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van Kampen A, Morningstar JE, Goudot G, Ingels N, Wenk JF, Nagata Y, Yaghoubian KM, Norris RA, Borger MA, Melnitchouk S, Levine RA, Jensen MO. Utilization of Engineering Advances for Detailed Biomechanical Characterization of the Mitral-Ventricular Relationship to Optimize Repair Strategies: A Comprehensive Review. Bioengineering (Basel) 2023; 10:601. [PMID: 37237671 PMCID: PMC10215167 DOI: 10.3390/bioengineering10050601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/10/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023] Open
Abstract
The geometrical details and biomechanical relationships of the mitral valve-left ventricular apparatus are very complex and have posed as an area of research interest for decades. These characteristics play a major role in identifying and perfecting the optimal approaches to treat diseases of this system when the restoration of biomechanical and mechano-biological conditions becomes the main target. Over the years, engineering approaches have helped to revolutionize the field in this regard. Furthermore, advanced modelling modalities have contributed greatly to the development of novel devices and less invasive strategies. This article provides an overview and narrative of the evolution of mitral valve therapy with special focus on two diseases frequently encountered by cardiac surgeons and interventional cardiologists: ischemic and degenerative mitral regurgitation.
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Affiliation(s)
- Antonia van Kampen
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- Leipzig Heart Centre, University Clinic of Cardiac Surgery, 02189 Leipzig, Germany
| | - Jordan E. Morningstar
- Department of Regenerative Medicine and Cell Biology, University of South Carolina, Charleston, SC 29425, USA
| | - Guillaume Goudot
- Cardiac Ultrasound Laboratory, Department of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Neil Ingels
- Department of Biomedical Engineering, University of Arkansas, Fayetteville, AR 72701, USA
| | - Jonathan F. Wenk
- Department of Mechanical Engineering, University of Kentucky, Lexington, KY 40508, USA;
| | - Yasufumi Nagata
- Cardiac Ultrasound Laboratory, Department of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Koushiar M. Yaghoubian
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Russell A. Norris
- Department of Regenerative Medicine and Cell Biology, University of South Carolina, Charleston, SC 29425, USA
| | - Michael A. Borger
- Leipzig Heart Centre, University Clinic of Cardiac Surgery, 02189 Leipzig, Germany
| | - Serguei Melnitchouk
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Robert A. Levine
- Cardiac Ultrasound Laboratory, Department of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Morten O. Jensen
- Department of Biomedical Engineering, University of Arkansas, Fayetteville, AR 72701, USA
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
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Calafiore AM, Prapas S, Totaro A, Guarracini S, Cargoni M, Katsavrias K, Fattouch K, Di Mauro M. Cutting the second order chords during mitral valve repair. J Card Surg 2022; 37:4072-4078. [PMID: 36378871 DOI: 10.1111/jocs.17194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/15/2022] [Accepted: 09/04/2022] [Indexed: 11/16/2022]
Abstract
The chordae tendinae connect the papillary muscles (PMs) to the mitral valve. While the first-order chordae serve to secure the leaflets to maintain valve closure and prevent mitral valve prolapse, the second-order chordae are believed to play a role in maintaining normal left ventricle size and geometry. The PMs, from where the chordae tendinae originate, function as shock absorbers that compensate for the geometric changes of the left ventricular wall. The second-order chordae connect the PMs to both trigons under tension. The tension distributed towards the second-order chordae has been demonstrate to be more than threefold that in their first-order counterpart. Cutting the second-order chordae puts all the tension on the first-order chordae, which are then closer to their rupture point. However, it has been experimentally demonstrated that the tension at which the first-order chordae break is 6.8 newtons (N), by far higher than the maximal tension reached, that is 0.4 N. Even if the clinical reports have been favorable, the importance of cutting the second-order chordae to recover curvature of the anterior leaflet and increase the coaptation length between the mitral valve leaflets has been slowly absorbed by the surgical world. Nevertheless, there are progressive demonstrations that chordal tethering affects the anterior leaflet not only in secondary, but also in primary mitral regurgitation, having a not negligible role in the long-term outcome of mitral repair.
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Affiliation(s)
| | - Sotirios Prapas
- Division of Cardiac Surgery A, Henry Dunant Hospital, Athens, Greece
| | - Antonio Totaro
- Department of Cardiovascular Diseases, Gemelli Molise, Campobasso, Italy
| | | | - Marco Cargoni
- Department of Surgical, Oncologic and Stomatological Disciplines, GVM Care & Research, Maria Eleonora Hospital, University of Palermo, Palermo, Italy
| | - Kostas Katsavrias
- Division of Cardiac Surgery A, Henry Dunant Hospital, Athens, Greece
| | - Khalil Fattouch
- Department of Cardiac Anesthesia, Mazzini Hospital, Teramo, Italy
| | - Michele Di Mauro
- Departmente of Cardio-Thoracic and Vascular Surgery, Heart and Vascular Center, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC), Maastricht, The Netherlands
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3
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Xu D, Padala M. Commentary: The mitral valve and the left ventricle in functional mitral regurgitation: The puppet and the puppeteer. JTCVS OPEN 2021; 5:63-65. [PMID: 36003163 PMCID: PMC9390187 DOI: 10.1016/j.xjon.2020.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 11/24/2020] [Accepted: 11/27/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Dongyang Xu
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Emory University Hospital Midtown, Atlanta, Ga
| | - Muralidhar Padala
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Emory University Hospital Midtown, Atlanta, Ga
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
- Address for reprints: Muralidhar Padala, PhD, 380B Northyards Blvd, Atlanta, GA 30313.
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Jaworek M, Lucherini F, Romagnoni C, Gelpi G, Contino M, Romitelli P, Antona C, Fiore GB, Vismara R. Modelling of Lesions Associated with Functional Mitral Regurgitation in an Ex Vivo Platform. Ann Biomed Eng 2017; 45:2324-2334. [PMID: 28721493 DOI: 10.1007/s10439-017-1885-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 07/11/2017] [Indexed: 10/19/2022]
Abstract
Functional mitral regurgitation (FMR) is a complex pathology involving valvular and subvalvular structures reconfiguration, and its treatment is considered challenging. There is a lack of experimental models allowing for reliable preclinical FMR treatments' evaluation in a realistic setting. A novel approach to simulate FMR was developed and incorporated into an ex vivo passive beating heart platform. FMR was obtained by dilating the mitral annulus (MA) mainly in the antero-posterior direction and displacing the papillary muscles (PMs) apically and laterally by ad hoc designed and 3D printed dilation and displacing devices. It caused hemodynamic and valve morphology alterations. Isolated MA dilation (MAD) led to significantly increased antero-posterior distance (A-P) and decreased coaptation height (CH), tenting area (TA) and systolic leaflets angulation, resembling clinically recognized type I of mitral regurgitation with normal leaflet motion. Whereas concomitant MAD with PM displacement caused an increase in A-P, TA, CH. This geometrical configuration replicated typical determinants of type IIIb lesion with restricted leaflet motion. The proposed methods provided a realistic and repeatable ex vivo FMR model featuring two lesions clinically associated with the pathology. It bears a promise to be successfully utilized in preclinical studies, clinical training and medical education.
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Affiliation(s)
- Michal Jaworek
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Via Golgi 39, 20133, Milan, Italy. .,ForcardioLab - Fondazione per la Ricerca in Cardiochirurgia ONLUS, Milan, Italy.
| | - Federico Lucherini
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Via Golgi 39, 20133, Milan, Italy.,ForcardioLab - Fondazione per la Ricerca in Cardiochirurgia ONLUS, Milan, Italy
| | - Claudia Romagnoni
- ForcardioLab - Fondazione per la Ricerca in Cardiochirurgia ONLUS, Milan, Italy.,Cardiovascular Department, 'Luigi Sacco' General Hospital, Milan, Italy
| | - Guido Gelpi
- ForcardioLab - Fondazione per la Ricerca in Cardiochirurgia ONLUS, Milan, Italy.,Cardiovascular Department, 'Luigi Sacco' General Hospital, Milan, Italy
| | - Monica Contino
- ForcardioLab - Fondazione per la Ricerca in Cardiochirurgia ONLUS, Milan, Italy.,Cardiovascular Department, 'Luigi Sacco' General Hospital, Milan, Italy
| | | | - Carlo Antona
- ForcardioLab - Fondazione per la Ricerca in Cardiochirurgia ONLUS, Milan, Italy.,Cardiovascular Department, 'Luigi Sacco' General Hospital, Milan, Italy
| | - Gianfranco B Fiore
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Via Golgi 39, 20133, Milan, Italy.,ForcardioLab - Fondazione per la Ricerca in Cardiochirurgia ONLUS, Milan, Italy
| | - Riccardo Vismara
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Via Golgi 39, 20133, Milan, Italy.,ForcardioLab - Fondazione per la Ricerca in Cardiochirurgia ONLUS, Milan, Italy
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Shi W, McIver BV, Kalra K, Sarin EL, Schmarkey S, Duggan M, Thourani VH, Guyton RA, Padala M. A Swine Model of Percutaneous Intracoronary Ethanol Induced Acute Myocardial Infarction and Ischemic Mitral Regurgitation. J Cardiovasc Transl Res 2017; 10:391-400. [PMID: 28577038 DOI: 10.1007/s12265-017-9751-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 05/12/2017] [Indexed: 11/26/2022]
Abstract
Ischemic mitral regurgitation (IMR) is a frequent complication after a myocardial infarction (MI), which doubles mortality. Transcatheter mitral repairs are emerging as alternative treatment options to open heart surgery for IMR, but animal models to test them are lacking. We report a percutaneous swine model of IMR. Seventeen swine were randomized to (group 1, n = 12) MI causing IMR, and (group 2, n = 5) controls. In group 1, MI was induced via percutaneous ethanol injection into the obtuse marginal branches of the left circumflex artery, resulting in ST elevating myocardial infarction. Nine animals were survived to 8-10 weeks with weekly echocardiograms and three swine were survived to 16-20 weeks with MRI at termination. In group 1 animals, average IMR fraction at termination was 26.6 ± 2.3% in the echo group, and 24.51 ± 0.41% in the MRI group. None of the animals in group 2 had IMR. Left ventricular dysfunction and significant dilatation were evident in group 1 animals, compared to the controls. In conclusion, a reproducible model of IMR is reported for use in pre-clinical testing of new mitral technologies.
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Affiliation(s)
- Weiwei Shi
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Division of Cardiothoracic Surgery, Emory University, 380-B, Northyards Boulevard, Atlanta, GA, 30313, USA
| | - Bryant V McIver
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Division of Cardiothoracic Surgery, Emory University, 380-B, Northyards Boulevard, Atlanta, GA, 30313, USA
| | - Kanika Kalra
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Division of Cardiothoracic Surgery, Emory University, 380-B, Northyards Boulevard, Atlanta, GA, 30313, USA
| | - Eric L Sarin
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Division of Cardiothoracic Surgery, Emory University, 380-B, Northyards Boulevard, Atlanta, GA, 30313, USA
- INOVA Heart & Vascular Institute, Fairfax, VA, USA
| | - Susan Schmarkey
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Division of Cardiothoracic Surgery, Emory University, 380-B, Northyards Boulevard, Atlanta, GA, 30313, USA
| | - Michael Duggan
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Division of Cardiothoracic Surgery, Emory University, 380-B, Northyards Boulevard, Atlanta, GA, 30313, USA
- Division of Cardiac Anesthesiology, Emory University, Atlanta, USA
| | - Vinod H Thourani
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Division of Cardiothoracic Surgery, Emory University, 380-B, Northyards Boulevard, Atlanta, GA, 30313, USA
| | - Robert A Guyton
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Division of Cardiothoracic Surgery, Emory University, 380-B, Northyards Boulevard, Atlanta, GA, 30313, USA
| | - Muralidhar Padala
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Division of Cardiothoracic Surgery, Emory University, 380-B, Northyards Boulevard, Atlanta, GA, 30313, USA.
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6
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Mihos CG, Xydas S, Yucel E, Capoulade R, Williams RF, Mawad M, Garcia G, Santana O. Mitral valve repair and subvalvular intervention for secondary mitral regurgitation: a systematic review and meta-analysis of randomized controlled and propensity matched studies. J Thorac Dis 2017; 9:S582-S594. [PMID: 28740711 DOI: 10.21037/jtd.2017.05.56] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Combining a ring annuloplasty (Ring) with a mitral subvalvular intervention (Ring + subvalvular) in patients with secondary mitral regurgitation (MR) may improve mitral valve (MV) repair durability. However, the outcomes of this strategy compared with a Ring only, have not been clearly defined. METHODS A systematic review and meta-analysis was performed utilizing randomized controlled and propensity matched studies which compared a Ring + subvalvular versus Ring MV repair for the treatment of secondary MR. Risk ratio (RR), weighted mean difference (MD), and the 95% confidence interval (CI) were calculated by the Mantel-Haenszel and inverse-variance methods, for clinical outcomes and echocardiographic measures of follow-up MR, left ventricular (LV) reverse remodeling, and MV apparatus geometry. RESULTS Five studies were identified, with a total of 397 patients. Baseline characteristics were similar between groups, and all patients had moderate to severe secondary MR, with the vast majority in the setting of ischemic cardiomyopathy. A Ring + subvalvular repair consisted of papillary muscle approximation (n=2), papillary muscle relocation (n=2), or secondary chordal cutting (n=1). Follow-up ranged from 10.1 (mean range =0.25-42) to 69 [interquartile range (IQR) =23-82] months. When compared with Ring only at last follow-up, a Ring + subvalvular MV repair was associated with: (I) a smaller MR grade (MD =-0.44, 95% CI -0.69 to -0.19; P=0.0005); (II) a reduced risk of moderate or greater recurrent MR (RR =0.43, 95% CI, 0.27-0.66; P=0.0002); (III) a smaller mean LV end-diastolic diameter (MD =-3.56 mm, 95% CI -5.40 to -1.73; P=0.0001) and a greater ejection fraction (MD =2.64%, 95% CI, 0.13-5.15; P=0.04); and, (IV) an improved MV apparatus geometry. There were no differences in operative mortality, post-operative morbidity, or follow-up survival between surgical approaches. CONCLUSIONS When compared with Ring only, a Ring + subvalvular MV repair is associated with greater LV reverse remodeling and systolic function, less recurrence of moderate or greater MR, and an improved geometry of the MV apparatus at short and mid-term follow-up.
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Affiliation(s)
- Christos G Mihos
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Steve Xydas
- Columbia University Division of Cardiac Surgery, 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
| | - Roy F Williams
- Columbia University Division of Cardiac Surgery, Mount Sinai Heart Institute, Miami Beach, FL, USA
| | - Maurice Mawad
- Columbia University Division of Cardiac Surgery, Mount Sinai Heart Institute, Miami Beach, FL, USA
| | - Guillermo Garcia
- Department of Anesthesia, Mount Sinai Medical Center, Miami Beach, FL, USA
| | - Orlando Santana
- Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
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7
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Abstract
Ischemic mitral prolapse (IMP) is a pathologic entity encountered in about one-third among the patients undergoing surgery for ischemic mitral regurgitation (IMR). IMP is generally the result of a papillary muscle injury consequent to myocardial, but the recent literature is progressively unveiling a more complex pathogenesis. The mechanisms underlying its development regards the impairment of one or more components of the mitral apparatus, which comprises the annulus, the chordae tendineae, the papillary muscle and the left ventricular wall. IMP is not only a disorder of valvular function, but also entails coexistent aspects of a geometric disturbance of the mitral valve configuration and of the left ventricular function and dimension and a correct understanding of all these aspects is crucial to guide and tailor the correct therapeutic strategy to be adopted. Localization of prolapse, anatomic features of the prolapsed leaflets and the subvalvular apparatus should be carefully evaluated as also constituting the major determinants defining patient's outcomes. This review will summarize our current understanding of the pathophysiology and clinical evidence on IMP with a particular focus on the surgical treatment.
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Affiliation(s)
- Francesco Nappi
- Cardiac Surgery Centre Cardiologique du Nord de Saint-Denis, Paris, France
| | - Spadaccio Cristiano
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, UK;; University of Glasgow Institute of Cardiovascular and Medical Sciences, Glasgow, UK
| | - Antonio Nenna
- Department of Cardiovascular Surgery, University Campus Bio-Medico di Roma, Rome, Italy
| | - Massimo Chello
- Department of Cardiovascular Surgery, University Campus Bio-Medico di Roma, Rome, Italy
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8
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Revuelta JM, León JM. Insuficiencia mitral isquémica crónica: fuente de confusión. CIRUGIA CARDIOVASCULAR 2016. [DOI: 10.1016/j.circv.2015.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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9
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Levine RA, Hagége AA, Judge DP, Padala M, Dal-Bianco JP, Aikawa E, Beaudoin J, Bischoff J, Bouatia-Naji N, Bruneval P, Butcher JT, Carpentier A, Chaput M, Chester AH, Clusel C, Delling FN, Dietz HC, Dina C, Durst R, Fernandez-Friera L, Handschumacher MD, Jensen MO, Jeunemaitre XP, Le Marec H, Le Tourneau T, Markwald RR, Mérot J, Messas E, Milan DP, Neri T, Norris RA, Peal D, Perrocheau M, Probst V, Pucéat M, Rosenthal N, Solis J, Schott JJ, Schwammenthal E, Slaugenhaupt SA, Song JK, Yacoub MH. Mitral valve disease--morphology and mechanisms. Nat Rev Cardiol 2015; 12:689-710. [PMID: 26483167 DOI: 10.1038/nrcardio.2015.161] [Citation(s) in RCA: 231] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Mitral valve disease is a frequent cause of heart failure and death. Emerging evidence indicates that the mitral valve is not a passive structure, but--even in adult life--remains dynamic and accessible for treatment. This concept motivates efforts to reduce the clinical progression of mitral valve disease through early detection and modification of underlying mechanisms. Discoveries of genetic mutations causing mitral valve elongation and prolapse have revealed that growth factor signalling and cell migration pathways are regulated by structural molecules in ways that can be modified to limit progression from developmental defects to valve degeneration with clinical complications. Mitral valve enlargement can determine left ventricular outflow tract obstruction in hypertrophic cardiomyopathy, and might be stimulated by potentially modifiable biological valvular-ventricular interactions. Mitral valve plasticity also allows adaptive growth in response to ventricular remodelling. However, adverse cellular and mechanobiological processes create relative leaflet deficiency in the ischaemic setting, leading to mitral regurgitation with increased heart failure and mortality. Our approach, which bridges clinicians and basic scientists, enables the correlation of observed disease with cellular and molecular mechanisms, leading to the discovery of new opportunities for improving the natural history of mitral valve disease.
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Affiliation(s)
- Robert A Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Yawkey 5E, Boston, MA 02114, USA
| | - Albert A Hagége
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | | | | | - Jacob P Dal-Bianco
- Massachusetts General Hospital, Cardiac Ultrasound Laboratory, Harvard Medical School, Boston, MA, USA
| | | | | | | | - Nabila Bouatia-Naji
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | - Patrick Bruneval
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | | | - Alain Carpentier
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | | | | | | | - Francesca N Delling
- Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | | | - Christian Dina
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | - Ronen Durst
- Hadassah-Hebrew University Medical Centre, Jerusalem, Israel
| | - Leticia Fernandez-Friera
- Hospital Universitario HM Monteprincipe and the Centro Nacional de Investigaciones Cardiovasculares, Carlos III (CNIC), Madrid, Spain
| | - Mark D Handschumacher
- Massachusetts General Hospital, Cardiac Ultrasound Laboratory, Harvard Medical School, Boston, MA, USA
| | | | - Xavier P Jeunemaitre
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | - Hervé Le Marec
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | - Thierry Le Tourneau
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | | | - Jean Mérot
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | - Emmanuel Messas
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | - David P Milan
- Cardiovascular Research Center, Harvard Medical School, Boston, MA, USA
| | - Tui Neri
- Aix-Marseille University, INSERM UMR 910, Marseille, France
| | | | - David Peal
- Cardiovascular Research Center, Harvard Medical School, Boston, MA, USA
| | - Maelle Perrocheau
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | - Vincent Probst
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | - Michael Pucéat
- Aix-Marseille University, INSERM UMR 910, Marseille, France
| | | | - Jorge Solis
- Hospital Universitario HM Monteprincipe and the Centro Nacional de Investigaciones Cardiovasculares, Carlos III (CNIC), Madrid, Spain
| | - Jean-Jacques Schott
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | | | - Susan A Slaugenhaupt
- Center for Human Genetic Research, MGH Research Institute, Harvard Medical School, Boston, MA, USA
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Nappi F, Spadaccio C, Chello M, Lusini M, Acar C. Double row of overlapping sutures for downsizing annuloplasty decreases the risk of residual regurgitation in ischaemic mitral valve repair. Eur J Cardiothorac Surg 2015; 49:1182-7. [PMID: 26351400 DOI: 10.1093/ejcts/ezv291] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 07/22/2015] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The aim of this study was to evaluate a novel insertion technique of the prosthetic ring that would further magnify the degree of annulus narrowing, thereby reducing the potential for a residual leak in ischaemic mitral valve repair. METHODS Thirty-six patients with ischaemic mitral regurgitation (MR) were randomly assigned into two groups. In 18 patients, the prosthetic ring was inserted in the conventional manner with a single row of sutures (control group). In the remaining 18 patients, the ring was attached using a double row of sutures tied both on the inner and on the outer part of the sewing cuff. Both groups had similar preoperative clinical and echocardiographic characteristics with severe leaflet tethering: mean tenting area >2.5 cm(2), mean anterior leaflet angle >25° and posterior leaflet angle >45°. The mean prosthetic ring sizes inserted in both groups were identical (mean: 27.3 mm). RESULTS At 12 months, there was no clinical event except for 1 rehospitalization in the control group. The mean mitral regurgitation grade was higher in the control group than in the group with the double row of sutures at 1.6 ± 0.9 vs 0.7 ± 0.3 (P = 0.0003). Annulus diameter reduction was less pronounced in the control group when compared with the group with the double row of sutures, both in the parasternal long-axis: 29.3 ± 3 vs 26.3 ± 3 mm (P = 0.0003) and in apical four-chamber views: 31 ± 3 vs 28 ± 2 mm (P = 0.003). Leaflet tethering indices were greater in the control group than in the group with the double row of sutures: tenting area: 1.42 ± 0.3 vs 1.1 ± 0.5 cm(2) (P = 0.002), anterior leaflet angle: 33 ± 3° vs 28 ± 5° (P = 0.0009) and posterior leaflet angle: 110 ± 13° vs 80 ± 11° (P = 0.0001). Left ventricular function parameters were not statistically different among the two groups. CONCLUSION A double row of overlapping sutures for attaching the prosthetic ring in downsizing annuloplasty is more efficient in narrowing the mitral annulus than the conventional technique in ischaemic mitral repair. Even in high-risk patients whose leaflets were severely tethered on echocardiography, it almost eliminated the risk of MR recurrence in this study.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiovascular Surgery, University Campus Bio-Medico, Rome, Italy Department of Cardiac Surgery, Centre Cardiologique du Nord, Saint Denis, France
| | - Cristiano Spadaccio
- Department of Cardiovascular Surgery, University Campus Bio-Medico, Rome, Italy
| | - Massimo Chello
- Department of Cardiovascular Surgery, University Campus Bio-Medico, Rome, Italy
| | - Mario Lusini
- Department of Cardiovascular Surgery, University Campus Bio-Medico, Rome, Italy
| | - Christophe Acar
- Department of Cardiothoracic Surgery, Hôpital Pitié-Salpétrière, Paris, France
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11
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A Quantitative Approach to the Intraoperative Echocardiographic Assessment of the Mitral Valve for Repair. Anesth Analg 2015; 121:34-58. [DOI: 10.1213/ane.0000000000000726] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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12
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Targeted Mybpc3 Knock-Out Mice with Cardiac Hypertrophy Exhibit Structural Mitral Valve Abnormalities. J Cardiovasc Dev Dis 2015; 2:48-65. [PMID: 26819945 PMCID: PMC4725593 DOI: 10.3390/jcdd2020048] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
MYBPC3 mutations cause hypertrophic cardiomyopathy, which is frequently associated with mitral valve (MV) pathology. We reasoned that increased MV size is caused by localized growth factors with paracrine effects. We used high-resolution echocardiography to compare Mybpc3-null, heterozygous, and wild-type mice (n = 84, aged 3–6 months) and micro-CT for MV volume (n = 6, age 6 months). Mybpc3-null mice showed left ventricular hypertrophy, dilation, and systolic dysfunction compared to heterozygous and wild-type mice, but no systolic anterior motion of the MV or left ventricular outflow obstruction. Compared to wild-type mice, echocardiographic anterior leaflet length (adjusted for left ventricular size) was greatest in Mybpc3-null mice (1.92 ± 0.08 vs. 1.72 ± 0.08 mm, p < 0.001), as was combined leaflet thickness (0.23 ± 0.04 vs. 0.15 ± 0.02 mm, p < 0.001). Micro-CT analyses of Mybpc3-null mice demonstrated increased MV volume (0.47 ± 0.06 vs. 0.15 ± 0.06 mm3, p = 0.018) and thickness (0.35 ± 0.04 vs. 0.12 ± 0.04 mm, p = 0.002), coincident with increased markers of TGFβ activity compared to heterozygous and wild-type littermates. Similarly, excised MV from a patient with MYBPC3 mutation showed increased TGFβ activity. We conclude that MYBPC3 deficiency causes hypertrophic cardiomyopathy with increased MV leaflet length and thickness despite the absence of left ventricular outflow-tract obstruction, in parallel with increased TGFβ activity. MV changes in hypertrophic cardiomyopathy may be due to paracrine effects, which represent targets for therapeutic studies.
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Zeng X, Zou L, Levine RA, Guerrero JL, Handschumacher MD, Sullivan SM, Braithwaite GJC, Stone JR, Solis J, Muratoglu OK, Vlahakes GJ, Hung J. Efficacy of polymer injection for ischemic mitral regurgitation: persistent reduction of mitral regurgitation and attenuation of left ventricular remodeling. JACC Cardiovasc Interv 2015; 8:355-363. [PMID: 25596792 DOI: 10.1016/j.jcin.2014.09.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 09/22/2014] [Accepted: 09/25/2014] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The aim of this study was to examine the chronic effects of polyvinyl-alcohol (PVA) injection on mitral regurgitation (MR) reduction, mitral valve geometry, and left ventricular (LV) remodeling in a chronic ischemic MR sheep model. BACKGROUND Previous studies have demonstrated acute efficacy of PVA hydrogel polymer injection into infarcted myocardium underlying the papillary muscle to relieve MR by papillary muscle repositioning. However, the chronic efficacy of PVA injection in the chronic infarction setting remains unclear. METHODS Sixteen sheep developed chronic MR 8 weeks after induced inferoposterior myocardial infarction. Ten consecutive sheep underwent PVA injection (PVA group) and 6 sheep served as control subjects with saline injection. Epicardial 2-/3-dimensional echocardiography was performed at the baseline, chronic MR (pre-injection), and sacrifice (8 weeks after injection) stages. RESULTS Both groups were comparable at the baseline and chronic MR stages. At sacrifice, MR decreased from moderate to trace or mild (vena contracta: 0.17 ± 0.08 cm vs. 0.56 ± 0.10 cm, p < 0.001) in the PVA group but progressed to moderate to severe in the control group. End-systolic and -diastolic volumes remained stable in the PVA group but increased significantly in the control group (both p < 0.05). At sacrifice, compared with the control group, the PVA group had significantly less left ventricular remodeling (end-systolic volume: 41.1 ± 10.4 ml vs. 55.9 ± 12.4 ml, p < 0.05), lower MR severity (vena contracta: 0.17 ± 0.08 cm vs. 0.60 ± 0.14 cm, p < 0.01), and favorable changes in mitral valve geometry. CONCLUSIONS Polymer injection in a chronic ischemic MR model results in persistent reduction of MR and attenuation of continued left ventricular remodeling over 8 weeks of follow-up.
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Affiliation(s)
- Xin Zeng
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Boston, Massachusetts
| | - Lin Zou
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Boston, Massachusetts
| | - Robert A Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Boston, Massachusetts
| | - J Luis Guerrero
- Cardiac Surgery Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Mark D Handschumacher
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Boston, Massachusetts
| | - Suzanne M Sullivan
- Cardiac Surgery Division, Massachusetts General Hospital, Boston, Massachusetts
| | | | - James R Stone
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jorge Solis
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Boston, Massachusetts
| | - Orhun K Muratoglu
- Biomaterials Laboratory, Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Gus J Vlahakes
- Cardiac Surgery Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Judy Hung
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Boston, Massachusetts.
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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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Beaudoin J, Levine RA, Guerrero JL, Yosefy C, Sullivan S, Abedat S, Handschumacher MD, Szymanski C, Gilon D, Palmeri NO, Vlahakes GJ, Hajjar RJ, Beeri R. Late repair of ischemic mitral regurgitation does not prevent left ventricular remodeling: importance of timing for beneficial repair. Circulation 2013; 128:S248-52. [PMID: 24030415 DOI: 10.1161/circulationaha.112.000124] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Ischemic mitral regurgitation (MR) is a frequent complication of myocardial infarction associated with left ventricular (LV) dilatation and dysfunction, which doubles mortality. At the molecular level, moderate ischemic MR is characterized by a biphasic response, with initial compensatory rise in prohypertrophic and antiapoptotic signals, followed by their exhaustion. We have shown that early MR repair 30 days after myocardial infarction is associated with LV reverse remodeling. It is not known whether MR repair performed after the exhaustion of compensatory mechanisms is also beneficial. We hypothesized that late repair will not result in LV reverse remodeling. METHODS AND RESULTS Twelve sheep underwent distal left anterior descending coronary artery ligation to create apical myocardial infarction and implantation of an LV-to-left atrium shunt to create standardized moderate volume overload. At 90 days, animals were randomized to shunt closure (late repair) versus sham (no repair). LV remodeling was assessed by 3-dimensional echocardiography, dP/dt, preload-recruitable stroke work, and myocardial biopsies. At 90 days, animals had moderate volume overload, LV dilatation, and reduced ejection fraction (all P<0.01 versus baseline, P=NS between groups). Shunt closure at 90 days corrected the volume overload (regurgitant fraction 6 ± 5% versus 27 ± 16% for late repair versus sham, P<0.01) but was not associated with changes in LV volumes (end-diastolic volume 106 ± 15 versus 110 ± 22 mL; end-systolic volume 35 ± 6 versus 36 ± 6 mL) or increases in preload-recruitable stroke work (41 ± 7 versus 39 ± 13 mL mm Hg) or dP/dt (803 ± 210 versus 732 ± 194 mm Hg/s) at 135 days (all P=NS). Activated Akt, central in the hypertrophic process, and signal transducer and activator of transcription 3 (STAT3), a critical node in the hypertrophic stimulus by cytokines, were equally depressed in both groups. CONCLUSIONS Late correction of moderate volume overload after myocardial infarction did not improve LV volume or contractility. Upregulation of prohypertrophic intracellular pathways was not observed. This contrasts with previously reported study in which early repair (30 days) reversed LV remodeling. This suggests a window of opportunity to repair ischemic MR after which no beneficial effect on LV is observed, despite successful repair.
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Affiliation(s)
- Jonathan Beaudoin
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA (J.B., R.A.L., J.L.G., C.Y., S.S., M.D.H., C.S., N.O.P., G.J.V., R.B.); Cardiovascular Research Center, Heart Institute, Hadassah-Hebrew University Medical Center, Ein-Karem, Jerusalem, Israel (S.A., D.G., R.B.); and Cardiovascular Research Center, Cardiovascular Institute, Mt Sinai School of Medicine, New York, NY (R.J.H.)
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Calafiore AM, Refaie R, Iacò AL, Asif M, Al Shurafa HS, Al-Amri H, Romeo A, Di Mauro M. Chordal cutting in ischemic mitral regurgitation: a propensity-matched study. J Thorac Cardiovasc Surg 2013; 148:41-6. [PMID: 24041764 DOI: 10.1016/j.jtcvs.2013.07.036] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Revised: 06/24/2013] [Accepted: 07/19/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The optimal surgical treatment of ischemic mitral regurgitation (MR) has not been well defined. Second-order chordal cutting (CC), in selected patients, can improve surgical outcomes. METHODS From 2007 to 2011, 31 patients underwent CC for ischemic MR. The indication was the presence of increased tethering of the anterior leaflet, with a bending angle (BA) <145°. Patients with same echocardiographic characteristics were identified and propensity matched for age, ejection fraction (EF), MR grade, diameters, and BA. Only patients with preoperative and follow-up echocardiograms were included and divided into 2 groups of 26 patients each, CC and no-CC. RESULTS Preoperatively, in the CC and no-CC groups, the age was 61 ± 9 and 62 ± 10 years, EF was 31% ± 5% and 29% ± 8%, MR grade (0-4) was 3.6 ± 0.6 and 3.3 ± 0.8, and diastolic and systolic dimension was 56 ± 7 and 43 ± 8 mm and 57 ± 11 and 44 ± 11 mm, respectively. The New York Heart Association class and BA was 2.7 ± 0.6 and 2.6 ± 0.7 and 137° ± 4° and 137° ± 6°, respectively. All patients underwent overreductive annuloplasty. In the CC group, second-order chords were cut using aortotomy. After a mean of 33 ± 15 months, the MR grade was 0.6 ± 0.6 and 1.1 ± 0.8 (P = .014) and the EF was 40% ± 5% and 35% ± 7% (P = .005) in the CC and no-CC groups, respectively. The corresponding diastolic and systolic diameters were 52 ± 5 and 38 ± 8 mm and 53 ± 11 and 41 ± 12 mm (P = NS). The modifications were significant only in the CC group (P = .022 and P = .029 for the diastolic and systolic dimensions, respectively). The corresponding New York Heart Association class decreased to 1.1 ± 0.3 and 1.5 ± 0.6 (P = .004). The BA increased to 182° ± 4° in the CC (P < .001) and remained unchanged (137° ± 6°) in the no-CC group. CONCLUSIONS In selected patients with a BA <145° and coaptation depth ≤10 mm, CC is related to less MR return or persistence, improved EF, and lower New York Heart Association class.
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Affiliation(s)
- Antonio M Calafiore
- Department of Adult Cardiac Surgery, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia.
| | - Reda Refaie
- Department of Adult Cardiac Surgery, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Angela L Iacò
- Department of Adult Cardiac Surgery, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia. Department of Cardiothoracic Surgery,c Mansoura University, Mansoura, Egypt
| | - Mahmood Asif
- Department of Adult Cardiac Surgery, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Heythem S Al Shurafa
- Department of Adult Cardiology, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Hussein Al-Amri
- Department of Adult Cardiology, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Antonella Romeo
- Department of Cardiology, University of Catania, Catania, Italy
| | - Michele Di Mauro
- Department of Adult Cardiac Surgery, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia; Department of Cardiology, University of L'Aquila, L'Aquila, Italy
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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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Szymanski C, Messas E. Ischemic mitral regurgitation: New concepts. Arch Cardiovasc Dis 2013; 106:183-7. [DOI: 10.1016/j.acvd.2013.03.058] [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] [Received: 03/04/2013] [Accepted: 03/04/2013] [Indexed: 10/26/2022]
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Szymanski C, Bel A, Cohen I, Touchot B, Handschumacher MD, Desnos M, Carpentier A, Menasché P, Hagège AA, Levine RA, Messas E. Comprehensive annular and subvalvular repair of chronic ischemic mitral regurgitation improves long-term results with the least ventricular remodeling. Circulation 2012; 126:2720-7. [PMID: 23139296 DOI: 10.1161/circulationaha.111.033472] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Undersized ring annuloplasty for ischemic mitral regurgitation (MR) is associated with variable results and >30% MR recurrence. We tested whether subvalvular repair by severing second-order mitral chordae can improve annuloplasty by reducing papillary muscle tethering. METHODS AND RESULTS Posterolateral myocardial infarction known to produce chronic remodeling and MR was created in 28 sheep. At 3 months, sheep were randomized to sham surgery versus isolated undersized annuloplasty versus isolated bileaflet chordal cutting versus the combined therapy (n=7 each). At baseline, chronic myocardial infarction (3 months), and euthanasia (6.6 months), we measured left ventricular (LV) volumes and ejection fraction, wall motion score index, MR regurgitation fraction and vena contracta, mitral annulus area, and posterior leaflet restriction angle (posterior leaflet to mitral annulus area) by 2-dimensional and 3-dimensional echocardiography. All groups were comparable at baseline and chronic myocardial infarction, with mild to moderate MR (MR vena contracta, 4.6±0.1 mm; MR regurgitation fraction, 24.2±2.9%) and mitral annulus dilatation (P<0.01). At euthanasia, MR progressed to moderate to severe in controls but decreased to trace with ring plus chordal cutting versus trace to mild with chordal cutting alone versus mild to moderate with ring alone (MR vena contracta, 5.9±1.1 mm in controls, 0.5±0.08 with both, 1.0±0.3 with chordal cutting alone, 2.0±0.4 with ring alone; P<0.01). In addition, LV end-systolic volume increased by 108% in controls versus 28% with ring plus chordal cutting, less than with each intervention alone (P<0.01). In multivariate analysis, LV end-systolic volume and mitral annulus area most strongly predicted MR (r(2)=0.82, P<0.01). CONCLUSIONS Comprehensive annular and subvalvular repair improves long-term reduction of both chronic ischemic MR and LV remodeling without decreasing global or segmental LV function at follow-up.
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Affiliation(s)
- Catherine Szymanski
- Department of Cardio-Vascular Medicine, Hôpital Européen Georges Pompidou, INSERM U 633, PARCC, 20 Rue Leblanc, 75015 Paris, France
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Mitral valve surgery in low ejection fraction, severe ischemic mitral regurgitation patients: should we repair them all? Curr Opin Cardiol 2012; 27:111-7. [PMID: 22274572 DOI: 10.1097/hco.0b013e32834fec29] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The optimal surgical treatment of chronic ischemic mitral regurgitation still is the subject of much debate in the surgical and cardiological communities. Although combined restrictive mitral annuloplasty and revascularization has demonstrated good results with regard to improvement of clinical status, low rates of recurrent mitral regurgitation and sustained left ventricular reverse remodeling, a survival benefit still has not been demonstrated. In addition, not all patients improve. Remaining issues in this field relate to identification of patients who will benefit from treatment, and to further improve and individualize treatment modalities. RECENT FINDINGS More data support the use of restrictive mitral annuloplasty and revascularization. New surgical techniques to improve mitral competence (posterior leaflet augmentation) and to promote left ventricular reverse remodeling in severely dilated hearts (addressing the subvalvular apparatus) are promising. Disease-specific annuloplasty rings have not (yet) proven additional value. New imaging modalities are available to assess the many components that constitute the complex pathophysiology of remodeling. SUMMARY The remaining challenge for cardiologists and surgeons is how to integrate data from different imaging techniques that assess mitral valve geometry and left ventricular size, geometry, function and potential functional recovery in order to individualize and optimize the surgical approach to patients with chronic ischemic mitral regurgitation.
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de Vlaming A, Sauls K, Hajdu Z, Visconti RP, Mehesz AN, Levine RA, Slaugenhaupt SA, Hagège A, Chester AH, Markwald RR, Norris RA. Atrioventricular valve development: new perspectives on an old theme. Differentiation 2012; 84:103-16. [PMID: 22579502 DOI: 10.1016/j.diff.2012.04.001] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Revised: 03/26/2012] [Accepted: 04/01/2012] [Indexed: 11/19/2022]
Abstract
Atrioventricular valve development commences with an EMT event whereby endocardial cells transform into mesenchyme. The molecular events that induce this phenotypic change are well understood and include many growth factors, signaling components, and transcription factors. Besides their clear importance in valve development, the role of these transformed mesenchyme and the function they serve in the developing prevalve leaflets is less understood. Indeed, we know that these cells migrate, but how and why do they migrate? We also know that they undergo a transition to a mature, committed cell, largely defined as an interstitial fibroblast due to their ability to secrete various matrix components including collagen type I. However, we have yet to uncover mechanisms by which the matrix is synthesized, how it is secreted, and how it is organized. As valve disease is largely characterized by altered cell number, cell activation, and matrix disorganization, answering questions of how the valves are built will likely provide us with information of real clinical relevance. Although expression profiling and descriptive or correlative analyses are insightful, to advance the field, we must now move past the simplicity of these assays and ask fundamental, mechanistic based questions aimed at understanding how valves are "built". Herein we review current understandings of atrioventricular valve development and present what is known and what isn't known. In most cases, basic, biological questions and hypotheses that were presented decades ago on valve development still are yet to be answered but likely hold keys to uncovering new discoveries with relevance to both embryonic development and the developmental basis of adult heart valve diseases. Thus, the goal of this review is to remind us of these questions and provide new perspectives on an old theme of valve development.
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Affiliation(s)
- Annemarieke de Vlaming
- Department of Regenerative Medicine and Cell Biology, School of Medicine, Cardiovascular Developmental Biology Center, Children's Research Institute, Medical University of South Carolina, Charleston, SC 29425, 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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Padala M, Gyoneva L, Yoganathan AP. Effect of anterior strut chordal transection on the force distribution on the marginal chordae of the mitral valve. J Thorac Cardiovasc Surg 2011; 144:624-633.e2. [PMID: 22154223 DOI: 10.1016/j.jtcvs.2011.10.032] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2011] [Revised: 09/12/2011] [Accepted: 10/20/2011] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Transection of the secondary chordae on the anterior leaflet of the mitral valve to relieve leaflet tethering and reduce regurgitation is an experimentally proven procedure to correct functional mitral regurgitation. In the present study, we sought to investigate whether transecting the secondary chordae would have an effect on the marginal chordal force on the same leaflet. METHODS Adult porcine mitral valves (n = 8) were studied in a pulsatile heart simulator, in which the papillary muscle positions can be precisely positioned. Miniature transducers were inserted into the anterior marginal chordae to measure the chordal forces. Each valve was studied under baseline conditions, 3 different tethering conditions (apical, apical-lateral, and apical-lateral-posterior), and after chordal cutting in the 3 tethering conditions. The temporal changes and peak and average marginal chordal forces under each condition are reported. RESULTS Apical tethering increased the marginal chordal force by an average of 96% but remained unchanged after chordal cutting. With apical-lateral tethering, the marginal chordal force increased by 210% from baseline and increased further to 350% of baseline after chordal cutting. After apical-lateral-posterior tethering, the marginal chordal force increased to 335% of baseline before transection and by 548% after transection. CONCLUSIONS The increase in the marginal chordal force after secondary chordal cutting depends on the location of the papillary muscles and the extent of leaflet tethering. Although chordal cutting might not alter the valve mechanics under minimal leaflet tethering, it significantly affects the mechanics when the leaflet tethering is more pronounced, which is typically seen in patients with functional mitral regurgitation.
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Affiliation(s)
- Muralidhar Padala
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA
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Lang RM, Tsang W, Weinert L, Mor-Avi V, Chandra S. Valvular Heart Disease. J Am Coll Cardiol 2011; 58:1933-44. [DOI: 10.1016/j.jacc.2011.07.035] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Revised: 07/14/2011] [Accepted: 07/18/2011] [Indexed: 10/16/2022]
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Circulation: Cardiovascular Imaging
Editors' Picks. Circ Cardiovasc Imaging 2011. [DOI: 10.1161/circimaging.111.968867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The following articles are being highlighted as part of
Circulation: Cardiovascular Imaging's
Topic Review. This series summarizes the most important articles, as selected by the editors, that have published in the
Circulation
portfolio. The studies included in this article represent the most significant research in the area of structural heart disease, cardiac function, aortic disease, and molecular imaging.
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Circulation: Cardiovascular Imaging
Editors' Picks. Circ Cardiovasc Imaging 2011. [DOI: 10.1161/circimaging.111.967299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The following are highlights from the new series,
Circulation: Cardiovascular Imaging
Topic Review. This series summarizes the most important articles, as selected by the editors, that have been published in the
Circulation
portfolio. The objective of this new series is to provide our readership with a timely, comprehensive selection of important articles that are relevant to the imaging and general cardiology audience. The studies included in this article represent the most significant research in the area of coronary artery disease.
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