvard Medical School; Boston MA USA
| | - Mary P. Orencole
- Cardiac Arrhythmia Service; Massachusetts General Hospital; Harvard Medical School; Boston MA USA
| | | | - Orlando Santana
- Columbia University Division of Cardiology; Mount Sinai Heart Institute; Miami Beach FL USA
| | - Jagmeet P. Singh
- Cardiac Arrhythmia Service; Massachusetts General Hospital; Harvard Medical School; Boston MA USA
| | - Michael H. Picard
- Cardiac Ultrasound Laboratory; Massachusetts General Hospital; Harvard Medical School; Boston MA USA
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25
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Chatterjee NA, Gold MR, Waggoner AD, Picard MH, Stein KM, Yu Y, Meyer TE, Wold N, Ellenbogen KA, Singh JP. Longer Left Ventricular Electric Delay Reduces Mitral Regurgitation After Cardiac Resynchronization Therapy: Mechanistic Insights From the SMART-AV Study (SmartDelay Determined AV Optimization: A Comparison to Other AV Delay Methods Used in Cardiac Resynchronization Therapy). Circ Arrhythm Electrophysiol 2017; 9:CIRCEP.116.004346. [PMID: 27906653 DOI: 10.1161/circep.116.004346] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Accepted: 10/05/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Mitral regurgitation (MR) is associated with worse survival in those undergoing cardiac resynchronization therapy (CRT). Left ventricular (LV) lead position in CRT may ameliorate mechanisms of MR. We examine the association between a longer LV electric delay (QLV) at the LV stimulation site and MR reduction after CRT. METHODS AND RESULTS QLV was assessed retrospectively in 426 patients enrolled in the SMART-AV study (SmartDelay Determined AV Optimization: A Comparison to Other AV Delay Methods Used in CRT). QLV was defined as the time from QRS onset to the first large peak of the LV electrogram. Linear regression and logistic regression were used to assess the association between baseline QLV and MR reduction at 6 months (absolute change in vena contracta width and odds of ≥1 grade reduction in MR). At baseline, there was no difference in MR grade, LV dyssynchrony, or LV volumes in those with QLV above versus below the median (95 ms). After multivariable adjustment, increasing QLV was an independent predictor of MR reduction at 6 months as reflected by an increased odds of MR response (odds ratio: 1.13 [1.03-1.25]/10 ms increase QLV; P=0.02) and a decrease in vena contracta width (P<0.001). At 3 months, longer QLV (≥median) was associated with significant decrease in LV end-systolic volume (ΔLV end-systolic volume -28.2±38.9 versus -4.9±33.8 mL, P<0.001). Adjustment for 3-month ΔLV end-systolic volume attenuated the association between QLV and 6-month MR reduction. CONCLUSIONS In patients undergoing CRT, longer QLV was an independent predictor of MR reduction at 6 months and associated with interval 3-month LV reverse remodeling. These findings provide a mechanistic basis for using an electric-targeting LV lead strategy at the time of CRT implant.
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Affiliation(s)
| | | | | | | | | | - Yinghong Yu
- For the author affiliations, please see the Appendix
| | | | - Nicholas Wold
- For the author affiliations, please see the Appendix
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Bertrand PB, Schwammenthal E, Levine RA, Vandervoort PM. Exercise Dynamics in Secondary Mitral Regurgitation: Pathophysiology and Therapeutic Implications. Circulation 2017; 135:297-314. [PMID: 28093494 DOI: 10.1161/circulationaha.116.025260] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Secondary mitral valve regurgitation (MR) remains a challenging problem in the diagnostic workup and treatment of patients with heart failure. Although secondary MR is characteristically dynamic in nature and sensitive to changes in ventricular geometry and loading, current therapy is mainly focused on resting conditions. An exercise-induced increase in secondary MR, however, is associated with impaired exercise capacity and increased mortality. In an era where a multitude of percutaneous solutions are emerging for the treatment of patients with heart failure, it becomes important to address the dynamic component of secondary MR during exercise as well. A critical reappraisal of the underlying disease mechanisms, in particular the dynamic component during exercise, is of timely importance. This review summarizes the pathophysiological mechanisms involved in the dynamic deterioration of secondary MR during exercise, its functional and prognostic impact, and the way current treatment options affect the dynamic lesion and exercise hemodynamics in general.
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Affiliation(s)
- Philippe B Bertrand
- From Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium (P.B.B., P.M.V.); Faculty of Medicine and Life Sciences, Hasselt University, Belgium (P.B.B., P.M.V.); Heart Center, Sheba Medical Center, Tel Hashomer, Israel (E.S.); and Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston (R.A.L.).
| | - Ehud Schwammenthal
- From Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium (P.B.B., P.M.V.); Faculty of Medicine and Life Sciences, Hasselt University, Belgium (P.B.B., P.M.V.); Heart Center, Sheba Medical Center, Tel Hashomer, Israel (E.S.); and Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston (R.A.L.)
| | - Robert A Levine
- From Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium (P.B.B., P.M.V.); Faculty of Medicine and Life Sciences, Hasselt University, Belgium (P.B.B., P.M.V.); Heart Center, Sheba Medical Center, Tel Hashomer, Israel (E.S.); and Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston (R.A.L.)
| | - Pieter M Vandervoort
- From Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium (P.B.B., P.M.V.); Faculty of Medicine and Life Sciences, Hasselt University, Belgium (P.B.B., P.M.V.); Heart Center, Sheba Medical Center, Tel Hashomer, Israel (E.S.); and Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston (R.A.L.)
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Beaudoin J, Singh JP, Szymonifka J, Zhou Q, Levine RA, Januzzi JL, Truong QA. Novel Heart Failure Biomarkers Predict Improvement of Mitral Regurgitation in Patients Receiving Cardiac Resynchronization Therapy-The BIOCRT Study. Can J Cardiol 2016; 32:1478-1484. [PMID: 27527259 PMCID: PMC5123954 DOI: 10.1016/j.cjca.2016.05.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Revised: 05/19/2016] [Accepted: 05/25/2016] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) improves mitral regurgitation (MR) in a subset of patients. We hypothesized that biomarkers (amino-terminal pro-B type natriuretic peptide, high-sensitivity troponin I, galectin-3 [gal-3], and soluble ST2) might predict MR response after CRT. METHODS We measured levels of biomarkers during CRT implantation in 132 patients with a subsequent 2-year follow-up. MR was graded as no-trace, mild, moderate, or severe at baseline and at 6 months. RESULTS In patients with baseline at least mild MR, 56% had improvement at 6 months, with lower 2-year mortality vs patients without improvement (0% vs 18%; P = 0.002). At baseline, patients with MR improvement had lower high-sensitivity troponin I and gal-3 levels compared with those without improvement (19 vs 40 pg/L; P = 0.01; 14 vs 18 ng/mL; P = 0.007). In multivariable analyses, higher log-transformed gal-3 (odds ratio, 0.15; 95% confidence interval, 0.04-0.65; P = 0.01) remained an independent predictor for MR nonimprovement. Levels of pro-B type natriuretic peptide and soluble ST2 were lower at follow-up in patients with MR improvement (potentially reflecting reduced myocardial stretch and stress) without reaching statistical significance. CONCLUSIONS Higher galectin levels at the time of CRT implantation are associated with MR nonresponse.
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Affiliation(s)
- Jonathan Beaudoin
- Institut Universitaire de Cardiologie et de Pneumologie de Québec - Université Laval, Québec City, Quebec, Canada; Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - Jagmeet P Singh
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiac Arrhythmia Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jackie Szymonifka
- Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and Weill Cornell Medical College, New York, New York, USA
| | - Qing Zhou
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert A Levine
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - James L Januzzi
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Quynh A Truong
- Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and Weill Cornell Medical College, New York, New York, USA
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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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Ebrille E, DeSimone CV, Vaidya VR, Chahal AA, Nkomo VT, Asirvatham SJ. Ventricular pacing - Electromechanical consequences and valvular function. Indian Pacing Electrophysiol J 2016; 16:19-30. [PMID: 27485561 PMCID: PMC4936653 DOI: 10.1016/j.ipej.2016.02.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Although great strides have been made in the areas of ventricular pacing, it is still appreciated that dyssynchrony can be malignant, and that appropriately placed pacing leads may ameliorate mechanical dyssynchrony. However, the unknowns at present include: 1. The mechanisms by which ventricular pacing itself can induce dyssynchrony; 2. Whether or not various pacing locations can decrease the deleterious effects caused by ventricular pacing; 3. The impact of novel methods of pacing, such as atrioventricular septal, lead-less, and far-field surface stimulation; 4. The utility of ECG and echocardiography in predicting response to therapy and/or development of dyssynchrony in the setting of cardiac resynchronization therapy (CRT) lead placement; 5. The impact of ventricular pacing-induced dyssynchrony on valvular function, and how lead position correlates to potential improvement. This review examines the existing literature to put these issues into context, to provide a basis for understanding how electrical, mechanical, and functional aspects of the heart can be distorted with ventricular pacing. We highlight the central role of the mitral valve and its function as it relates to pacing strategies, especially in the setting of CRT. We also provide future directions for improved pacing modalities via alternative pacing sites and speculate over mechanisms on how lead position may affect the critical function of the mitral valve and thus overall efficacy of CRT.
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Affiliation(s)
- Elisa Ebrille
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA; Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | | | - Vaibhav R Vaidya
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Anwar A Chahal
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA; Clinical and Translational Science, Mayo Graduate School, Rochester, MN, USA
| | - Vuyisile T Nkomo
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Samuel J Asirvatham
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA; Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA.
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Spartera M, Galderisi M, Mele D, Cameli M, D'Andrea A, Rossi A, Mondillo S, Novo G, Esposito R, D'Ascenzi F, Montisci R, Gallina S, Margonato A, Agricola E. Role of cardiac dyssynchrony and resynchronization therapy in functional mitral regurgitation. Eur Heart J Cardiovasc Imaging 2016; 17:471-80. [DOI: 10.1093/ehjci/jev352] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 12/14/2015] [Indexed: 12/28/2022] Open
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Ushijima T, Nishida T, Kan-O M, Tominaga R. Left ventricular pacing can be a complementary solution for systolic anterior motion after mitral valve plasty. Eur J Cardiothorac Surg 2015; 49:1004-5. [PMID: 25904766 DOI: 10.1093/ejcts/ezv121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 03/04/2015] [Indexed: 11/12/2022] Open
Abstract
A 54-year old man underwent redo mitral valve (MV) plasty because of recurrent mitral regurgitation (MR). Intraoperative transoesophageal echocardiography revealed severe MR and turbulent flow at the left ventricular (LV) outflow tract associated with systolic anterior motion of the MV. Various medical treatments, additional surgical correction, and atrial and right ventricular pacing had failed to resolve the MR associated with systolic anterior motion. LV pacing, however, markedly attenuated MR. Temporary LV pacing was discontinued on postoperative day 2, and subsequently MR associated with systolic anterior motion has not recurred. LV dyssynchrony resulting from conduction disturbances might cause systolic anterior motion immediately after MV plasty. We speculate that LV pacing eliminated LV dyssynchrony and improved the MR associated with systolic anterior motion. Temporary LV pacing can be performed easily and safely at the time of MV plasty. LV pacing can be a complementary treatment for systolic anterior motion and resultant MR.
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Affiliation(s)
- Tomoki Ushijima
- Department of Cardiovascular Surgery, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Takahiro Nishida
- Department of Cardiovascular Surgery, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Meikun Kan-O
- Department of Cardiovascular Surgery, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Ryuji Tominaga
- Department of Cardiovascular Surgery, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
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Upadhyay GA, Chatterjee NA, Kandala J, Friedman DJ, Park MY, Tabtabai SR, Hung J, Singh JP. Assessing mitral regurgitation in the prediction of clinical outcome after cardiac resynchronization therapy. Heart Rhythm 2015; 12:1201-8. [PMID: 25708879 DOI: 10.1016/j.hrthm.2015.02.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) has been shown to reduce mitral regurgitation (MR), although the clinical impact of this improvement remains uncertain. OBJECTIVES We sought to evaluate the impact of MR improvement on clinical outcome after CRT and to assess predictors and mechanism for change in MR. METHODS This was a cohort study of patients undergoing CRT for conventional indications with baseline and follow-up echocardiography (at 6 months). MR severity was classified into 4 grades. The primary end point was time to all-cause death or time to first heart failure (HF) hospitalization assessed at 3 years. RESULTS A total of 439 patients were included: median age was 70.2 years, 90 (20.5%) were women, 255 (58.1%) with ischemic cardiomyopathy, and mean QRS width was 162 ms. Worsening severity of baseline MR was independently predictive of HF or all-cause mortality (hazard ratio 1.33; 95% confidence interval 1.01-1.75; P = .042). Reduction in MR after CRT was significantly associated with lower HF hospitalization and improved survival (hazard ratio 0.65; 95% confidence interval 0.49-0.85; P = .002). Degree of baseline MR and longer surface QRS to left ventricular lead time were significant predictors of MR change. Patients with MR reduction exhibited lower mitral valve tenting area (P < .001) and coaptation height (P < .001) than those with stable or worsening MR, suggestive of improved ventricular geometry as a mechanism for change in MR. CONCLUSION Degree of baseline MR and change in MR after CRT predicted all-cause mortality and HF hospitalization at 3 years. Longer surface QRS to left ventricular lead time at implant may be a means to target MR improvement.
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Affiliation(s)
- Gaurav A Upadhyay
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts; Heart Rhythm Center, Section of Cardiology, University of Chicago, Chicago, Illinois
| | | | - Jagdesh Kandala
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts
| | - Daniel J Friedman
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts
| | - Mi-Young Park
- Echocardiography Laboratory of the Massachusetts General Hospital, Boston, Massachusetts
| | | | - Judy Hung
- Echocardiography Laboratory of the Massachusetts General Hospital, Boston, Massachusetts
| | - Jagmeet P Singh
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts.
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Atta S, Bashandy M, Zaky S. Baseline QRS width and mitral regurgitation behavior after cardiac resynchronization therapy among patients with dilated cardiomyopathy. Egypt Heart J 2014. [DOI: 10.1016/j.ehj.2013.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Ramakrishna H, Ghadimi K, Augoustides JGT. Incidental moderate mitral regurgitation in patients undergoing coronary artery bypass grafting: update on guidelines and key randomized trials. J Cardiothorac Vasc Anesth 2014; 28:189-193. [PMID: 24440010 DOI: 10.1053/j.jvca.2013.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Indexed: 11/11/2022]
Abstract
Incidental moderate mitral regurgitation (MR) in patients presenting for coronary artery bypass grafting (CABG) is not only common but also probably adversely affects clinical outcome. The echocardiographic evaluation of incidental MR must be comprehensive and integrated, as it remains a cornerstone in management decisions. Current guidelines support surgical mitral intervention in this setting as a reasonable option, reflecting clinical equipoise towards moderate MR in the setting of planned CABG. There are currently 2 major randomized trials in progress that will test whether surgical correction of moderate MR combined with CABG improves major clinical outcomes as compared to CABG alone. These landmark trials will be completed in the near future. In the interim, significant progress in the fields of cardiac resynchronization therapy, transcatheter mitral valve intervention, and minimally invasive mitral valve surgery promise to affect the management alternatives for moderate MR in patients undergoing CABG regardless of operative risk. It is likely that in the coming decade there will be less tolerance for incidental moderate MR given its already known outcome effects and the multimodal interventions that continue to mature with better safety profiles.
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Affiliation(s)
| | - Kamrouz Ghadimi
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John G T Augoustides
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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Lin QS, Fang F, Yu CM, Zhang YC, Hsiung MC, Salgo IS, Looi JL, Wan S, Wong RH, Underwood MJ, Sun JP, Yin WH, Wei J, Jin CN, Tsai SK, Ji L, Lee APW. Dynamic assessment of the changing geometry of the mitral apparatus in 3D could stratify abnormalities in functional mitral regurgitation and potentially guide therapy. Int J Cardiol 2014; 176:878-84. [DOI: 10.1016/j.ijcard.2014.08.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Revised: 07/07/2014] [Accepted: 08/02/2014] [Indexed: 10/24/2022]
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Dal-Bianco JP, Beaudoin J, Handschumacher MD, Levine RA. Basic mechanisms of mitral regurgitation. Can J Cardiol 2014; 30:971-81. [PMID: 25151282 DOI: 10.1016/j.cjca.2014.06.022] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Revised: 06/16/2014] [Accepted: 06/22/2014] [Indexed: 12/17/2022] Open
Abstract
Any structural or functional impairment of the mitral valve (MV) apparatus that exhausts MV tissue redundancy available for leaflet coaptation will result in mitral regurgitation (MR). The mechanism responsible for MV malcoaptation and MR can be dysfunction or structural change of the left ventricle, the papillary muscles, the chordae tendineae, the mitral annulus, and the MV leaflets. The rationale for MV treatment depends on the MR mechanism and therefore it is essential to identify and understand normal and abnormal MV and MV apparatus function.
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Affiliation(s)
- Jacob P Dal-Bianco
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan Beaudoin
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Department of Cardiology, Québec City, Québec, Canada
| | - Mark D Handschumacher
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert A Levine
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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Auger D, Hoke U, Thijssen J, Abate E, Yiu KH, Ewe SH, Witkowski TG, Leong DP, Holman ER, Ajmone Marsan N, Schalij MJ, Bax JJ, Delgado V. Effect of cardiac resynchronization therapy on the sequence of mechanical activation assessed by two-dimensional radial strain imaging. Am J Cardiol 2014; 113:982-7. [PMID: 24462070 DOI: 10.1016/j.amjcard.2013.11.059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 11/26/2013] [Accepted: 11/26/2013] [Indexed: 11/18/2022]
Abstract
Cardiac resynchronization therapy (CRT) induces left ventricular (LV) reverse remodeling by synchronizing LV mechanical activation. We evaluated changes in segmental LV activation after CRT and related them to CRT response. A total of 292 patients with heart failure (65 ± 10 years, 77% men) treated with CRT underwent baseline echocardiographic assessment of LV volumes and ejection fraction. Time-to-peak radial strain was measured for 6 midventricular LV segments with speckle-tracking strain imaging. Moreover, the time difference between the peak radial strain of the anteroseptal and the posterior segments was calculated to obtain LV dyssynchrony. After 6 months, LV volumes, segmental LV mechanical activation timings, and LV dyssynchrony were reassessed. Response to CRT was defined as ≥15% decrease in LV end-systolic volume at 6-month follow-up. Responders (n = 177) showed LV resynchronization 6 months after CRT (LV dyssynchrony from 200 ± 127 to 85 ± 86 ms; p <0.001) by earlier activation of the posterior segment (from 438 ± 141 to 394 ± 132 ms; p = 0.001) and delayed activation of the anteroseptal segment (from 295 ± 155 to 407 ± 138 ms; p <0.001). In contrast, nonresponders (n = 115) experienced an increase in LV dyssynchrony 6 months after CRT (from 106 ± 86 to 155 ± 112 ms; p = 0.001) with an earlier activation of posterior wall (from 391 ± 139 to 355 ± 136 ms; p = 0.039) that did not match the delayed anteroseptal activation (from 360 ± 148 to 415 ± 122 ms; p = 0.001). In conclusion, responders to CRT showed LV resynchronization through balanced lateral and anteroseptal activations. In nonresponders, LV dyssynchrony remains, by posterior wall preactivation and noncompensatory delayed septal wall activation.
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Affiliation(s)
- Dominique Auger
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands; Department of Cardiology, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Ulas Hoke
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Joep Thijssen
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Elena Abate
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Kai-Hang Yiu
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - See Hooi Ewe
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Tomasz G Witkowski
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Darryl P Leong
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Eduard R Holman
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Martin J Schalij
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.
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Gabrielli L, Sitges M, Mont L. Assessing reverse remodeling in heart failure patients treated with cardiac resynchronization therapy and its impact on prognosis. Expert Rev Cardiovasc Ther 2014; 10:1437-48. [DOI: 10.1586/erc.12.137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Sardari A, Ashraf H, Khorsand M, Zoroufian A, Sahebjam M, Jalali A, Sadeghian H. Correlation between Mitral Regurgitation and Myocardial Mechanical Dyssynchrony and QRS Duration in Patients with Cardiomyopathy. J Tehran Heart Cent 2014; 9:147-52. [PMID: 25870638 PMCID: PMC4394052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 06/23/2014] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Several competing geometric and hemodynamic factors are suggested as contributing mechanisms for functional mitral regurgitation (MR) in heart failure patients. We aimed to study the relationships between the severity of MR and the QRS duration and dyssynchrony markers in patients with ischemic or dilated cardiomyopathy. METHODS We prospectively evaluated 251 heart failure patients with indications for echocardiographic evaluation of possible cardiac resynchronization therapy. All the patients were subjected to transthoracic echocardiography and tissue Doppler imaging to evaluate the left ventricular (LV) synchronicity. The patients were divided into two groups according to the severity of MR: ≤ mild MR and ≥ moderate MR. The effects of different dyssynchrony indices were adjusted for global and regional left ventricular remodeling parameters. RESULTS From the 251 patients (74.5% male, mean age = 53.38 ± 16.68 years), 130 had ≤ mild MR and 121 had ≥ moderate MR. There were no differences between the groups regarding the mean age, frequency of sex, and etiology of cardiomyopathy. The LV systolic and diastolic dimensions were greater in the patients with ≥ moderate MR (all p values < 0.001). Among the different echocardiographic factors, the QRS duration (150.75 ± 34.66 vs. 126.77 ± 29.044 ms; p value = 0.050) and interventricular mechanical delay (41.60 ± 29.50 vs. 35.00 ms ± 22.01; p value = 0.045) were significantly longer in the patients with ≤ mild MR in the univariate analysis. After adjusting the effect of these parameters on the severity of MR for the regional and global LV remodeling parameters, no significant impact of the QRS duration and dyssynchrony indices was observed. CONCLUSION Our results showed that the degree of functional MR was not associated with the QRS duration and inter- and intraventricular dyssynchrony in our patients with cardiomyopathy. No association was found between the severity of MR and the ischemic or dilated etiology for cardiomyopathy.
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Affiliation(s)
| | | | | | | | | | | | - Hakimeh Sadeghian
- Corresponding Author: Hakimeh Sadeghian, Associate Professor of Cardiology, Echocardiography Department, Tehran Heart Center, North Kargar Street, Tehran, Iran. 1411713138. Tel: +98 21 88029257. Fax: +98 21 88029256. E-mail:
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Abstract
Patients with heart failure and decreased function frequently develop discoordinate contraction because of electric activation delay. Often termed dyssynchrony, this further decreases systolic function and chamber efficiency and worsens morbidity and mortality. In the mid- 1990s, a pacemaker-based treatment termed cardiac resynchronization therapy (CRT) was developed to restore mechanical synchrony by electrically activating both right and left sides of the heart. It is a major therapeutic advance for the new millennium. Acute chamber effects of CRT include increased cardiac output and mechanical efficiency and reduced mitral regurgitation, whereas reduction in chamber volumes ensues more chronically. Patient candidates for CRT have a prolonged QRS duration and discoordinate wall motion, although other factors may also be important because ≈30% of such selected subjects do not respond to the treatment. In contrast to existing pharmacological inotropes, CRT both acutely and chronically increases cardiac systolic function and work, yet it also reduces long-term mortality. Recent studies reveal unique molecular and cellular changes from CRT that may also contribute to this success. Heart failure with dyssynchrony displays decreased myocyte and myofilament function, calcium handling, β-adrenergic responsiveness, mitochondrial ATP synthase activity, cell survival signaling, and other changes. CRT reverses many of these abnormalities often by triggering entirely new pathways. In this review, we discuss chamber, circulatory, and basic myocardial effects of dyssynchrony and CRT in the failing heart, and we highlight new research aiming to better target and implement CRT, as well as leverage its molecular effects.
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Affiliation(s)
- Jonathan A Kirk
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Barsoum EA, Bhat T, Asti D, Kowalski M, Vazzana T. Cardiac resynchronization therapy in acute pulmonary edema: A case report. World J Cardiol 2013; 5:355-358. [PMID: 24109499 PMCID: PMC3783988 DOI: 10.4330/wjc.v5.i9.355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2013] [Revised: 08/14/2013] [Accepted: 08/20/2013] [Indexed: 02/06/2023] Open
Abstract
We are reporting a case of 71-year old lady with a dual chamber demand pacemaker, who developed acute pulmonary edema due to an acute left ventricular (LV) dysfunction and worsening in mitral valve regurgitation after atrioventricular nodal ablation for uncontrolled atrial fibrillation. This was attributed to right ventricular apical pacing leading to LV dyssynchronization. Patient dramatically improved within 12-24 h after upgrading her single chamber pacemaker to biventricular pacing. Our case demonstrates that biventricular pacing can be an effective modality of treatment of acute congestive heart failure. In particular, it can be used when it is secondary to LV dysfunction and severe mitral regurgitation attributed to significant dyssynchrony created by right ventricular pacing in patients with atrioventricular nodal ablation for chronic atrial fibrillation.
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Onishi T, Onishi T, Marek JJ, Ahmed M, Haberman SC, Oyenuga O, Adelstein E, Schwartzman D, Saba S, Gorcsan J. Mechanistic features associated with improvement in mitral regurgitation after cardiac resynchronization therapy and their relation to long-term patient outcome. Circ Heart Fail 2013; 6:685-93. [PMID: 23733917 DOI: 10.1161/circheartfailure.112.000112] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Mechanisms of mitral regurgitation (MR) reduction with cardiac resynchronization therapy (CRT) are complex, and their association with long-term outcome is unclear. We sought to elucidate mechanistic features of reduction in MR with CRT, which impact long-term patient survival. METHODS AND RESULTS A prospective longitudinal study of 277 patients with heart failure with QRS width ≥ 120 ms and ejection fraction ≤ 35% for CRT was performed. Quantitative echocardiography, including dyssynchrony analysis, was performed at baseline. MR was quantified by color Doppler before and 6 months after CRT. Predefined end points of death, transplant, or left ventricular assist device were tracked during 4 years. There were 114 (48%) patients with CRT with significant MR (≥ moderate) at baseline; of whom 48 (42%) patients had MR improvement, and 24 (19%) patients had MR worsening after CRT. The 66 events (47 deaths, 10 transplantations, and 9 left ventricular assist devices) were strongly associated with significant MR after CRT (hazard ratio, 3.58; 95% confidence interval, 2.18-5.87; P<0.0001). Three echocardiographic features were independently associated with amelioration of significant MR after CRT by multivariable analysis: anteroseptal to posterior wall radial strain dyssynchrony >200 ms, lack of severe left ventricular dilatation (end-systolic dimension index <29 mm/m(2)), and lack of echocardiographic scar at papillary muscle insertion sites (all P<0.05) and, when combined, were additively associated with long-term survival (P=0.0001). CONCLUSIONS Significant MR after CRT was strongly associated with less favorable long-term survival. Echocardiographic mechanistic features were identified that were associated with improvement in MR after CRT and favorable long-term survival.
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Affiliation(s)
- Tetsuari Onishi
- Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, PA 15213-2582, USA
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Abstract
The mitral valve apparatus is a complex 3-dimensional (3D) functional unit that is critical to unidirectional heart pump function. This review details the normal anatomy, histology, and function of the main mitral valve apparatus components: mitral annulus, mitral valve leaflets, chordae tendineae, and papillary muscles. Two-dimensional and 3D echocardiography is ideally suited to examine the mitral valve apparatus and has provided important insights into the mechanism of mitral valve disease. An overview of standardized echocardiography image acquisition and interpretation is provided. Understanding normal mitral valve apparatus function is essential to comprehend alterations in mitral valve disease and the rationale for repair strategies.
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Kramer DB, Reynolds MR, Mitchell SL. Resynchronization: considering device-based cardiac therapy in older adults. J Am Geriatr Soc 2013; 61:615-21. [PMID: 23581915 DOI: 10.1111/jgs.12174] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Cardiac resynchronization therapy (CRT) is a device-based treatment available to select individuals with systolic heart failure (HF), a large proportion of whom are aged 65 and older. As the field of CRT advances, together with shifting demographics and expanded indications for implantation, there is a need for practitioners caring for older adults to understand what is and is not known about the use of CRT specifically in this population. Clinical trials demonstrating benefits for severe and mild HF have uncertain generalizability to older adults. Other studies demonstrate that device-related complications may be more common with CRT than with simpler devices and more common in older adults. CRT clinical trials also may not adequately capture outcomes and concerns specific to older adults, including quality of life and end-of-life care experiences. Informed decision-making by clinicians, policy-makers, and patients will require greater understanding of the use and outcomes of CRT in older persons.
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Affiliation(s)
- Daniel B Kramer
- Hebrew Senior Life Institute for Aging Research, Boston, MA 02215, USA.
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Affiliation(s)
- Paul A Grayburn
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX 75226, USA.
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Weiner RB, Baggish AL, Chen-Tournoux A, Marshall JE, Gaggin HK, Bhardwaj A, Mohammed AA, Rehman SU, Barajas L, Barajas J, Gregory SA, Moore SA, Semigran MJ, Januzzi JL. Improvement in structural and functional echocardiographic parameters during chronic heart failure therapy guided by natriuretic peptides: mechanistic insights from the ProBNP Outpatient Tailored Chronic Heart Failure (PROTECT) study. Eur J Heart Fail 2012; 15:342-51. [PMID: 23132825 DOI: 10.1093/eurjhf/hfs180] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
AIMS We sought to determine if heart failure (HF) care with a goal to lower N-terminal pro B-type natriuretic peptide (NT-proBNP) concentrations, compared with standard of care (SOC) management, is associated with improvement in echocardiographic parameters of cardiac structure and function. METHODS AND RESULTS Of 151 subjects with HF due to left ventricular systolic dysfunction (LVSD) prospectively randomized to NT-proBNP-guided vs. SOC HF care, 116 had serial echocardiographic data. Endpoints in this echocardiographic study included the relationship between change in NT-proBNP and LV reverse remodelling, as well as associations between biomarker-guided therapy and measures of diastolic function, right ventricular (RV) size and function, estimates of LV filling pressure and RV systolic pressure (RVSP), and the degree of mitral regurgitation (MR). After a mean of 10 months of study procedures, in adjusted analyses, final NT-proBNP concentrations predicted risk of remodelling [hazard ratio (HR) ↑LV end-diastolic volume index = 1.43, 95% confidence interval (CI) 1.10-1.86, P = 0.007; HR ↑LV end-systolic volume index = 1.54, 95% CI 1.10-1.91, P = 0.01; HR ↓LV ejection fraction (LVEF) = 1.53, 905% CI 1.12-1.89, P = 0.02]. In addition to greater improvement in LVEF and reductions in LV volume, compared with SOC, NT-proBNP-guided patients showed significant decreases in the ratio of early transmitral peak velocity to early diastolic peak annular velocity (E/E'), pulmonary vein peak S velocity, RV fractional area change, RVSP, and MR severity. CONCLUSION NT-proBNP concentrations may serve as a non-invasive indicator of the state of cardiac structure and function in HF due to LVSD. Multiple, prognostically meaningful echocardiographic variables improved more significantly in patients treated with NT-proBNP-guided care vs. SOC.
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Affiliation(s)
- Rory B Weiner
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
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Timek TA, Miller DC. Another multidisciplinary look at ischemic mitral regurgitation. Semin Thorac Cardiovasc Surg 2012; 23:220-31. [PMID: 22172360 DOI: 10.1053/j.semtcvs.2011.07.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2011] [Indexed: 12/31/2022]
Abstract
Ischemic mitral regurgitation (IMR) continues to challenge surgeons and scientists alike. This vexing clinical entity frequently complicates myocardial infarction and carries a poor prognosis both in the setting of coronary disease and idiopathic dilated cardiomyopathy. Ischemic mitral regurgitation encompasses a difficult patient population that is characterized by high operative mortality, poor long term outcomes, and frequent recurrent insufficiency after standard surgical repair. Yet optimal surgical repair and improved clinical outcomes can only be achieved with better knowledge of the pathophysiology of IMR which is still incompletely understood. The causative mechanism of IMR appears to lie in the annular and subvalvular frame of the valve rather than leaflet or chordal structure leading to such labels as "ischemic," "functional," "non-organic," and "cardiomyopathy associated" being applied in the clinical literature. Although ischemic mitral regurgitation is a prevailing clinical entity, it has not been consistently defined in the literature, contributing to considerable confusion and contradictory results of clinical studies. As the mechanisms of pathophysiology have been better elucidated, novel surgical and interventional strategies have been developed recently to provide better treatment for this difficult patient population. In this review, we undertake a multidisciplinary update of the pathophysiology, classification, and surgical and interventional treatment of ischemic mitral regurgitation in today's clinical practice.
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Affiliation(s)
- Tomasz A Timek
- West Michigan Cardiothoracic Surgeons and Spectrum Health System, Grand Rapids, Michigan, USA
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Kandala J, Altman RK, Park MY, Singh JP. Clinical, laboratory, and pacing predictors of CRT response. J Cardiovasc Transl Res 2012; 5:196-212. [PMID: 22362181 DOI: 10.1007/s12265-012-9352-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Accepted: 02/08/2012] [Indexed: 01/21/2023]
Abstract
A decade of research has established the role of cardiac resynchronization therapy (CRT) in medically refractory, moderate to severe systolic heart failure (HF) with intraventricular conduction delay. CRT is an electrical therapy instituted to reestablish ventricular synchronization in order to improve cardiac function and favorably modulate the neurohormonal system. CRT confers a mortality benefit, improved HF hospitalizations, and functional outcome in this population, but not all patients consistently demonstrate a positive CRT response. The nonresponder rate varies from 20% to 40%, depending on the defined response criteria. Efforts to improve response to CRT have focused on a number of fronts. Methods to optimize the correction of electrical and mechanical dyssynchrony, which is the primary target of CRT, has been the focus of research, in addition to improving patient selection and optimizing post-implant care. However, a major issue in dealing with improving nonresponse rates has been finding an accurate and generally accepted definition of "response" itself. The availability of a standard consensus definition of CRT response would enable the estimation of nonresponder burden accurately and permit the development of strategies to improve CRT response. In this review, we define various aspects of "response" to CRT and outline variability in the definition criteria and the problems with its inconsistencies. We describe clinical, laboratory, and pacing predictors that influence CRT response and outcome and how to optimize response.
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Affiliation(s)
- Jagdesh Kandala
- Cardiac Arrhythmia Service, Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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Matsumoto K, Tanaka H, Okajima K, Hayashi T, Kajiya T, Kawai H, Hirata KI. Relation between left ventricular morphology and reduction in functional mitral regurgitation by cardiac resynchronization therapy in patients with idiopathic dilated cardiomyopathy. Am J Cardiol 2011; 108:1327-34. [PMID: 21864818 DOI: 10.1016/j.amjcard.2011.06.052] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Revised: 06/27/2011] [Accepted: 06/27/2011] [Indexed: 11/30/2022]
Abstract
The presence of functional mitral regurgitation (MR) is considered a significant risk factor for poor clinical prognosis in patients with idiopathic dilated cardiomyopathy (IDC). The objectives of this study were to test the hypothesis that not only global but also local left ventricular (LV) remodeling, including the position of the papillary muscles, may contribute to the development of MR in patients with IDC and wide QRS durations and can be reversed with cardiac resynchronization therapy (CRT). Eighty-four subjects were studied, 44 patients with IDC who underwent CRT and 40 age- and gender-matched controls. The position of the posteromedial papillary muscle was similar in the 2 groups, whereas the position of the anterolateral papillary muscle in patients with IDC was displaced more posteriorly than in controls. Multivariate analysis revealed that reduction in coaptation height (β = 0.44, p <0.001) and LV dyssynchrony by speckle-tracking radial strain (β = 0.303, p <0.01) were independent determinants of reduction in MR 5 ± 2 days after CRT; in contrast, restoration of the position of the posteriorly displaced anterolateral papillary muscle (β = 0.50, p <0.001) and the increase in sphericity index (β = 0.440, p <0.001) were identified as independent determinants of reduction in MR 6 ± 1 months after CRT. In conclusion, asymmetric local LV remodeling was observed at baseline, and asymmetric local LV reverse remodeling was observed at long-term follow-up after CRT in patients with IDC. Furthermore, different parameters contribute to the reduction in MR observed at short- and long-term follow-up after CRT.
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Affiliation(s)
- Kensuke Matsumoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
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Grayburn PA, Roberts BJ, Aston S, Anwar A, Hebeler RF, Brown DL, Mack MJ. Mechanism and severity of mitral regurgitation by transesophageal echocardiography in patients referred for percutaneous valve repair. Am J Cardiol 2011; 108:882-7. [PMID: 21741608 DOI: 10.1016/j.amjcard.2011.05.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2011] [Revised: 05/06/2011] [Accepted: 05/06/2011] [Indexed: 10/18/2022]
Abstract
Percutaneous mitral valve repair with the MitraClip has been shown to decrease mitral regurgitation (MR) severity, left ventricular volumes, and functional class in patients with severe (3+ or 4+) MR. Determination of which patients are optimal candidates for MitraClip therapy versus surgery has not been rigorously evaluated. Transesophageal echocardiography was prospectively performed in 113 consecutive patients referred for potential MitraClip therapy under the REALISM continued access registry. MR severity was assessed quantitatively in all patients. Mitral valve anatomy and feasibility of MitraClip placement were assessed by transesophageal echocardiography and clinical parameters. MR was degenerative (mitral valve prolapse) in 60 patients (53%), functional (anatomically normal) in 44 (39%), and thickened with restricted motion (Carpentier IIIB classification) in 9 (8%). MR was mild in 19 patients (17%), moderate in 27 (24%), and severe (3 to 4+) in 67 (59%) by Transesophageal echocardiography. MitraClip placement was performed in only 17 of 113 patients (15%); all were successful. Surgical mitral valve repair was performed in 25 patients (22%), mitral valve replacement in 12 (11%). Most patients (59 of 113, 52%) were treated medically, usually because MR was not severe enough to warrant intervention. In conclusion, most patients referred for MitraClip therapy do not have severe enough MR to warrant intervention. Of those with clinical need for intervention, surgery is more often recommended for anatomic or clinical reasons. Three-dimensional transesophageal echocardiography with quantitative assessment of MR severity is helpful in evaluating these patients.
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