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Estévez-Loureiro R, Lorusso R, Taramasso M, Torregrossa G, Kini A, Moreno PR. Management of Severe Mitral Regurgitation in Patients With Acute Myocardial Infarction: JACC Focus Seminar 2/5. J Am Coll Cardiol 2024; 83:1799-1817. [PMID: 38692830 DOI: 10.1016/j.jacc.2023.09.840] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 09/19/2023] [Indexed: 05/03/2024]
Abstract
Severe acute mitral regurgitation after myocardial infarction includes partial and complete papillary muscle rupture or functional mitral regurgitation. Although its incidence is <1%, mitral regurgitation after acute myocardial infarction frequently causes hemodynamic instability, pulmonary edema, and cardiogenic shock. Medical management has the worst prognosis, and mortality has not changed in decades. Surgery represents the gold standard, but it is associated with high rates of morbidity and mortality. Recently, transcatheter interventions have opened a new door for management that may improve survival. Mechanical circulatory support restores vital organ perfusion and offers the opportunity for a steadier surgical repair. This review focuses on the diagnosis and the interventional management, both surgical and transcatheter, with a glance on future perspectives to enhance patient management and eventually decrease mortality.
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Affiliation(s)
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | | | - Gianluca Torregrossa
- Department of Cardiothoracic Surgery, Lankenau Heart Institute, Wynnewood, Pennsylvania, USA; Department of Cardiothoracic Surgery, Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
| | - Annapoorna Kini
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Pedro R Moreno
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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2
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Zhang RS, Ro R, Bamira D, Vainrib A, Zhang L, Nayar AC, Saric M, Bernard S. Echocardiography in the Recognition and Management of Mechanical Complications of Acute Myocardial Infarction. Curr Cardiol Rep 2024; 26:393-404. [PMID: 38526749 DOI: 10.1007/s11886-024-02042-5] [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: 03/11/2024] [Indexed: 03/27/2024]
Abstract
PURPOSE OF REVIEW Although rare, the development of mechanical complications following an acute myocardial infarction is associated with a high morbidity and mortality. Here, we review the clinical features, diagnostic strategy, and treatment options for each of the mechanical complications, with a focus on the role of echocardiography. RECENT FINDINGS The growth of percutaneous structural interventions worldwide has given rise to new non-surgical options for management of mechanical complications. As such, select patients may benefit from a novel use of these established treatment methods. A thorough understanding of the two-dimensional, three-dimensional, color Doppler, and spectral Doppler findings for each mechanical complication is essential in recognizing major causes of hemodynamic decompensation after an acute myocardial infarction. Thereafter, echocardiography can aid in the selection and maintenance of mechanical circulatory support and potentially facilitate the use of a percutaneous intervention.
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Affiliation(s)
- Robert S Zhang
- Division of Cardiology, New York University Grossman School of Medicine, 550 First Avenue, New York, NY, 10016, USA
| | - Richard Ro
- Division of Cardiology, New York University Grossman School of Medicine, 550 First Avenue, New York, NY, 10016, USA
| | - Daniel Bamira
- Division of Cardiology, New York University Grossman School of Medicine, 550 First Avenue, New York, NY, 10016, USA
| | - Alan Vainrib
- Division of Cardiology, New York University Grossman School of Medicine, 550 First Avenue, New York, NY, 10016, USA
| | - Lily Zhang
- Division of Cardiology, New York University Grossman School of Medicine, 550 First Avenue, New York, NY, 10016, USA
| | - Ambika C Nayar
- Division of Cardiology, New York University Grossman School of Medicine, 550 First Avenue, New York, NY, 10016, USA
| | - Muhamed Saric
- Division of Cardiology, New York University Grossman School of Medicine, 550 First Avenue, New York, NY, 10016, USA
| | - Samuel Bernard
- Division of Cardiology, New York University Grossman School of Medicine, 550 First Avenue, New York, NY, 10016, USA.
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3
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Boyle C, Nguyen K, Steiner J, Macon CJ, Marbach JA. Mitral Regurgitation Complicated by Cardiogenic Shock: Reassessing Risk Stratification and Therapeutic Strategies. Interv Cardiol Clin 2024; 13:191-205. [PMID: 38432762 DOI: 10.1016/j.iccl.2023.11.003] [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] [Indexed: 03/05/2024]
Abstract
Mitral regurgitation complicated by cardiogenic shock creates a unique and devastating risk profile for patients and poses significant difficulties for physicians who lack a comprehensive range of effective management strategies. Supportive measures such as intravenous vasodilators, intra-aortic balloon pumps, and percutaneous ventricular assist devices are often necessary to stabilize patients prior to definitive treatment with surgical mitral valve replacement or trans-catheter edge-to-edge repair. This review evaluates the evidence for the available supportive and definitive management strategies in patients with mitral regurgitation complicated by cardiogenic shock and presents a framework to aid clinicians in navigating the complex clinical decision-making process. Additionally, the authors review emerging transcatheter mitral valve replacement technologies that hold promise for expanding the therapeutic armamentarium and improving patient outcomes.
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Affiliation(s)
- Carla Boyle
- Division of Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, 3161 Southwest Pavilion Loop, Portland, OR 97239, USA
| | - Khoa Nguyen
- Division of Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, 3161 Southwest Pavilion Loop, Portland, OR 97239, USA
| | - Johannes Steiner
- Division of Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, 3161 Southwest Pavilion Loop, Portland, OR 97239, USA
| | - Conrad J Macon
- Division of Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, 3161 Southwest Pavilion Loop, Portland, OR 97239, USA
| | - Jeffrey A Marbach
- Division of Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, 3161 Southwest Pavilion Loop, Portland, OR 97239, USA.
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4
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Shuvy M, Maisano F. Evolving indications for transcatheter mitral edge-to-edge repair. EUROINTERVENTION 2024; 20:e230-e238. [PMID: 38389473 PMCID: PMC10870010 DOI: 10.4244/eij-d-23-00700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 11/22/2023] [Indexed: 02/24/2024]
Abstract
Transcatheter mitral edge-to-edge repair (TEER) is an established procedure for managing mitral regurgitation (MR) in high-risk patients. It is effective in treating both primary and secondary MR, as reported in the surgical and interventional literature. Over time, TEER has gained popularity and achieved procedural success in various anatomies. The less invasive nature of TEER, along with its high safety profile and immediate haemodynamic improvement suggest potential benefits in high-risk populations who are not normally included in major trials. These patients, often deemed unsuitable for surgical intervention, are typically managed conservatively, despite accumulating evidence suggesting the potential of clinical improvement by reducing MR through TEER. Examples include post-myocardial infarction MR, patients with hypertrophic obstructive cardiomyopathy and patients experiencing recurrent MR after surgical intervention. This review discusses the utilisation of TEER beyond recognised indications, examining outcomes and limitations in diverse patient populations. Further studies are warranted to evaluate the benefits of TEER in clinical scenarios beyond the current indications.
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Affiliation(s)
- Mony Shuvy
- Jesselson Integrated Heart Centre, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Francesco Maisano
- Valve Center and Cardiac Surgery, IRCCS Ospedale San Raffaele and Faculty of Medicine, Università Vita Salute San Raffaele, Milan, Italy
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5
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Funaishi K, Kasahara H, Oki N, Nakatogawa T, Yamanoi K. Papillary fibroelastoma originating from the atrial septum touching the mitral valve leading to infective endocarditis: a case report. J Cardiothorac Surg 2024; 19:79. [PMID: 38336753 PMCID: PMC10858540 DOI: 10.1186/s13019-024-02584-3] [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: 04/26/2023] [Accepted: 01/30/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Cardiac papillary fibroelastoma is a rare benign tumor, which is often mistaken for a vegetation. Predominantly asymptomatic, it can cause life-threatening complications. Although rare, mobile papillary fibroelastoma movement between affected valves may hamper valve closure and damage the valve, leading to valvular regurgitation. Endothelial damage increases the risk of developing infective endocarditis. We report a rare case of a highly mobile papillary fibroelastoma originating from the atrial septum touching the mitral valve, leading to mitral regurgitation and, eventually, infective endocarditis. CASE PRESENTATION A 26-year-old woman with suspected infective endocarditis was referred to us from a previous hospital after having experienced intermittent fever for a month. Before the fever, she had been experiencing exertional dyspnea. In addition, she had undergone a cesarean section two weeks before this admission. A transthoracic echocardiogram showed a mobile mass originating from the atrial septum touching the mitral valve with severe mitral regurgitation. Computed tomography revealed an occluded right profunda femoris artery with an embolus. Infective endocarditis associated with a mobile vegetation with high embolic risk was diagnosed, and urgent surgery was performed. Following the surgery, examinations revealed papillary fibroelastoma originating from the atrial septum and infective endocarditis of the mitral valve. The histopathological examination confirmed that a mass initially thought to be a mobile vegetation was a papillary fibroelastoma. The postoperative course was uneventful except for pericarditis. There has been no recurrence of infective endocarditis or papillary fibroelastoma. CONCLUSIONS The highly mobile papillary fibroelastoma was thought to have caused both chronic mitral regurgitation and infective endocarditis. Mobile papillary fibroelastomas can cause endothelial damage to nearby valves and predispose patients to infective endocarditis.
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Affiliation(s)
- Koji Funaishi
- Department of Cardiovascular Surgery, Hiratsuka City Hospital, 1-19-1 Minamihara, Hiratsuka, Kanagawa, 254-0065, Japan.
| | - Hirofumi Kasahara
- Department of Cardiovascular Surgery, Hiratsuka City Hospital, 1-19-1 Minamihara, Hiratsuka, Kanagawa, 254-0065, Japan
| | - Naohiko Oki
- Department of Cardiovascular Surgery, Hiratsuka City Hospital, 1-19-1 Minamihara, Hiratsuka, Kanagawa, 254-0065, Japan
| | - Tomoyori Nakatogawa
- Department of Cardiology, Chigasaki Municipal Hospital, 5-15-1 Honson, Chigasaki, Kanagawa, 253-0042, Japan
| | - Kazuhiro Yamanoi
- Department of Pathology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
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Kawase K, Okamoto K, Harada S, Nomura Y, Shimada S, Komae H, Kuroda R, Ideyama M, Soma K, Mizoguchi M, Higurashi Y, Ukai K, Adachi-Katayama M, Miwa T, Wakimoto Y, Oyabu T, Jubishi D, Hashimoto H, Okugawa S, Ono M, Doi K, Ushiku T, Tsutsumi T. A case of hypervirulent K1-ST23 Klebsiella pneumoniae endocarditis and papillary muscle rupture secondary to multiple site abscesses. J Infect Chemother 2024; 30:154-158. [PMID: 37776972 DOI: 10.1016/j.jiac.2023.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 09/15/2023] [Accepted: 09/26/2023] [Indexed: 10/02/2023]
Abstract
Hypervirulent Klebsiella pneumoniae (hvKP) causes multisite infections and abscesses. However, endocarditis is a rare presentation of hvKP infection. Herein, we report a case of K. pneumoniae native valve infective endocarditis secondary to community-acquired liver and prostate abscesses. The patient developed papillary muscle rupture, leading to mitral regurgitation, and underwent emergent mitral valve replacement. The diagnosis of endocarditis was confirmed microbiologically and histologically. The causative strain belonged to the hypermucoid K1 capsular genotype and possessed the rmpA gene. The genome sequence was deposited in GenBank under the accession number JAQZBZ000000000.
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Affiliation(s)
- Kyotaro Kawase
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Koh Okamoto
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan.
| | - Sohei Harada
- Department of Infection Control and Prevention, University of Tokyo Hospital, Tokyo, Japan
| | - Yusuke Nomura
- Department of Infection Control and Prevention, University of Tokyo Hospital, Tokyo, Japan
| | - Shogo Shimada
- Department of Cardiac Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Hyoe Komae
- Department of Cardiac Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Ryohei Kuroda
- Department of Pathology, The University of Tokyo Hospital, Tokyo, Japan
| | - Mana Ideyama
- Department of Pathology, The University of Tokyo Hospital, Tokyo, Japan
| | - Katsura Soma
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Miyuki Mizoguchi
- Department of Infection Control and Prevention, University of Tokyo Hospital, Tokyo, Japan
| | - Yoshimi Higurashi
- Department of Infection Control and Prevention, University of Tokyo Hospital, Tokyo, Japan
| | - Kohei Ukai
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Maho Adachi-Katayama
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Toshiki Miwa
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Yuji Wakimoto
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Tatsunori Oyabu
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Daisuke Jubishi
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Hideki Hashimoto
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Shu Okugawa
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Kent Doi
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Tetsuo Ushiku
- Department of Pathology, The University of Tokyo Hospital, Tokyo, Japan
| | - Takeya Tsutsumi
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan; Department of Infection Control and Prevention, University of Tokyo Hospital, Tokyo, Japan
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7
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Misir HD, Demir N, Kasimzade F, Yahşi C. A case of post traumatic mitral chordae rupture mimicking acute respiratory distress syndrome. World J Emerg Med 2024; 15:322-324. [PMID: 39050215 PMCID: PMC11265627 DOI: 10.5847/wjem.j.1920-8642.2024.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 02/29/2024] [Indexed: 07/27/2024] Open
Affiliation(s)
- Hülya Deniz Misir
- Intensive Care Department, Ankara Bilkent City Hospital, Ankara 06800, Turkiye
| | - Nalan Demir
- Intensive Care Department, University of Health Sciences Ankara Bilkent City Hospital, Ankara 06800, Turkiye
| | - Ferit Kasimzade
- Cardiovascular Surgery Department, Ankara Bilkent City Hospital, Ankara 06800, Turkiye
| | - Cansu Yahşi
- Pulmonary Medicine Department, University of Health Sciences Ankara Bilkent City Hospital, Ankara 06800, Turkiye
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8
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Shuvy M, Maisano F, Strauss BH. Transcatheter Mitral Edge-to-Edge Repair for Treatment of Acute Mitral Regurgitation. Can J Cardiol 2023; 39:1382-1389. [PMID: 37209883 DOI: 10.1016/j.cjca.2023.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/18/2023] [Accepted: 05/15/2023] [Indexed: 05/22/2023] Open
Abstract
Acute mitral regurgitation (AMR) is a medical emergency which may lead to rapid clinical deterioration and is associated with high morbidity and mortality. The severity of the clinical presentation varies according to several factors, ranging from cardiogenic shock to a milder presentation. The medical management of AMR includes intravenous diuretics, vasodilators, inotropic support, and potentially mechanical support to stabilise patients. Patients persisting with refractory symptoms despite optimal medical therapy are considered for surgical intervention, but high-risk patients deemed to be inoperable frequently experience poor outcomes. This review highlights the variety of clinical presentations of AMR and the pitfalls in diagnosis and management. The emerging role of transcatheter edge-to-edge repair (TEER), particularly in high-risk patients early after myocardial infarction requiring urgent intervention, has demonstrated feasibility and promising efficacy. TEER is well tolerated and improves hemodynamic parameters in AMR. In a recent analysis, the in-hospital and 1-year mortality rates were significantly higher with surgical mitral interventions compared with TEER. The global TEER experience for treating AMR is encouraging, with reports indicating improved clinical outcomes in high-risk patients and its potential as a bridge to recovery. Early recognition of AMR, validated criteria for patient selection, optimal timing of the intervention as well as long-term outcomes and additional prospective data should be addressed in future studies.
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Affiliation(s)
- Mony Shuvy
- Jesselson Integrated Heart Centre, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University, Jerusalem, Israel.
| | | | - Bradley H Strauss
- Reichmann Chair in Cardiovascular Research, Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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9
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Lebehn M, Vahl T, Kampaktsis P, Hahn RT. Contemporary Evaluation and Clinical Treatment Options for Aortic Regurgitation. J Cardiovasc Dev Dis 2023; 10:364. [PMID: 37754793 PMCID: PMC10532324 DOI: 10.3390/jcdd10090364] [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: 07/28/2023] [Revised: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 09/28/2023] Open
Abstract
Aortic regurgitation (AR) is the third most frequent form of valvular disease and has increasing prevalence with age. This will be of increasing clinical importance with the advancing age of populations around the globe. An understanding of the various etiologies and mechanisms leading to AR requires a detailed understanding of the structure of the aortic valve and aortic root. While acute and chronic AR may share a similar etiology, their hemodynamic impact on the left ventricle (LV) and management are very different. Recent studies suggest current guideline recommendations for chronic disease may result in late intervention and suboptimal outcomes. Accurate quantitation of ventricular size and function, as well as grading of the severity of regurgitation, requires a multiparametric and multimodality imaging approach with an understanding of the strengths and weaknesses of each metric. Echocardiography remains the primary imaging modality for diagnosis with supplemental information provided by computed tomography (CT) and cardiac magnetic resonance imaging (CMR). Emerging transcatheter therapies may allow the treatment of patients at high risk for surgery, although novel methods to assess AR severity and its impact on LV size and function may improve the timing and outcomes of surgical intervention.
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Affiliation(s)
- Mark Lebehn
- Department of Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Torsten Vahl
- Department of Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA
- Cardiovascular Research Foundation, New York, NY 10019, USA
| | - Polydoros Kampaktsis
- Department of Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Rebecca T. Hahn
- Department of Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA
- Cardiovascular Research Foundation, New York, NY 10019, USA
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10
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Ekambaram K, Hassan K. Establishing a Novel Diagnostic Framework Using Handheld Point-of-Care Focused-Echocardiography (HoPE) for Acute Left-Sided Cardiac Valve Emergencies: A Bayesian Approach for Emergency Physicians in Resource-Limited Settings. Diagnostics (Basel) 2023; 13:2581. [PMID: 37568944 PMCID: PMC10416975 DOI: 10.3390/diagnostics13152581] [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: 06/13/2023] [Revised: 07/23/2023] [Accepted: 08/02/2023] [Indexed: 08/13/2023] Open
Abstract
Acute severe cardiac valve emergencies, such as acute severe mitral regurgitation (AMR) and acute severe aortic regurgitation (AAR), present significant challenges in terms of diagnosis and management. Handheld point-of-care ultrasound devices have emerged as potentially pivotal tools in ensuring the prompt and accurate diagnosis of these left-sided valve emergencies by emergency physicians, particularly in resource-limited settings. Despite the increased utilisation of point-of-care ultrasound by emergency physicians for the management of patients in states of acute cardiorespiratory failure, current diagnostic protocols cannot perform sufficient quantitative assessments of the left-sided cardiac valves. This review elucidates and evaluates the diagnostic utility of handheld point-of-care focused-echocardiography (HoPE) in native AMR and AAR by reviewing the relevant literature and the use of clinical case examples from the Emergency Department at Port Shepstone Regional Hospital (PSRH-ED)-a rural, resource-limited hospital located in KwaZulu-Natal, South Africa. Combining the findings of the review and clinical case illustrations, this review proceeds to synthesise a novel, Bayesian-inspired, iterative diagnostic framework that integrates HoPE into the evaluation of patients with acute cardiorespiratory failure and suspected severe left-sided valve lesions.
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Affiliation(s)
- Kamlin Ekambaram
- Port Shepstone Regional Hospital, University of KwaZulu-Natal, Durban 4041, South Africa
| | - Karim Hassan
- Life Bay View Private Hospital, Mossel Bay 6506, South Africa;
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11
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Duncan CF, Bowcock E, Pathan F, Orde SR. Mitral regurgitation in the critically ill: the devil is in the detail. Ann Intensive Care 2023; 13:67. [PMID: 37530859 PMCID: PMC10397171 DOI: 10.1186/s13613-023-01163-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/03/2023] [Indexed: 08/03/2023] Open
Abstract
Mitral regurgitation (MR) is common in the critically unwell and encompasses a heterogenous group of conditions with diverging therapeutic strategies. MR may present acutely with haemodynamic instability or more insidiously with failure to wean from mechanical ventilation. Critical illness is associated with marked physiological stress and haemodynamic changes that dynamically influence the severity and implication of MR. The expanding role of critical care echocardiography uniquely positions the intensivist to apply advanced bedside valvular assessment to recognise haemodynanically significant MR, manipulate and optimise cardiopulmonary physiology and identify patients requiring urgent cardiology and surgical referral. This review will consider common clinical scenarios, therapeutic strategies and the pearls and pitfalls of echocardiographic assessment and quantification in the critically unwell.
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Affiliation(s)
- Chris F Duncan
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, Sydney, NSW, 2747, Australia.
| | - Emma Bowcock
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, Sydney, NSW, 2747, Australia
| | - Faraz Pathan
- Department of Cardiology, Nepean Hospital, Kingswood, Sydney, NSW, 2747, Australia
- Nepean Clinical School of Medicine, Charles Perkin Centre Nepean, University of Sydney, Kingswood, Sydney, NSW, 2747, Australia
| | - Sam R Orde
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, Sydney, NSW, 2747, Australia
- University of Sydney, Camperdown, Sydney, NSW, 2006, Australia
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12
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Boudoulas KD, Triposkiadis F, Koenig S, Marmagkiolis K, Iliescu C, Pitsis A, Boudoulas H. Acute mitral regurgitation with and without acute heart failure. Heart Fail Rev 2023:10.1007/s10741-023-10322-5. [PMID: 37414917 DOI: 10.1007/s10741-023-10322-5] [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: 05/08/2023] [Indexed: 07/08/2023]
Abstract
Acute severe mitral regurgitation (MR) is rare, but often leads to cardiogenic shock, pulmonary edema, or both. Most common causes of acute severe MR are chordae tendineae (CT) rupture, papillary muscle (PM) rupture, and infective endocarditis (IE). Mild to moderate MR is often seen in patients with acute myocardial infarction (AMI). CT rupture in patients with floppy mitral valve/mitral valve prolapse is the most common etiology of acute severe MR today. In IE, native or prosthetic valve damage can occur (leaflet perforation, ring detachment, other), as well as CT or PM rupture. Since the introduction of percutaneous revascularization in AMI, the incidence of PM rupture has substantially declined. In acute severe MR, the hemodynamic effects of the large regurgitant volume into the left atrium (LA) during left ventricular (LV) systole, and in turn back into the LV during diastole, are profound as the LV and LA have not had time to adapt to this additional volume. A rapid, but comprehensive evaluation of the patient with acute severe MR is essential in order to define the underline cause and apply appropriate management. Echocardiography with Doppler provides vital information related to the underlying pathology. Coronary arteriography should be performed in patients with an AMI to define coronary anatomy and need for revascularization. In acute severe MR, medical therapy should be used to stabilize the patient before intervention (surgery, transcatheter); mechanical support is often required. Diagnostic and therapeutic steps should be individualized, and a multi-disciplinary team approach should be utilized.
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Affiliation(s)
- Konstantinos Dean Boudoulas
- Division of Cardiovascular Medicine, The Ohio State University, 473 W. 12th Avenue, Suite 200, Columbus, OH, 43210, USA
| | | | - Sara Koenig
- Davis Heart and Lung Research Institute, The Ohio State University, Columbus, USA
| | - Konstantinos Marmagkiolis
- Tampa Heart, Tampa, FL, USA
- Department of Internal Medicine, University of South Florida, Tampa, FL, USA
| | - Cezar Iliescu
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Harisios Boudoulas
- Division of Cardiovascular Medicine, The Ohio State University, 473 W. 12th Avenue, Suite 200, Columbus, OH, 43210, USA.
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, USA.
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13
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Kaddoura R, Al-Hijji M. Transcatheter Mitral Valve Repair in Acute and Critical Cardiac Conditions. Heart Views 2023; 24:29-40. [PMID: 37124432 PMCID: PMC10144416 DOI: 10.4103/heartviews.heartviews_73_22] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 01/22/2023] [Indexed: 02/24/2023] Open
Abstract
Acute mitral valve regurgitation (MR) is an emergency condition that requires an early diagnosis of the etiology and rapid management. Surgical intervention is the first-line treatment for acute severe MR. However, many patients are denied surgical intervention due to the acute risk of surgery. Transcatheter mitral valve repair (TMVr) is a less invasive technique and becoming a potential alternative to surgery in inoperable patients but is underrepresented in the literature. This review aims to discuss the published data on the use of TMVr in unstable MR patients presenting with acute or critical cardiac conditions.
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Affiliation(s)
- Rasha Kaddoura
- Department of Pharmacy, Heart Hospital Hamad Medical Corporation, Doha, Qatar
| | - Mohammed Al-Hijji
- Department of Adult Cardiology, Heart Hospital Hamad Medical Corporation, Doha, Qatar
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Perel N, Asher E, Taha L, Levy N, Steinmetz Y, Karameh H, Karmi M, Maller T, Harari E, Dvir D, Glikson M, Carasso S, Shuvy M. Urgent Transcatheter Edge-to-Edge Repair for Severe Mitral Regurgitation in Patients with Refractory Cardiogenic Shock. J Clin Med 2022; 11:jcm11195617. [PMID: 36233485 PMCID: PMC9573095 DOI: 10.3390/jcm11195617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 09/14/2022] [Accepted: 09/17/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Patients suffering from cardiogenic shock (CS) and mitral regurgitation (MR) demonstrate worse prognosis, with higher mortality rates. We sought to evaluate the effectiveness of urgent valve intervention of the mitral valve, using transcatheter edge-to-edge repair (TEER) procedures in patients presenting with CS in a tertiary Intensive Coronary Care Unit (ICCU). Methods and Results Patients with unremitting CS and severe MR were selected for urgent TEER. Baseline clinical and echocardiographic characteristics were recorded, as well as procedural success (MR severity and hemodynamics), and 30-days and 6-month mortality. Urgent TEER was done in 13 patients, whose average age was 70 years; 12 (92%) of the patients were male. All 13 patients had suffered previous ischemic heart disease—12 (92%) with either acute severe MR or worsening of previously known MR by an acute ischemic event. Using the SCAI criteria, 8 patients (61%) were classified as ‘E’ (Extreme) category; 4 (31%) were classified as ‘C’. At 30 days, 12 out of the 13 patients survived (corresponding to an 8% mortality rate); all of those 12 patients remained alive at 6 months post-admission/procedure. Conclusions The use of TEER was associated with greater 30-day and 6-month survival rates, compared to the worldwide mortality rates of patients admitted with CS. This finding may change the previous paradigm that CS and MR are associated with the worst outcome, and we might be able to offer these patients a safe and effective therapeutic option.
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Affiliation(s)
- Nimrod Perel
- Jesselson Integrated Heart Centre, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University, 12, Shmu’el Bait, P.O. 3235, Jerusalem 9103102, Israel
| | - Elad Asher
- Jesselson Integrated Heart Centre, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University, 12, Shmu’el Bait, P.O. 3235, Jerusalem 9103102, Israel
| | - Luoay Taha
- Jesselson Integrated Heart Centre, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University, 12, Shmu’el Bait, P.O. 3235, Jerusalem 9103102, Israel
| | - Nir Levy
- Jesselson Integrated Heart Centre, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University, 12, Shmu’el Bait, P.O. 3235, Jerusalem 9103102, Israel
| | - Yoed Steinmetz
- Jesselson Integrated Heart Centre, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University, 12, Shmu’el Bait, P.O. 3235, Jerusalem 9103102, Israel
| | - Hani Karameh
- Jesselson Integrated Heart Centre, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University, 12, Shmu’el Bait, P.O. 3235, Jerusalem 9103102, Israel
| | - Mohammad Karmi
- Jesselson Integrated Heart Centre, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University, 12, Shmu’el Bait, P.O. 3235, Jerusalem 9103102, Israel
| | - Tomer Maller
- Jesselson Integrated Heart Centre, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University, 12, Shmu’el Bait, P.O. 3235, Jerusalem 9103102, Israel
| | - Emanuel Harari
- Jesselson Integrated Heart Centre, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University, 12, Shmu’el Bait, P.O. 3235, Jerusalem 9103102, Israel
| | - Danny Dvir
- Jesselson Integrated Heart Centre, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University, 12, Shmu’el Bait, P.O. 3235, Jerusalem 9103102, Israel
| | - Michael Glikson
- Jesselson Integrated Heart Centre, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University, 12, Shmu’el Bait, P.O. 3235, Jerusalem 9103102, Israel
| | - Shemy Carasso
- Jesselson Integrated Heart Centre, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University, 12, Shmu’el Bait, P.O. 3235, Jerusalem 9103102, Israel
- The Azrieli Faculty of Medicine, Bar Ilan University, Zefat 1311502, Israel
| | - Mony Shuvy
- Jesselson Integrated Heart Centre, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University, 12, Shmu’el Bait, P.O. 3235, Jerusalem 9103102, Israel
- Correspondence: ; Tel.: +972-2-6555955; Fax: +972-2-5645222
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15
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Acute Ischaemic Mitral Valve Regurgitation. J Clin Med 2022; 11:jcm11195526. [PMID: 36233410 PMCID: PMC9571705 DOI: 10.3390/jcm11195526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/04/2022] [Accepted: 09/13/2022] [Indexed: 12/03/2022] Open
Abstract
Acute ischaemic mitral regurgitation (IMR) is an increasingly rare and challenging complication following acute myocardial infarction. Despite recent technical advances in both surgical and percutaneous interventions, a poor prognosis is often associated with this challenging patient cohort. In this review, we revisit the diagnosis and typical echocardiographic features, and evaluate current surgical and percutaneous treatment options for patients with acute IMR.
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16
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Bernard S, Deferm S, Bertrand PB. Acute valvular emergencies. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:653-665. [PMID: 35912478 DOI: 10.1093/ehjacc/zuac086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 07/05/2022] [Accepted: 07/08/2022] [Indexed: 06/15/2023]
Abstract
Acute valvular emergencies represent an important cause of cardiogenic shock. However, their clinical presentation and initial diagnostic testing are often non-specific, resulting in delayed diagnosis. Moreover, metabolic disarray or haemodynamic instability may result in too great a risk for emergent surgery. This review will focus on the aetiology, clinical presentation, diagnostic findings, and treatment options for patients presenting with native acute left-sided valvular emergencies. In addition to surgery, options for medical therapy, mechanical circulatory support, and novel percutaneous interventions are discussed.
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Affiliation(s)
- Samuel Bernard
- Department of Cardiology, New York University School of Medicine, New York, NY, USA
| | - Sebastien Deferm
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Faculty of Medicine & Life Sciences, Hasselt University, Hasselt, Belgium
| | - Philippe B Bertrand
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Faculty of Medicine & Life Sciences, Hasselt University, Hasselt, Belgium
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17
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Transcatheter edge-to-edge repair in patients with mitral regurgitation and cardiogenic shock: a new therapeutic target. Curr Opin Crit Care 2022; 28:426-433. [PMID: 35856980 DOI: 10.1097/mcc.0000000000000952] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Cardiogenic shock with significant mitral regurgitation portends a poor prognosis with limited therapeutic options. Herein, we review the available evidence regarding the patient characteristics, management, impact of transcatheter edge-to-edge repair (TEER) on hemodynamics, and clinical outcomes of patients with cardiogenic shock and mitral regurgitation. RECENT FINDINGS Several observational studies and systematic reviews have demonstrated the feasibility and safety of TEER in cardiogenic shock complicated by degenerative or functional mitral regurgitation. Surgical interventions for mitral regurgitation remain limited owing to the risk profile of patients in cardiogenic shock. TEER has been studied in both degenerative and functional mitral regurgitation and remains feasible in the critically ill population. Moreover, TEER is associated with reduction in mitral regurgitation and improvement in-hospital and long-term mortality. SUMMARY TEER remains a promising therapeutic option in cardiogenic shock complicated by significant mitral regurgitation, but additional research is required to identify patient and procedural characteristics, hemodynamic parameters, and the optimal time for intervention. Moreover, future randomized controlled trials are in progress to evaluate the potential benefit of TEER against medical management in cardiogenic shock and mitral regurgitation.
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18
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Bucklew E, Noory A, Okumus N, Radhakrishnan S, Mahabir S, Samra G, Dysert K, Cheema T, Ivanova V. Acute Cardiac Emergencies. Crit Care Nurs Q 2022; 45:200-217. [PMID: 35617087 DOI: 10.1097/cnq.0000000000000405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Acute cardiac emergencies are life threatening. The initial responses to acute cardiac emergencies must be rapid, efficient, skillful, and well-planned. The goal of this article is to provide information that can be used to facilitate the prompt recognition and treatment of the most common acute cardiac emergencies.
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Affiliation(s)
- Eric Bucklew
- Cardiovascular Institute (Drs Bucklew, Noory, Okumus, Radhakrishnan, Mahabir, Samra, and Ivanova) and Division of Pulmonary Critical Care Medicine (Ms Dysert and Dr Cheema), Allegheny Health Network, Pittsburgh, Pennsylvania; and Drexel University College of Medicine, Pittsburgh, Pennsylvania (Dr Ivanova)
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19
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Taha FA, Naeim H, Amoudi O, Alnozha F, Almutairi M, Abuelatta R. Transcatheter Mitral Valve Repair Technique in Specific Severe Mitral Regurgitation: Tips, Tricks, and Outcomes. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2022; 6:100043. [PMID: 37274546 PMCID: PMC10236813 DOI: 10.1016/j.shj.2022.100043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 03/06/2022] [Accepted: 04/14/2022] [Indexed: 06/06/2023]
Abstract
Background In specific patients with severe mitral regurgitation (MR), mitral valve (MV) pathology is unique and requires creative transcatheter repair techniques. This study aimed to evaluate the feasibility and safety of a new transcatheter MV repair technique, using occluder devices in symptomatic high-surgical-risk patients with severe MR, either due to MV leaflet (MVL) perforations or due to post-clips residual MR, and to report on their 6-month outcomes. Methods The study enrolled all high-risk patients with severe MR due to MVL perforations and post-clips residual MR who underwent transcatheter MV repair using occluder devices, from November 2016 to August 2019. Results The study enrolled 16 patients; 9 (56.25%) with MVL perforations and 7 (43.75%) with post-MitraClip (Abbott Laboratories, Abbott Park, Illinois) residual MR, with a mean age of 55.75 ± 16.69 years. Mean perforation/jet diameters were 5.75 ± 1.67 and 6.5 ± 1.93 mm, and the mean 3D-vena contracta area was 0.54 ± 0.14 cm2. Perforations were crossed retrograde (transaortic in 7 [43.75%] patients and transapical in 2 [12.5%] patients), and post-MitraClip devices residual jets were crossed antegrade (transvenous/transseptal). Six (37.5%) patients required arteriovenous loop formation for device deployment, that was antegrade transvenous/transseptal in 13 (81.25%) patients and retrograde transapical in 3 (18.75%) patients. Devices used were Amplatzer-ASO in 10 (62.5%) patients and Amplatzer-VP-II in 6 (37.5%) patients. Mean procedural and fluoroscopy times were 55.13 ± 16.24 and 16.25 ± 4.03 minutes, respectively. Patients passed successfully, without MV gradient change or device-related complications. Conclusions Transcatheter MV repair of MVL perforations/post-clips residual MR is a new, feasible, and safe technique for high-surgical-risk patients.
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Affiliation(s)
- Fatma Aboalsoud Taha
- Adult Cardiology Department, Madinah Cardiac Center, Madinah, Saudi Arabia
- Cardiology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Hesham Naeim
- Adult Cardiology Department, Madinah Cardiac Center, Madinah, Saudi Arabia
| | - Osama Amoudi
- Adult Cardiology Department, Madinah Cardiac Center, Madinah, Saudi Arabia
| | - Fareed Alnozha
- Adult Cardiology Department, Madinah Cardiac Center, Madinah, Saudi Arabia
| | - Mansour Almutairi
- Adult Cardiology Department, Madinah Cardiac Center, Madinah, Saudi Arabia
| | - Reda Abuelatta
- Adult Cardiology Department, Madinah Cardiac Center, Madinah, Saudi Arabia
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20
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Peters AS, Duggan JP, Trachiotis GD, Antevil JL. Epidemiology of Valvular Heart Disease. Surg Clin North Am 2022; 102:517-528. [PMID: 35671771 DOI: 10.1016/j.suc.2022.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Acquired diseases of the aortic and mitral valves are the most common cause of morbidity and mortality among Valvular heart diseases. Aortic stenosis (AS) is increasing in incidence in the United States (4,43 US), driven largely by an aging demographic. Aortic valve replacement is the only effective treatment of AS and has a dramatic mortality benefit. Mitral valve regurgitation (MR) is the most common form of valvular heart disease (VHD) in the US, whereby MR is most often the result of mitral valve prolapse; rheumatic heart disease (RHD) is a more common etiology of MR in underdeveloped countries. interventions for MR in the US are increasing.
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Affiliation(s)
- Alex S Peters
- Department of Surgery, Walter Reed National Military Medical Center, 4494 Palmer Road North, Bethesda, MD 20814, USA
| | - John P Duggan
- Department of Surgery, Walter Reed National Military Medical Center, 4494 Palmer Road North, Bethesda, MD 20814, USA
| | - Gregory D Trachiotis
- Division of Cardiology, Cardiothoracic Surgery and Heart Center, Washington DC Veterans Affairs Medical Center, 50 Irving Street Northwest, Washington, DC 20422, USA; Department of Surgery, George Washington University Hospital, 900 23rd St NW, Washington, DC 20037, USA
| | - Jared L Antevil
- Division of Cardiothoracic Surgery, Washington DC Veterans Affairs Medical Center, 50 Irving Street Northwest, Washington, DC 20422, USA.
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21
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Ahmed EA, Schaff HV, Geske JB, Lee AT, King KS, Dearani JA, Nishimura RA, Ommen SR. Optimal Management of Mitral Regurgitation Due to Ruptured Mitral Chordae Tendineae in Patients With Hypertrophic Cardiomyopathy. Semin Thorac Cardiovasc Surg 2022; 35:476-482. [PMID: 35598764 DOI: 10.1053/j.semtcvs.2022.05.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 05/13/2022] [Indexed: 11/11/2022]
Abstract
There is continued controversy regarding surgical management of patients with hypertrophic cardiomyopathy (HCM) and intrinsic mitral valve disease; some clinicians favor prosthetic replacement as this corrects left ventricular outflow tract (LVOT) obstruction and valve leakage. In this study, we investigated the management and late outcome of operation for mitral regurgitation (MR) due to ruptured chordae tendineae in patients with HCM. We analyzed 49 consecutive patients with HCM and MR due to ruptured mitral valve chordae. Echocardiograms and operative reports were reviewed to classify valve anatomy and surgical methods. Information on late outcomes was obtained from electronic medical records and follow-up surveys. The mean age of the 36 men and 13 women was 61.9 ± 12.5 years; significant resting or provoked LVOT obstruction was present at the time of surgery in 46 patients. During the index operation, mitral valve repair was performed in 45 patients, and prosthetic replacement was necessary for 4 patients. Concomitant septal myectomy was performed in 46 patients. There were no hospital deaths or deaths within 30 days of operation. Five and ten-year survival estimates (Kaplan-Meier) were 92% and 71%. During follow-up at a median of 7.9 years, 3 patients underwent reoperation for MV replacement, 5 days, 3 years, and 14 years following valve repair. Ruptured mitral chordae may result in severe mitral valve regurgitation in patients with hypertrophic cardiomyopathy. Valvuloplasty at the time of septal myectomy is safe with an acceptably low rate of recurrent MR requiring prosthetic replacement.
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Affiliation(s)
- Eglal A Ahmed
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
| | - Jeffrey B Geske
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Alexander T Lee
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Katherine S King
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Rick A Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Steve R Ommen
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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22
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Kataria R, Castagna F, Madan S, Kim P, Saeed O, Adjepong YA, Melainis AA, Taub C, Garcia MJ, Latib A, Jorde UP. Severity of Functional Mitral Regurgitation on Admission for Acute Decompensated Heart Failure Predicts Long-Term Risk of Rehospitalization and Death. J Am Heart Assoc 2021; 11:e022908. [PMID: 34935442 PMCID: PMC9075195 DOI: 10.1161/jaha.121.022908] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Functional mitral regurgitation (FMR) has emerged as a therapeutic target in patients with chronic heart failure and left ventricular systolic dysfunction. The significance of FMR in acute decompensated heart failure remains obscure. We systematically investigated the prevalence and clinical significance of FMR on admission in patients admitted with acute decompensated heart failure and left ventricular systolic dysfunction. Methods and Results The study was a single‐center, retrospective review of patients admitted with acute decompensated heart failure and left ventricular systolic dysfunction between 2012 and 2017. Patients were divided into 3 groups of FMR: none/mild, moderate, and moderate‐to‐severe/severe FMR. The primary outcome was 1‐year post‐discharge all‐cause mortality. We also compared these groups for 6‐month heart failure hospitalization rates. Of 2303 patients, 39% (896) were women. Median left ventricular ejection fraction was 25%. Four hundred and fifty‐three (20%) patients had moderate‐to‐severe/severe FMR, which was independently associated with 1‐year all‐cause mortality. Moderate or worse FMR was found in 1210 (53%) patients and was independently associated with 6‐month heart failure hospitalization. Female sex was independently associated with higher severity of FMR. Conclusions More than half of patients hospitalized with acute decompensated heart failure and left ventricular systolic dysfunction had at least moderate FMR, which was associated with increased readmission rates and mortality. Intensified post‐discharge follow‐up should be undertaken to eliminate FMR amenable to pharmacological therapy and enable timely and appropriate intervention for persistent FMR. Further studies are needed to examine sex‐related disparities in FMR.
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Affiliation(s)
- Rachna Kataria
- Montefiore-Einstein Heart and Vascular CenterMontefiore Medical Center and Albert Einstein College of Medicine Bronx NY
| | - Francesco Castagna
- Montefiore-Einstein Heart and Vascular CenterMontefiore Medical Center and Albert Einstein College of Medicine Bronx NY
| | - Shivank Madan
- Montefiore-Einstein Heart and Vascular CenterMontefiore Medical Center and Albert Einstein College of Medicine Bronx NY
| | - Paul Kim
- Montefiore-Einstein Heart and Vascular CenterMontefiore Medical Center and Albert Einstein College of Medicine Bronx NY
| | - Omar Saeed
- Montefiore-Einstein Heart and Vascular CenterMontefiore Medical Center and Albert Einstein College of Medicine Bronx NY
| | - Yaw A Adjepong
- Department of Medicine Yale School of Medicine New Haven CT
| | - Angelos A Melainis
- Division of Medicine Jacobi Medical CenterAlbert Einstein College of Medicine Bronx NY
| | - Cynthia Taub
- Section of Cardiovascular Medicine Dartmouth-Hitchcock Medical Center Lebanon NH
| | - Mario J Garcia
- Montefiore-Einstein Heart and Vascular CenterMontefiore Medical Center and Albert Einstein College of Medicine Bronx NY
| | - Azeem Latib
- Montefiore-Einstein Heart and Vascular CenterMontefiore Medical Center and Albert Einstein College of Medicine Bronx NY
| | - Ulrich P Jorde
- Montefiore-Einstein Heart and Vascular CenterMontefiore Medical Center and Albert Einstein College of Medicine Bronx NY
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23
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Kanzaki H, Amaki M, Okada A, Takahama H, Izumi C, Anzai T. Influence of Left Ventricular Function on the "Aortic Regurgitation Index" Proposed for the Hemodynamic Assessment of Postprocedural Aortic Regurgitation. Int Heart J 2021; 62:1019-1025. [PMID: 34544972 DOI: 10.1536/ihj.21-028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The aortic regurgitation (AR) index, proposed as an objective indicator of postprocedural AR, decreases in proportion to AR severity, besides reportedly providing additional prognostic information. Meanwhile, left ventricular (LV) function has also been considered an essential prognostic factor. This study aimed to clarify whether LV function affected the AR index using cardiac catheterization data.A retrospective study was performed in patients whose LV function was evaluated using a micromanometer-tipped catheter. Patients with grade 2 or higher AR were excluded to explore non-AR factors affecting the AR index value. The AR index was calculated as a ratio of the gradient between the aortic diastolic blood pressure (DBP) and the LV end-diastolic pressure (EDP) to the aortic systolic blood pressure (SBP): AR Index = [ (DBP - LVEDP) / SBP] × 100.A total of 64 patients [age, 62 (interquartile range: 48-70) years; LV ejection fraction, 19% (16%-26%) ] were examined. AR index values ranged from 18.3 to 68.6. Despite having no AR, two patients displayed an AR index < 25, indicating significant AR. Multiple-regression analysis revealed that LV diastolic stiffness (β = -0.750, P < 0.001), LV max dP/dt (β = -0.296, P = 0.006), and heart rate (β = 0.284, P = 0.011) were independent determinants of the AR index value.Patients with impaired LV diastolic function and preserved systolic function had low AR index values. The additional prognostic information of the AR index may be related to LV diastolic function.
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Affiliation(s)
- Hideaki Kanzaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Makoto Amaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Atsushi Okada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hiroyuki Takahama
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
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24
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Kawabata A, Funakoshi H, Ito J, Santanda T, Norisue Y, Watanabe H. Diagnostic delay of acute mitral regurgitation during the coronavirus disease 2019 pandemic: a case report. Int J Emerg Med 2021; 14:38. [PMID: 34281499 PMCID: PMC8287556 DOI: 10.1186/s12245-021-00365-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 06/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Diagnostic errors or delays can cause serious consequences for patient safety, especially in the emergency department. Anchoring bias is one of the major factors leading to diagnostic error. During the coronavirus disease 2019 (COVID-19) pandemic, the high probability of COVID-19 in febrile patients could be a major cause of anchoring bias leading to diagnostic error. In addition, certain evaluations such as auscultation are difficult to perform on a casual basis due to the increased risk of contact infection, which lead to inadequate assessment of the patients with valvular disease. Acute mitral regurgitation (MR) could be a fatal disease in the emergency department, especially if there is a diagnostic error or delay in diagnosis. It is often reported that diagnosis can be difficult even though there is no treatment other than emergent surgery. The diagnosis of acute MR has become more difficult because coronavirus disease 2019 (COVID-19) pandemic could affect our daily practice especially in febrile patients. We report a case of a diagnostic delay of a febrile patient because of anchoring bias during the COVID-19 pandemic. CASE PRESENTATION A 45-year-old man presented to the emergency department complaining of acute dyspnea and fever. Based on vital signs and computed tomography of the chest, acute pneumonia due to COVID-19 was suspected. Auscultation was avoided because of facility rule based on concern of contact infection. After admission to the intensive care unit, Doppler echocardiography revealed acute mitral regurgitation, and transesophageal echocardiography revealed mitral valve tendon rupture. After confirming the negative result for the polymerase chain reaction of severe acute respiratory syndrome coronavirus 2, mitral valvuloplasty was performed on the third day after admission. The patient was discharged 14 days after admission without complications. CONCLUSIONS In COVID-19 pandemic, anchoring bias suspecting COVID-19 among febrile patients becomes a strong heuristic factor. A thorough history and physical examination is still important in febrile patients presenting with dyspnea to ensure the correct diagnosis of acute mitral regurgitation.
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Affiliation(s)
- Azumi Kawabata
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32, Todaijima, Urayasu, Chiba, 279-0001, Japan
| | - Hiraku Funakoshi
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32, Todaijima, Urayasu, Chiba, 279-0001, Japan.
| | - Joji Ito
- Department of Cardiovascular Surgery, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32, Todaijima, Urayasu, Chiba, 279-0001, Japan
| | - Takushi Santanda
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32, Todaijima, Urayasu, Chiba, 279-0001, Japan
| | - Yasuhiro Norisue
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32, Todaijima, Urayasu, Chiba, 279-0001, Japan
| | - Hiroyuki Watanabe
- Department of Cardiology, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32, Todaijima, Urayasu, Chiba, 279-0001, Japan
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25
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2020 ACC/AHA guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2021; 162:e183-e353. [PMID: 33972115 DOI: 10.1016/j.jtcvs.2021.04.002] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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26
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Miyazaki R, Watanabe K, Kaneko M, Nagamine S, Hara N, Nakamura T, Nagata Y, Nozato T, Ashikaga T. Acute Ischemic Mitral Regurgitation Treated by Percutaneous Coronary Intervention after an Accurate Diagnosis on Transesophageal Echocardiography. Intern Med 2021; 60:1417-1421. [PMID: 33281155 PMCID: PMC8170240 DOI: 10.2169/internalmedicine.5502-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
An 80-year-old woman with acute posterolateralmyocardial infarction, cardiogenic shock, and acute heart failure was admitted to our hospital. Transthoracic echocardiography (TTE) showed dysfunction of the left ventricular inferolateral wall motion and severe mitral valve regurgitation (MR). Emergency coronary angiography revealed triple-vessel stenosis. We performed transesophageal echocardiography in the catheter room to diagnose the cause of MR. Severe tenting of the mitral valve and no rupture of the papillary muscles were revealed. We considered ischemic MR likely to improve with revascularization and performed percutaneous coronary intervention. Subsequently, the patient's circulatory dynamics rapidly stabilized, and MR was significantly improved on follow-up TTE.
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Affiliation(s)
- Ryoichi Miyazaki
- Department of Cardiology, Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | - Keita Watanabe
- Department of Cardiology, Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | - Masakazu Kaneko
- Department of Cardiology, Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | - Sho Nagamine
- Department of Cardiology, Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | - Nobuhiro Hara
- Department of Cardiology, Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | - Tomofumi Nakamura
- Department of Cardiology, Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | - Yasutoshi Nagata
- Department of Cardiology, Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | - Toshihiro Nozato
- Department of Cardiology, Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | - Takashi Ashikaga
- Department of Cardiology, Japanese Red Cross Musashino Hospital, Tokyo, Japan
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Mohananey D, Aljadah M, Smith AAH, Haines JF, Patel S, Villablanca P, Ramakrishna H. The 2020 ACC/AHA Guidelines for Management of Patients With Valvular Heart Disease: Highlights and Perioperative Implications. J Cardiothorac Vasc Anesth 2021; 36:1467-1476. [PMID: 34011447 DOI: 10.1053/j.jvca.2021.04.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 04/10/2021] [Indexed: 12/26/2022]
Abstract
Valvular heart disease contributes to a large burden of morbidity and mortality in the United States. During the last decade there has been a paradigm shift in the management of valve disease, primarily driven by the emergence of novel transcatheter technologies. In this article, the latest update of the American College of Cardiology/American Heart Association valve heart disease guidelines is reviewed.
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Affiliation(s)
- Divyanshu Mohananey
- Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Michael Aljadah
- Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Aaron A H Smith
- Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Jeremiah F Haines
- Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Sahishnu Patel
- Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, WI
| | | | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Acute aortic regurgitation underestimated by transesophageal echocardiography after preparatory balloon aortic valvuloplasty during transcatheter aortic valve implantation for severe aortic stenosis. Cardiovasc Interv Ther 2021; 36:395-397. [PMID: 33792843 DOI: 10.1007/s12928-021-00773-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 05/29/2020] [Indexed: 10/21/2022]
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29
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Feng L, Gao H, Qi N, Danton M, Hill NA, Luo X. Fluid-structure interaction in a fully coupled three-dimensional mitral-atrium-pulmonary model. Biomech Model Mechanobiol 2021; 20:1267-1295. [PMID: 33770307 PMCID: PMC8298265 DOI: 10.1007/s10237-021-01444-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 03/01/2021] [Indexed: 12/17/2022]
Abstract
This paper aims to investigate detailed mechanical interactions between the pulmonary haemodynamics and left heart function in pathophysiological situations (e.g. atrial fibrillation and acute mitral regurgitation). This is achieved by developing a complex computational framework for a coupled pulmonary circulation, left atrium and mitral valve model. The left atrium and mitral valve are modelled with physiologically realistic three-dimensional geometries, fibre-reinforced hyperelastic materials and fluid–structure interaction, and the pulmonary vessels are modelled as one-dimensional network ended with structured trees, with specified vessel geometries and wall material properties. This new coupled model reveals some interesting results which could be of diagnostic values. For example, the wave propagation through the pulmonary vasculature can lead to different arrival times for the second systolic flow wave (S2 wave) among the pulmonary veins, forming vortex rings inside the left atrium. In the case of acute mitral regurgitation, the left atrium experiences an increased energy dissipation and pressure elevation. The pulmonary veins can experience increased wave intensities, reversal flow during systole and increased early-diastolic flow wave (D wave), which in turn causes an additional flow wave across the mitral valve (L wave), as well as a reversal flow at the left atrial appendage orifice. In the case of atrial fibrillation, we show that the loss of active contraction is associated with a slower flow inside the left atrial appendage and disappearances of the late-diastole atrial reversal wave (AR wave) and the first systolic wave (S1 wave) in pulmonary veins. The haemodynamic changes along the pulmonary vessel trees on different scales from microscopic vessels to the main pulmonary artery can all be captured in this model. The work promises a potential in quantifying disease progression and medical treatments of various pulmonary diseases such as the pulmonary hypertension due to a left heart dysfunction.
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Affiliation(s)
- Liuyang Feng
- School of Mathematics and Statistics, University of Glasgow, Glasgow, G12 8SQ, UK.
| | - Hao Gao
- School of Mathematics and Statistics, University of Glasgow, Glasgow, G12 8SQ, UK
| | - Nan Qi
- Institute of Marine Science and Technology, Shandong University, Shangdong, 266237, People's Republic of China
| | - Mark Danton
- Department of Cardiac Surgery, Royal Hospital for Children, Glasgow, UK
| | - Nicholas A Hill
- School of Mathematics and Statistics, University of Glasgow, Glasgow, G12 8SQ, UK
| | - Xiaoyu Luo
- School of Mathematics and Statistics, University of Glasgow, Glasgow, G12 8SQ, UK
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30
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Wedin JO, Vikholm P, Alström U, Schiller P. Severe chronic aortic regurgitation after percutaneous coronary intervention: a case report and literature review. EUROPEAN HEART JOURNAL-CASE REPORTS 2021; 5:ytab044. [PMID: 34113755 PMCID: PMC8186922 DOI: 10.1093/ehjcr/ytab044] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/01/2020] [Accepted: 01/27/2021] [Indexed: 11/14/2022]
Abstract
Background Severe aortic regurgitation (AR) is an extremely rare complication after coronary catheterization and percutaneous coronary intervention (PCI), where most reported cases have required relatively urgent surgical intervention due to acute-onset AR and cardiac decompensation. Case summary We report a case of a 60-year-old woman that previously presented with a non-ST-elevation myocardial infarction (NSTEMI) due to an ostial right coronary artery stenosis. During the course of 2 years, she developed five recurrent NSTEMI due to in-stent thrombosis, necessitating either a new coronary stent or balloon. She developed a chronic severe AR due to a drug-eluting coronary stent protruding from the right coronary artery and underwent successful aortic valve replacement and coronary artery by-pass grafting. Discussion We performed a literature review and identified 16 reported cases of iatrogenic severe aortic regurgitation related to coronary catheterization or percutaneous coronary intervention. All patients developed an acute aortic regurgitation and, thus, we report the first case of a delayed complication caused by a protruding coronary stent. The surgical strategy is related to the extent of the damage, where smaller perforations or lacerations seems to be feasible for aortic valve repair and larger defects more often lead to aortic valve replacement. Our patient developed a fibrotic right coronary cusp which could not be used to perform a successful aortic valve repair.
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Affiliation(s)
- Johan O Wedin
- Department of Cardiothoracic Surgery and Anesthesiology, Entrance 50, 7th Floor, Uppsala University Hospital, SE-75185 Uppsala, Sweden
| | - Per Vikholm
- Department of Cardiothoracic Surgery and Anesthesiology, Entrance 50, 7th Floor, Uppsala University Hospital, SE-75185 Uppsala, Sweden
| | - Ulrica Alström
- Department of Cardiothoracic Surgery and Anesthesiology, Entrance 50, 7th Floor, Uppsala University Hospital, SE-75185 Uppsala, Sweden
| | - Petter Schiller
- Department of Cardiothoracic Surgery and Anesthesiology, Entrance 50, 7th Floor, Uppsala University Hospital, SE-75185 Uppsala, Sweden
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31
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 143:e72-e227. [PMID: 33332150 DOI: 10.1161/cir.0000000000000923] [Citation(s) in RCA: 548] [Impact Index Per Article: 182.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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32
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 77:e25-e197. [PMID: 33342586 DOI: 10.1016/j.jacc.2020.11.018] [Citation(s) in RCA: 782] [Impact Index Per Article: 260.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Davis JW, Virk F, Ahmad M. Acute infective endocarditis masquerading as septic shock with acute respiratory distress syndrome. Clin Case Rep 2020; 8:3149-3153. [PMID: 33363896 PMCID: PMC7752453 DOI: 10.1002/ccr3.3261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 08/02/2020] [Indexed: 11/17/2022] Open
Abstract
Any new pulmonary edema warrants an urgent rule out of acute cardiac dysfunction. Because sepsis protocols emphasize rapid stabilization and treatment over etiologic evaluation, some cases of endocarditis may be missed as sepsis with acute respiratory distress syndrome.
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Affiliation(s)
- John W. Davis
- Division of CardiologyDepartment of Internal MedicineUniversity of Texas Medical BranchGalvestonTXUSA
| | - Fawad Virk
- Division of CardiologyDepartment of Internal MedicineUniversity of Texas Medical BranchGalvestonTXUSA
| | - Masood Ahmad
- Division of CardiologyDepartment of Internal MedicineUniversity of Texas Medical BranchGalvestonTXUSA
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34
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Shouls G, Bagnall TJ, Pandya B. The “Cooing Pigeon”. JACC Case Rep 2020; 2:2162-2165. [PMID: 34317129 PMCID: PMC8299863 DOI: 10.1016/j.jaccas.2020.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/23/2020] [Accepted: 08/07/2020] [Indexed: 12/05/2022]
Abstract
We present a case of acute aortic homograft regurgitation manifesting as a new-onset “cooing” murmur in a patient with congenital heart disease who did not have signs of clinical decompensation or evidence of infective endocarditis. He underwent successful transcatheter aortic valve implantation following a diagnosis of sterile acute valvular degeneration. (Level of Difficulty: Intermediate.)
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Affiliation(s)
- Genevieve Shouls
- Cardiology Department, St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
- Address for correspondence: Dr Genevieve Shouls, Cardiology Department, St George’s University Hospitals NHS Foundation Trust, Blackshaw Road, Tooting, London SW170QT, United Kingdom.
| | - Timothy J. Bagnall
- Cardiology Department, Kingston Hospital, Kingston Upon Thames, United Kingdom
| | - Bejal Pandya
- Grown-Up Congenital Heart Disease Department, Barts Heart Centre, London, United Kingdom
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35
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Perioperative Extracorporeal Membrane Oxygenation for Refractory Cardiopulmonary Failure Complicating Papillary Muscle Rupture. Heart Lung Circ 2020; 30:303-309. [PMID: 33092963 DOI: 10.1016/j.hlc.2020.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 09/14/2020] [Indexed: 11/23/2022]
Abstract
The prognosis of papillary muscle rupture (PMR) leading to acute mitral regurgitation, pulmonary oedema, and cardiogenic shock remains dismal, with survival dependent on prompt recognition and surgical intervention. The use of extracorporeal membrane oxygenation (ECMO) for circulatory and/or respiratory support in critically ill patients failing conventional treatment has significantly increased in the past few years, mainly owing to technology improvements that have rendered the provision of this technique simpler and safer. In this report, four cases of refractory cardiopulmonary collapse complicating ischaemic and traumatic PMR successfully managed perioperatively with ECMO are presented. In this context, a review of the potential role of perioperative ECMO support for cardiogenic shock secondary to cardiac mechanical complications is also provided.
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36
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Cordeiro C, Trehan S, Heaton JN, Bezwada P, Garyali S. Intermittent Recovery of Severe Acute Aortic Regurgitation Arising From Infective Endocarditis. Cureus 2020; 12:e10462. [PMID: 33083165 PMCID: PMC7566985 DOI: 10.7759/cureus.10462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
This case reports a 47-year-old male with a history of IV drug abuse, presenting with one week of left lower back pain. During the initial treatment, the patient became hemodynamically unstable, requiring vasopressor support. Transthoracic echocardiography (TTE) revealed a 1 cm x 1 cm aortic valve vegetation with severe aortic regurgitation and potential perforation of the valve leaflet. After hemodynamic stability was achieved, the patient left against medical advice, refusing urgent valvular surgery. Subsequent follow-up unveiled repeated recurrence of symptoms and surgical repair of the aortic valve.
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Affiliation(s)
| | - Siddhant Trehan
- Internal Medicine, The Brooklyn Hospital Center, Brooklyn, USA
| | - Joseph N Heaton
- Internal Medicine, The Brooklyn Hospital Center, Brooklyn, USA
| | - Prema Bezwada
- Cardiology, The Brooklyn Hospital Center, Brooklyn, USA
| | - Samir Garyali
- Cardiology, The Brooklyn Hospital Center, Brooklyn, USA
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37
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Atreya AR, Kawamoto K, Yelavarthy P, Arain MA, Cohen DG, Wanamaker BL, El Ela AA, Romano MA, Grossman PM. Acute Myocardial Infarction and Papillary Muscle Rupture in the COVID-19 Era. JACC Case Rep 2020; 2:1637-1641. [PMID: 32839759 PMCID: PMC7438054 DOI: 10.1016/j.jaccas.2020.06.037] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 06/26/2020] [Indexed: 11/26/2022]
Abstract
Mechanical complications of acute myocardial infarction are infrequent in the modern era of primary percutaneous coronary intervention, but they are associated with high mortality rates. Papillary muscle rupture with acute severe mitral regurgitation is one such life-threatening complication that requires early detection and urgent surgical intervention. (Level of Difficulty: Beginner.).
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Affiliation(s)
- Auras R Atreya
- Division of Cardiovascular Medicine and Cardiac Surgery, Frankel Cardiovascular Center, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Kris Kawamoto
- Division of Cardiovascular Medicine and Cardiac Surgery, Frankel Cardiovascular Center, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Prasanthi Yelavarthy
- Division of Cardiovascular Medicine and Cardiac Surgery, Frankel Cardiovascular Center, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Mansoor A Arain
- Division of Cardiovascular Medicine and Cardiac Surgery, Frankel Cardiovascular Center, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - David G Cohen
- Division of Cardiovascular Medicine and Cardiac Surgery, Frankel Cardiovascular Center, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Brett L Wanamaker
- Division of Cardiovascular Medicine and Cardiac Surgery, Frankel Cardiovascular Center, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ashraf Abou El Ela
- Division of Cardiovascular Medicine and Cardiac Surgery, Frankel Cardiovascular Center, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Matthew A Romano
- Division of Cardiovascular Medicine and Cardiac Surgery, Frankel Cardiovascular Center, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Paul M Grossman
- Division of Cardiovascular Medicine and Cardiac Surgery, Frankel Cardiovascular Center, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
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38
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Kovach CP, Bell S, Kataruka A, Reisman M, Don C. Outcomes of urgent/emergent transcatheter mitral valve repair (MitraClip): A single center experience. Catheter Cardiovasc Interv 2020; 97:E402-E410. [PMID: 32588956 DOI: 10.1002/ccd.29084] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 05/20/2020] [Accepted: 05/31/2020] [Indexed: 01/06/2023]
Abstract
OBJECTIVES To describe the outcomes of urgent/emergent transcatheter edge-to-edge mitral valve repair (TMVr) and compare the clinical, echocardiographic, and procedural characteristics of survivors and nonsurvivors. BACKGROUND TMVr is a treatment strategy for select patients with severe primary or secondary mitral regurgitation. However, knowledge regarding outcomes for urgent/emergent TMVr is limited. METHODS All urgent or emergent TMVr procedures using MitraClip performed at the University of Washington Medical Center between January 2018 and March 2019 were identified and clinical, echocardiographic, hemodynamic, procedural, and outcomes data were obtained by chart review. Outcomes included all-cause mortality, hospital mortality, procedural success, periprocedural complications, and hospital readmission. RESULTS Of the 20 patients who underwent urgent/emergent TMVr, eight were treated for cardiogenic shock (CS), four for acute decompensated heart failure (ADHF) with hypoxemic respiratory failure requiring mechanical ventilation, and eight for ADHF with failure of inpatient medical therapy. Mechanical circulatory support (MCS) was used in six patients; preceding TMVr in three patients and immediately post-TMVr in three patients. Overall, 30-day mortality and hospital readmission rates were 21 and 13%, respectively. Over a median 153 days (IQR 20-491) of follow-up, 10 patients (50%) died. Preprocedure CS, new or ongoing MCS post-TMVr, refractory respiratory failure post-TMVr, and acute kidney injury post-TMVr were associated with mortality. CONCLUSIONS In a single-center retrospective analysis, urgent/emergent TMVr in high-risk patients with ADHF or CS was associated with high short-term mortality and periprocedural complications. Prospective studies are warranted to inform patient selection and periprocedural management for urgent/emergent TMVr.
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Affiliation(s)
- Christopher P Kovach
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora, Colorado, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Sean Bell
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Akash Kataruka
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Mark Reisman
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Creighton Don
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington, USA.,Cardiology Section, Department of Medicine, Puget Sound Veterans Affairs Hospital, Seattle, Washington, USA
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39
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Man With Sudden Dyspnea and Hemoptysis. Ann Emerg Med 2020; 75:668-678. [DOI: 10.1016/j.annemergmed.2019.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Indexed: 11/22/2022]
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40
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Sakamoto A, Enomoto Y, Watabe H, Koyama Y, Matsumoto Y, Shimojo N, Marushima A, Kawano S, Inoue Y. Acute mitral valve regurgitation causing severe alveolar hemorrhage. Acute Med Surg 2020; 7:e504. [PMID: 32431845 PMCID: PMC7231572 DOI: 10.1002/ams2.504] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 02/25/2020] [Accepted: 03/04/2020] [Indexed: 02/04/2023] Open
Abstract
Background Acute mitral regurgitation could occur without common symptoms like hemodynamic instability, but with dyspnea, hemoptysis, and right‐sided infiltration on radiography. We report a case of severe alveolar hemorrhage caused by acute mitral regurgitation, which occurred in the absence of shock. Case Presentation A 40‐year‐old man presented with dyspnea with bloody phlegm and hypoxia, despite being hemodynamically stable. Chest radiography revealed right‐sided infiltration, and bronchoscopy showed fresh bloody phlegm in his tracheae. No specific findings were detected with any tests. After treatment with several medications and support with extracorporeal membrane oxygenation, his condition improved, although the etiology of the disease remained unknown. Transthoracic and transesophageal echocardiogram revealed severe mitral valve regurgitation with ruptured mitral chordae tendineae. These suggested that the sudden onset of mitral valve regurgitation had caused severe alveolar hemorrhage. Conclusion Severe alveolar hemorrhage, especially with right‐sided infiltration on chest radiography, should be considered a symptom of acute mitral regurgitation.
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Affiliation(s)
- Ayaka Sakamoto
- Department of Emergency and Critical Care Medicine University of Tsukuba Hospital Tsukuba Japan
| | - Yuki Enomoto
- Department of Emergency and Critical Care Medicine University of Tsukuba Hospital Tsukuba Japan
| | - Hiroaki Watabe
- Department of Emergency and Critical Care Medicine University of Tsukuba Hospital Tsukuba Japan
| | - Yasuaki Koyama
- Department of Emergency and Critical Care Medicine University of Tsukuba Hospital Tsukuba Japan
| | - Yukei Matsumoto
- Department of Emergency and Critical Care Medicine University of Tsukuba Hospital Tsukuba Japan
| | - Nobutake Shimojo
- Department of Emergency and Critical Care Medicine University of Tsukuba Hospital Tsukuba Japan
| | - Aiki Marushima
- Department of Emergency and Critical Care Medicine University of Tsukuba Hospital Tsukuba Japan
| | - Satoru Kawano
- Department of Emergency and Critical Care Medicine University of Tsukuba Hospital Tsukuba Japan
| | - Yoshiaki Inoue
- Department of Emergency and Critical Care Medicine University of Tsukuba Hospital Tsukuba Japan
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Abstract
Infective endocarditis (IE) is defined by infection of either a native or prosthetic heart valve, endocardial surface or any cardiac prosthetic device. It is a disease of both the developed and developing world, although IE has evolved in the developed world to a disease markedly different to the disease encountered in the developing world. IE in developed nations is mainly a disease of older patients with degenerative heart valve disease or cardiac prosthetic material, with virulent Staphylococci the most common causative organism. Data regarding the epidemiology of IE in South Africa, a developing country, is limited. The available data suggest it is still a disease of younger patients with rheumatic heart disease (RHD), associated with penicillin-sensitive Streptococcal infection. Although novel diagnostic techniques and improved therapeutic options has emerged, the 1-year mortality rate has remained high in both the developed and developing world at around 30%.
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Affiliation(s)
- Alfonso Jan Pecoraro
- Division of Cardiology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Anton Frans Doubell
- Division of Cardiology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
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42
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Abstract
The annual incidence of infective endocarditis (IE) is estimated to be between 15 and 80 cases per million persons in population-based studies. The incidence of IE is markedly increased in patients with valve prostheses (>4 per 1,000) or with prior IE (>10 per 1,000). The interaction between platelets, microorganisms and diseased valvular endothelium is the cause of vegetations and valvular or perivalvular tissue destruction. Owing to its complexity, the diagnosis of IE is facilitated by the use of the standardized Duke-Li classification, which combines two major criteria (microbiology and imaging) with five minor criteria. However, the sensitivity of the Duke-Li classification is suboptimal, particularly in prosthetic IE, and can be improved by the use of PET or radiolabelled leukocyte scintigraphy. Prolonged antibiotic therapy is mandatory. Indications for surgery during acute IE depend on the presence of haemodynamic, septic and embolic complications. The most urgent indications for surgery are related to heart failure. In the past decade, the prevention of IE has been reoriented, with indications for antibiotic prophylaxis now limited to patients at high risk of IE undergoing dental procedures. Guidelines now emphasize the importance of nonspecific oral and cutaneous hygiene in individual patients and during health-care procedures.
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43
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Damluji AA, Forman DE, van Diepen S, Alexander KP, Page RL, Hummel SL, Menon V, Katz JN, Albert NM, Afilalo J, Cohen MG. Older Adults in the Cardiac Intensive Care Unit: Factoring Geriatric Syndromes in the Management, Prognosis, and Process of Care: A Scientific Statement From the American Heart Association. Circulation 2020; 141:e6-e32. [DOI: 10.1161/cir.0000000000000741] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Longevity is increasing, and more adults are living to the stage of life when age-related biological factors determine a higher likelihood of cardiovascular disease in a distinctive context of concurrent geriatric conditions. Older adults with cardiovascular disease are frequently admitted to cardiac intensive care units (CICUs), where care is commensurate with high age-related cardiovascular disease risks but where the associated geriatric conditions (including multimorbidity, polypharmacy, cognitive decline and delirium, and frailty) may be inadvertently exacerbated and destabilized. The CICU environment of procedures, new medications, sensory overload, sleep deprivation, prolonged bed rest, malnourishment, and sleep is usually inherently disruptive to older patients regardless of the excellence of cardiovascular disease care. Given these fundamental and broad challenges of patient aging, CICU management priorities and associated decision-making are particularly complex and in need of enhancements. In this American Heart Association statement, we examine age-related risks and describe some of the distinctive dynamics pertinent to older adults and emerging opportunities to enhance CICU care. Relevant assessment tools are discussed, as well as the need for additional clinical research to best advance CICU care for the already dominating and still expanding population of older adults.
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44
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Wakabayashi R, Ide S, Ishida T, Tanaka S, Kawamata M. Severe mitral regurgitation due to geometric changes in the mitral valve after surgical aortic valve replacement. JA Clin Rep 2019; 5:59. [PMID: 32025917 PMCID: PMC6967239 DOI: 10.1186/s40981-019-0277-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 08/26/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Severe mitral regurgitation (MR) after aortic valve replacement (AVR) is a serious complication. Although several causes of MR after AVR have been reported, severe MR due to geometric changes in the mitral valve imposed by an aortic valve prosthesis has not been reported. We here report a case of severe MR after AVR that was improved after re-AVR. CASE PRESENTATION A 77-year-old male underwent elective total aortic arch replacement and AVR. Mild MR was preoperatively identified. After surgery and separation from cardiopulmonary bypass, transesophageal echocardiography (TEE) demonstrated restriction and distortion of the anterior mitral leaflet and severe MR. Displacement of the anterior mitral annulus by the prosthetic aortic valve was strongly suspected to be the cause of MR, which should be surgically restored. Re-AVR using a small-sized valve was then performed. Consequently, the structural changes in the mitral valve were reverted and the MR was reduced. CONCLUSIONS Geometric changes in the mitral valve induced by an aortic valve prosthesis can cause massive increment of MR. Intraoperative TEE examination of the mitral apparatus is important when severe MR occurs after AVR.
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Affiliation(s)
- Ryo Wakabayashi
- Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan.
| | - Susumu Ide
- Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Takashi Ishida
- Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Satoshi Tanaka
- Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Mikito Kawamata
- Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
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Montrief T, Davis WT, Koyfman A, Long B. Mechanical, inflammatory, and embolic complications of myocardial infarction: An emergency medicine review. Am J Emerg Med 2019; 37:1175-1183. [DOI: 10.1016/j.ajem.2019.04.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 04/03/2019] [Indexed: 12/31/2022] Open
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Lu A, Chew STH. Successful use of extracorporeal cardiopulmonary membrane oxygenation in acute severe aortic regurgitation with cardiovascular collapse. PROCEEDINGS OF SINGAPORE HEALTHCARE 2019. [DOI: 10.1177/2010105818779600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We report the case of a 55-year-old man who was transferred from an overseas institution with an initial impression of non-ST-elevation myocardial infarction (NSTEMI). Subsequent investigation found a severe aortic regurgitation (AR) complicated by acute ischemic hepatitis and acute renal injury, and the patient developed cardiopulmonary collapse with pulseless electrical activity perioperatively. Cardiopulmonary resuscitation was commenced immediately, venoarterial extracorporeal membrane oxygenation (ECMO) was immediately set up to bridge for emergency aortic-valve replacement surgery. The patient was subsequently weaned off ECMO and made a complete recovery. We demonstrate the successful use of ECMO for resuscitation in a patient with AR complicated by cardiovascular collapse.
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Affiliation(s)
- Anqi Lu
- Division of Anesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore
| | - Sophia Tsong Huey Chew
- Division of Anesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore
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47
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Abstract
The diagnosis of acute mitral regurgitation (MR) is often missed or delayed because the clinical presentation is substantially different from that in patients with chronic MR. Management of acute MR depends on the specific aetiology of valve dysfunction and there is a lack of consensus on the optimal therapeutic approach in many patients. In particular, management of secondary MR due to acute ischaemia is challenging because of unique mechanisms of valve incompetence compared with chronic ischaemic MR. Another clinical challenge is management of acute MR due to transient systolic anterior motion of the mitral valve in the acute phase of Takotsubo cardiomyopathy, which commonly resolves within a few weeks. Additionally, iatrogenic MR induced by intraventricular devices is a recently recognised aetiology of acute MR. Acute primary MR typically requires early surgical intervention, for example, with a flail leaflet or endocarditis, because of acute cardiovascular decompensation with an abrupt increase in left atrial pressure. In an emergency situation and high surgical risk, a percutaneous mitral valve edge-to-edge repair is an alternative therapeutic option. Firm diagnosis of the severity and aetiology of acute MR is necessary for proper decision making, including timing and types of surgical intervention.
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Affiliation(s)
- Nozomi Watanabe
- Department of Clinical Laboratory, Noninvasive Cardiovascular Imaging, Miyazaki Medical Association Hospital Cardiovascular Center, Miyazaki, 880-0834, Japan
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48
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Jolobe OM. Acute presentations of infective endocarditis. Am J Emerg Med 2019; 37:557-558. [DOI: 10.1016/j.ajem.2018.07.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 07/24/2018] [Accepted: 07/26/2018] [Indexed: 10/28/2022] Open
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Sengun B, Yıldırım I, Yıldız Ö, Çeliker A. Retrograde transcatheter closure of anterior mitral valve leaflet perforation. Ann Pediatr Cardiol 2019; 12:312-314. [PMID: 31516291 PMCID: PMC6716313 DOI: 10.4103/apc.apc_162_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Transcatheter closure of mitral valve leaflet perforation is a very rarely performed and a difficult procedure for repairing the defect. Herein, we are the first to report on both the safety and feasibility of percutaneous retrograde transcatheter closure of anterior mitral valve leaflet perforation with an AMPLATZER™ Duct Occluder II (6 mm × 6 mm, ADO II; Abbott Vascular, IL, USA) device in a 19-year-old patient with a severe mitral valve regurgitation following cardiac surgery.
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Affiliation(s)
- Berke Sengun
- Department of Pediatric Cardiology, Koç University School of Medicine, Istanbul, Turkey
| | - Işıl Yıldırım
- Department of Pediatric Cardiology, Koç University School of Medicine, Istanbul, Turkey
| | - Ömer Yıldız
- Department of Cardiology, Koç University School of Medicine, Istanbul, Turkey
| | - Alpay Çeliker
- Department of Pediatric Cardiology, Koç University School of Medicine, Istanbul, Turkey
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50
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Two-dimensional global longitudinal strain is superior to left ventricular ejection fraction in prediction of outcome in patients with left-sided infective endocarditis. Int J Cardiol 2018; 260:118-123. [PMID: 29622424 DOI: 10.1016/j.ijcard.2018.01.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Revised: 12/10/2017] [Accepted: 01/10/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Impaired cardiac function is the main predictor of poor outcome in infective endocarditis (IE). Global longitudinal strain (GLS) derived from two-dimensional strain echocardiography has proven superior in prediction of long-term outcome as compared to left ventricular ejection fraction (LVEF) in valvular disease and heart failure in general. Whether measurements of cardiac deformation can predict survival in patients with IE has not previously been investigated. METHODS The study included consecutive patients with Duke definite IE who underwent transthoracic and transesophageal echocardiography within 7 days. Clinical and echocardiographic markers associated with 1-year survival were identified using a Cox-proportional hazards model that included propensity adjustment for surgery. Reclassification statistics including receiver operating characteristic curves and net reclassification improvement were applied to LVEF and GLS, respectively. RESULTS A cohort of 190 patients met eligibility criteria. LVEF and GLS were both prognostic markers of mortality. Independent markers of 1-year mortality were S. aureus IE (HR:2.02; 95%CI 1.11-5.72, p = .022), diabetes (HR:2.05; 95%CI 1.12-3.75, p = .020), embolic stroke (HR:3.95; 95%CI 1.93-8.10, p < .001) and LVEF<45% (HR: 3.02; 95% CI 1.70-5.38, p < .001), GLS> -15.4% (HR:2.95; 95%CI 1.52-5.72, p < .001). Adding LVEF<45% to a model with known risk factors of IE did not significantly improve risk classification, whereas addition of GLS to the model resulted in significant increase (AUC = 0.763, p < .001). CONCLUSIONS When treatment was taken into account, LVEF<45% and GLS > -15.4% were both associated with adverse long-term outcome in left-sided IE. GLS >-15.4 % was significantly associated with 1-year mortality in the multivariate analysis. Further, GLS was superior to LVEF in risk prediction and risk discrimination of long-term outcome in patients with left-sided IE.
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