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van Kampen A, Morningstar JE, Goudot G, Ingels N, Wenk JF, Nagata Y, Yaghoubian KM, Norris RA, Borger MA, Melnitchouk S, Levine RA, Jensen MO. Utilization of Engineering Advances for Detailed Biomechanical Characterization of the Mitral-Ventricular Relationship to Optimize Repair Strategies: A Comprehensive Review. Bioengineering (Basel) 2023; 10:601. [PMID: 37237671 PMCID: PMC10215167 DOI: 10.3390/bioengineering10050601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/10/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023] Open
Abstract
The geometrical details and biomechanical relationships of the mitral valve-left ventricular apparatus are very complex and have posed as an area of research interest for decades. These characteristics play a major role in identifying and perfecting the optimal approaches to treat diseases of this system when the restoration of biomechanical and mechano-biological conditions becomes the main target. Over the years, engineering approaches have helped to revolutionize the field in this regard. Furthermore, advanced modelling modalities have contributed greatly to the development of novel devices and less invasive strategies. This article provides an overview and narrative of the evolution of mitral valve therapy with special focus on two diseases frequently encountered by cardiac surgeons and interventional cardiologists: ischemic and degenerative mitral regurgitation.
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Affiliation(s)
- Antonia van Kampen
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- Leipzig Heart Centre, University Clinic of Cardiac Surgery, 02189 Leipzig, Germany
| | - Jordan E. Morningstar
- Department of Regenerative Medicine and Cell Biology, University of South Carolina, Charleston, SC 29425, USA
| | - Guillaume Goudot
- Cardiac Ultrasound Laboratory, Department of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Neil Ingels
- Department of Biomedical Engineering, University of Arkansas, Fayetteville, AR 72701, USA
| | - Jonathan F. Wenk
- Department of Mechanical Engineering, University of Kentucky, Lexington, KY 40508, USA;
| | - Yasufumi Nagata
- Cardiac Ultrasound Laboratory, Department of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Koushiar M. Yaghoubian
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Russell A. Norris
- Department of Regenerative Medicine and Cell Biology, University of South Carolina, Charleston, SC 29425, USA
| | - Michael A. Borger
- Leipzig Heart Centre, University Clinic of Cardiac Surgery, 02189 Leipzig, Germany
| | - Serguei Melnitchouk
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Robert A. Levine
- Cardiac Ultrasound Laboratory, Department of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Morten O. Jensen
- Department of Biomedical Engineering, University of Arkansas, Fayetteville, AR 72701, USA
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
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Han Y, Chen T, Addetia K. Tricuspid Valve Prolapse: A Forgotten Mechanism of Primary Tricuspid Regurgitation? J Am Coll Cardiol 2023; 81:S0735-1097(22)07643-4. [PMID: 36813688 DOI: 10.1016/j.jacc.2022.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 12/12/2022] [Indexed: 02/22/2023]
Affiliation(s)
- Yuchi Han
- Cardiovascular Division, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA. https://twitter.com/tiffchenMD
| | - Tiffany Chen
- Cardiovascular Division, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Karima Addetia
- Cardiovascular Division, University of Chicago Heart & Vascular Center, Chicago, Illinois, USA
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Vriz O, Eltayeb A, Landi I, Anwar K, Alenazy A, Hiristova K, Kasprzak J, D'Andrea A, Amro B, Limongelli G, Bossone E, Imazio M. Transthoracic echocardiography for arrhythmic mitral valve prolapse: Phenotypic characterization as first step. Echocardiography 2022; 39:1158-1170. [PMID: 36029124 DOI: 10.1111/echo.15439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/09/2022] [Accepted: 08/09/2022] [Indexed: 11/30/2022] Open
Abstract
Mitral valve prolapse (MVP) is the most frequent valvulopathy with a prevalence of 1.2%-2.4% in general population and it is characterized by a benign course. Although it can be associated with some complications, ventricular arrhythmias (VA) and sudden cardiac death (SCD) as ultimate expressions, are the most worrying. The estimated risk of SCD in MVP is between 0.2% and 1.9% per year including both MVP patients with left ventricular (LV) dysfunction due to severe MR and MVP patients without significant MR. The latter ones constitute a particular phenotype called "malignant MVP" characterized by bileaflet myxomatous prolapse, ECG repolarization abnormalities and complex VAs (c-VAs) with polymorphic/right bundle branch block morphology (RBBB) and LV fibrosis of the papillary muscles (PMs) and inferobasal wall secondary to mechanical stretching visualized as late gadolinium enhancement (LGE) areas by cardiac magnetic resonance (CMR). In MVP, the first diagnostic approach is transthoracic echocardiography (TTE) that defines the presence of mitral annular disjunction (MAD) which seems to be associated with "arrhythmic MVP" (AMVP). From an ECG point of view, AMVP is characterized by frequent premature ventricular contractions (PVCs) arising from one or both PMs, fascicular tissue, and outflow tract, as well as by T-wave inversion in the inferolateral leads. The aim of the present paper is to describe TTE red flags that could identify MVP patients at high risk to develop complex arrhythmias as supported by the corresponding findings of LGE-CMR and anatomy studies. TTE could be a co-partner in phenotyping high-risk arrhythmic MVP patients.
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Affiliation(s)
- Olga Vriz
- Heart Centre, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Abdulla Eltayeb
- Heart Centre, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Irene Landi
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Kashif Anwar
- Heart Centre, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Ali Alenazy
- Heart Centre, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Krassimira Hiristova
- Department of Noninvasive Diagnostic Imaging, National Heart Hospital, Sofia, Bulgaria
| | - Jarek Kasprzak
- Cardiology, Bieganski Hospital, Medical University, Lodz, Poland
| | - Antonello D'Andrea
- Department of Cardiology, Umberto I Hospital, Luigi Vanvitelli University - Nocera Inferiore (ASL Salerno), Caserta, Italy
| | - Bandar Amro
- Heart Centre, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Giuseppe Limongelli
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", AORN dei Colli, Monaldi Hospital, Naples, Italy
| | - Eduardo Bossone
- Azienda Ospedaliera di Rilevanza Nazionale "A. Cardarelli" Hospital, Naples, Italy
| | - Massimo Imazio
- Department of Cardiology, University Hospital Santa Maria della Misericordia, Udine, Italy
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Fernández-Friera L, Salguero R, Vannini L, Argüelles AF, Arribas F, Solís J. Mechanistic insights of the left ventricle structure and fibrosis in the arrhythmogenic mitral valve prolapse. Glob Cardiol Sci Pract 2018; 2018:4. [PMID: 29644231 PMCID: PMC5857061 DOI: 10.21542/gcsp.2018.4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 12/20/2017] [Indexed: 01/03/2023] Open
Abstract
Mitral valve prolapse (MVP) is a common and benign condition. However, some anatomic forms have been recently associated with life-threatening ventricular arrhythmias and sudden cardiac death. Imaging MVP holds the promise of individualized MVP risk assessment. Noninvasive imaging techniques available today are playing an increasingly important role in the diagnosis, prognosis and monitoring of MVP. In this article, we will review the current evidence on arrhythmogenic MVP, with special focus on the utility of echocardiography and CMR for identifying benign and "malignant" forms of MVP. The clinical relevance of this manuscript lies in the value of imaging technology to improve MVP risk prediction, including those arrhythmic-MVP cases with a higher risk of sudden cardiac death.
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Affiliation(s)
- Leticia Fernández-Friera
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain
- HM Hospitales-Centro Integral de Enfermedades Cardiovasculares HM-CIEC, Madrid, Spain
| | | | - Luca Vannini
- Hospital Universitario 12 de Octubre, Madrid, Spain
- Universidad Rey Juan Carlos (PhD Etudent in Epidemiology and Public Health), Madrid
| | - Ana Fidalgo Argüelles
- HM Hospitales-Centro Integral de Enfermedades Cardiovasculares HM-CIEC, Madrid, Spain
| | | | - Jorge Solís
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain
- HM Hospitales-Centro Integral de Enfermedades Cardiovasculares HM-CIEC, Madrid, Spain
- Hospital Universitario 12 de Octubre, Madrid, Spain
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Capdeville M, Alfirevic A. A Game of Twister: What 3D TEE Rendering Tells Us About the Mitral Annulus During OPCAB. J Cardiothorac Vasc Anesth 2018; 32:341-343. [DOI: 10.1053/j.jvca.2017.09.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Indexed: 11/11/2022]
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Cho EJ, Park SJ, Lee GY, Kim EK, Chang SA, Choi JO, Lee SC, Park SW, Park PW. Effects of Decreased Annular Height and Annular Saddle-Shaped Non-Planarity in Degenerative Severe Mitral Regurgitation with Normal Left Ventricular Ejection Fraction: Real-Time 3D Transesophageal Echocardiography. J Cardiovasc Ultrasound 2017; 25:47-56. [PMID: 28770032 PMCID: PMC5526885 DOI: 10.4250/jcu.2017.25.2.47] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 05/09/2017] [Accepted: 05/23/2017] [Indexed: 11/22/2022] Open
Abstract
Background The extent of mitral annular (MA) remodeling and dysfunction is correlated with the severity of mitral regurgitation (MR) as well as left atrial (LA) and left ventricular (LV) dilation. MA dysfunction may be a useful prognostic factor for operative timing and MR recurrence after successful mitral valve (MV) repair. The aim of this study was to evaluate additive prognostic factors of MA non-planarity using real-time 3D transesophageal echocardiography (RT3D-TEE) analysis in patients with chronic severe MR and preserved LV systolic function. Methods Forty-seven patients with chronic severe MR and preserved LV systolic function scheduled for MV repair were prospectively enrolled. Echocardiographic studies were performed before surgery and postoperatively within 2 weeks and at least 6 months after surgery. RT3D-TEE was performed before the operation and immediately post-operative. Results Mean age was 55.4 ± 15.1 years and 24 were male. Annulus height/body surface area (BSA) obtained via RT3D-TEE was correlated with the degree of postoperative LA remodeling. Patients were divided into two groups by average baseline annulus height/BSA. Patients with normal annular height had a smaller postoperative LV end-diastolic dimension, LV end-systolic dimension and LA volume index than patients with decreased annular height. Preoperative annulus height/BSA values strongly predicted postoperative LA remodeling. Conclusion MA height may be a useful prognostic factor for determining the timing of surgery in patients with chronic primary MR. Annulus height/BSA assessed via RT3D-TEE may provide additional information predictive of postoperative LA remodeling after successful MV repair.
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Affiliation(s)
- Eun Jeong Cho
- Division of Cardiology, Department of Internal Medicine, Cardiovascular Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Division of Cardiology, Department of Internal Medicine, National Cancer Center, Goyang, Korea
| | - Sung-Ji Park
- Division of Cardiology, Department of Internal Medicine, Cardiovascular Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ga Yeon Lee
- Division of Cardiology, Department of Internal Medicine, Cardiovascular Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun Kyoung Kim
- Division of Cardiology, Department of Internal Medicine, Cardiovascular Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung-A Chang
- Division of Cardiology, Department of Internal Medicine, Cardiovascular Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin-Oh Choi
- Division of Cardiology, Department of Internal Medicine, Cardiovascular Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang-Chol Lee
- Division of Cardiology, Department of Internal Medicine, Cardiovascular Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Woo Park
- Division of Cardiology, Department of Internal Medicine, Cardiovascular Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Pyo Won Park
- Department of Thoracic Surgery, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Capoulade R, Piriou N, Serfaty JM, Le Tourneau T. Multimodality imaging assessment of mitral valve anatomy in planning for mitral valve repair in secondary mitral regurgitation. J Thorac Dis 2017; 9:S640-S660. [PMID: 28740719 PMCID: PMC5505945 DOI: 10.21037/jtd.2017.06.99] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Accepted: 06/13/2017] [Indexed: 12/23/2022]
Abstract
Secondary mitral regurgitation (MR) is frequent valvular heart disease and conveys worse prognostic. Therapeutic surgical or percutaneous options are available in the context of severe symptomatic secondary MR, but the best approach to treat these patients remains unclear, given the lack of clear clinical evidence of benefit. A comprehensive evaluation of the mitral valve apparatus and the left ventricle (LV) has the ability to clearly define and characterize the disease, and thus determine the best option for the patient to improve its clinical outcomes, as well as quality of life and symptoms. The current report reviews the mitral valve (MV) anatomy, the underlying mechanisms associated with secondary MR, the related therapeutic options available, and finally the usefulness of a multimodality imaging approach for the planning of surgical or percutaneous mitral valve intervention.
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Affiliation(s)
- Romain Capoulade
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Institut du Thorax, CHU Nantes, Nantes University, Nantes, France
| | - Nicolas Piriou
- Institut du Thorax, CHU Nantes, Nantes University, Nantes, France
- Department of Nuclear Medicine, CHU Nantes, Nantes University, Nantes, France
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8
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Hayashi A, Fukuda S, Mahara K, Hei S, Onoue T, Kado Y, Nagata Y, Iwataki M, Otani K, Miyamoto T, Oginosawa Y, Sonoda S, Eto M, Nishimura Y, Takanashi S, Levine RA, Otsuji Y. Left Atrial Remodeling in Segmental vs. Global Mitral Valve Prolapse - Three-Dimensional Echocardiography. Circ J 2016; 80:2533-2540. [PMID: 27829586 DOI: 10.1253/circj.cj-16-0694] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Segmental and global mitral valve prolapse (MVP) comprise 2 representative phenotypes in this syndrome. While mitral regurgitation (MR) severity is a major factor causing left atrial (LA) remodeling in MVP, prominent mitral valve (MV) annulus dilatation in global MVP may specifically cause inferiorly predominant LA remodeling. We compared MV annulus and LA geometry in patients with segmental and global MVP.Methods and Results:LA volume as well as inferior, middle, and superior LA cross-sectional areas (CSA) were measured on 3-D echocardiography in 20 controls, in 40 patients with segmental MVP, and in 18 with global MVP. On multivariate analysis, MR severity was primarily associated with LA dilatation in segmental MVP (P<0.001), while MV annular dilatation was primarily associated with LA dilatation in global MVP (P<0.001). Although there was no regional predominance in LA dilatation in segmental MVP, inferior predominance of LA dilatation was significant in global MVP (increase in inferior, middle, and superior LA-CSA relative to mean of the controls: +220±70% vs. +171±55% vs. +137±37%, P<0.001). CONCLUSIONS LA remodeling in segmental and global MVP is considerably different regarding its association with MR volume or MV annular dilatation and its regional predominance. While MR volume may mainly contribute to LA remodeling in segmental MVP, MV annular dilatation seems to have an important role in LA remodeling in global MVP. (Circ J 2016; 80: 2533-2540).
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Affiliation(s)
- Atsushi Hayashi
- Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine
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9
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Levine RA, Hagége AA, Judge DP, Padala M, Dal-Bianco JP, Aikawa E, Beaudoin J, Bischoff J, Bouatia-Naji N, Bruneval P, Butcher JT, Carpentier A, Chaput M, Chester AH, Clusel C, Delling FN, Dietz HC, Dina C, Durst R, Fernandez-Friera L, Handschumacher MD, Jensen MO, Jeunemaitre XP, Le Marec H, Le Tourneau T, Markwald RR, Mérot J, Messas E, Milan DP, Neri T, Norris RA, Peal D, Perrocheau M, Probst V, Pucéat M, Rosenthal N, Solis J, Schott JJ, Schwammenthal E, Slaugenhaupt SA, Song JK, Yacoub MH. Mitral valve disease--morphology and mechanisms. Nat Rev Cardiol 2015; 12:689-710. [PMID: 26483167 DOI: 10.1038/nrcardio.2015.161] [Citation(s) in RCA: 231] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Mitral valve disease is a frequent cause of heart failure and death. Emerging evidence indicates that the mitral valve is not a passive structure, but--even in adult life--remains dynamic and accessible for treatment. This concept motivates efforts to reduce the clinical progression of mitral valve disease through early detection and modification of underlying mechanisms. Discoveries of genetic mutations causing mitral valve elongation and prolapse have revealed that growth factor signalling and cell migration pathways are regulated by structural molecules in ways that can be modified to limit progression from developmental defects to valve degeneration with clinical complications. Mitral valve enlargement can determine left ventricular outflow tract obstruction in hypertrophic cardiomyopathy, and might be stimulated by potentially modifiable biological valvular-ventricular interactions. Mitral valve plasticity also allows adaptive growth in response to ventricular remodelling. However, adverse cellular and mechanobiological processes create relative leaflet deficiency in the ischaemic setting, leading to mitral regurgitation with increased heart failure and mortality. Our approach, which bridges clinicians and basic scientists, enables the correlation of observed disease with cellular and molecular mechanisms, leading to the discovery of new opportunities for improving the natural history of mitral valve disease.
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Affiliation(s)
- Robert A Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Yawkey 5E, Boston, MA 02114, USA
| | - Albert A Hagége
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | | | | | - Jacob P Dal-Bianco
- Massachusetts General Hospital, Cardiac Ultrasound Laboratory, Harvard Medical School, Boston, MA, USA
| | | | | | | | - Nabila Bouatia-Naji
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | - Patrick Bruneval
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | | | - Alain Carpentier
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | | | | | | | - Francesca N Delling
- Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | | | - Christian Dina
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | - Ronen Durst
- Hadassah-Hebrew University Medical Centre, Jerusalem, Israel
| | - Leticia Fernandez-Friera
- Hospital Universitario HM Monteprincipe and the Centro Nacional de Investigaciones Cardiovasculares, Carlos III (CNIC), Madrid, Spain
| | - Mark D Handschumacher
- Massachusetts General Hospital, Cardiac Ultrasound Laboratory, Harvard Medical School, Boston, MA, USA
| | | | - Xavier P Jeunemaitre
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | - Hervé Le Marec
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | - Thierry Le Tourneau
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | | | - Jean Mérot
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | - Emmanuel Messas
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | - David P Milan
- Cardiovascular Research Center, Harvard Medical School, Boston, MA, USA
| | - Tui Neri
- Aix-Marseille University, INSERM UMR 910, Marseille, France
| | | | - David Peal
- Cardiovascular Research Center, Harvard Medical School, Boston, MA, USA
| | - Maelle Perrocheau
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | - Vincent Probst
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | - Michael Pucéat
- Aix-Marseille University, INSERM UMR 910, Marseille, France
| | | | - Jorge Solis
- Hospital Universitario HM Monteprincipe and the Centro Nacional de Investigaciones Cardiovasculares, Carlos III (CNIC), Madrid, Spain
| | - Jean-Jacques Schott
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | | | - Susan A Slaugenhaupt
- Center for Human Genetic Research, MGH Research Institute, Harvard Medical School, Boston, MA, USA
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10
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Dina C, Bouatia-Naji N, Tucker N, Delling FN, Toomer K, Durst R, Perrocheau M, Fernandez-Friera L, Solis J, Le Tourneau T, Chen MH, Probst V, Bosse Y, Pibarot P, Zelenika D, Lathrop M, Hercberg S, Roussel R, Benjamin EJ, Bonnet F, Lo SH, Dolmatova E, Simonet F, Lecointe S, Kyndt F, Redon R, Le Marec H, Froguel P, Ellinor PT, Vasan RS, Bruneval P, Markwald RR, Norris RA, Milan DJ, Slaugenhaupt SA, Levine RA, Schott JJ, Hagege AA, Jeunemaitre X. Genetic association analyses highlight biological pathways underlying mitral valve prolapse. Nat Genet 2015; 47:1206-11. [PMID: 26301497 PMCID: PMC4773907 DOI: 10.1038/ng.3383] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 07/28/2015] [Indexed: 11/21/2022]
Abstract
Nonsyndromic mitral valve prolapse (MVP) is a common degenerative cardiac valvulopathy of unknown etiology that predisposes to mitral regurgitation, heart failure and sudden death. Previous family and pathophysiological studies suggest a complex pattern of inheritance. We performed a meta-analysis of 2 genome-wide association studies in 1,412 MVP cases and 2,439 controls. We identified 6 loci, which we replicated in 1,422 cases and 6,779 controls, and provide functional evidence for candidate genes. We highlight LMCD1 (LIM and cysteine-rich domains 1), which encodes a transcription factor and for which morpholino knockdown of the ortholog in zebrafish resulted in atrioventricular valve regurgitation. A similar zebrafish phenotype was obtained with knockdown of the ortholog of TNS1, which encodes tensin 1, a focal adhesion protein involved in cytoskeleton organization. We also showed expression of tensin 1 during valve morphogenesis and describe enlarged posterior mitral leaflets in Tns1(-/-) mice. This study identifies the first risk loci for MVP and suggests new mechanisms involved in mitral valve regurgitation, the most common indication for mitral valve repair.
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Affiliation(s)
- Christian Dina
- INSERM Unité Mixte de Recherche (UMR) 1087, Centre National de la Recherche Scientifique (CNRS) UMR 6291, Institut du Thorax, Nantes, France
- Centre Hospitalier Universitaire (CHU) Nantes, Université de Nantes, Nantes, France
| | - Nabila Bouatia-Naji
- INSERM UMR 970, Paris Cardiovascular Research Center, Paris, France
- Paris Descartes University, Paris Sorbonne Cité, Paris, France
| | - Nathan Tucker
- Cardiovascular Research Center, Massachusetts General Hospital, Charlestown, Massachusetts, USA
| | - Francesca N Delling
- Framingham Heart Study, Population Sciences Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, US National Institutes of Health, Framingham, Massachusetts, USA
- Department of Medicine (Cardiovascular Division), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Katelynn Toomer
- Department of Regenerative Medicine and Cell Biology, Cardiovascular Developmental Biology Center, Children's Research Institute, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ronen Durst
- Department of Cardiology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Maelle Perrocheau
- INSERM UMR 970, Paris Cardiovascular Research Center, Paris, France
- Paris Descartes University, Paris Sorbonne Cité, Paris, France
| | - Leticia Fernandez-Friera
- Hospital Universitario Montepríncipe, Universidad Centro de Estudios Universitarios (CEU) San Pablo, Madrid, Spain
- Centro Nacional de Investigaciones Cardiovasculares, Carlos III (CNIC), Madrid, Spain
| | - Jorge Solis
- Hospital Universitario Montepríncipe, Universidad Centro de Estudios Universitarios (CEU) San Pablo, Madrid, Spain
- Centro Nacional de Investigaciones Cardiovasculares, Carlos III (CNIC), Madrid, Spain
| | - Thierry Le Tourneau
- INSERM Unité Mixte de Recherche (UMR) 1087, Centre National de la Recherche Scientifique (CNRS) UMR 6291, Institut du Thorax, Nantes, France
- Centre Hospitalier Universitaire (CHU) Nantes, Université de Nantes, Nantes, France
| | - Ming-Huei Chen
- Framingham Heart Study, Population Sciences Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, US National Institutes of Health, Framingham, Massachusetts, USA
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Vincent Probst
- INSERM Unité Mixte de Recherche (UMR) 1087, Centre National de la Recherche Scientifique (CNRS) UMR 6291, Institut du Thorax, Nantes, France
- Centre Hospitalier Universitaire (CHU) Nantes, Université de Nantes, Nantes, France
| | - Yohan Bosse
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, Quebec, Canada
| | - Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, Quebec, Canada
| | | | - Mark Lathrop
- Centre National de Génotypage, Evry, France
- Génome Québec, Montreal, Quebec, Canada
| | - Serge Hercberg
- Paris Descartes University, Paris Sorbonne Cité, Paris, France
- Paris 13 University, Sorbonne Paris Cité, Bobigny, France
- INSERM U1153, Institut National de Recherche en Agronomie (INRA) U1125, Nutritional Epidemiology Research Unit, Epidemiology and Biostatistics Center, Bobigny, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Department of Public Health, Avicenne Hospital, Bobigny, France
- Paris Diderot University, Paris, France
| | - Ronan Roussel
- Paris Diderot University, Paris, France
- INSERM UMRS 1138, Centre de Recherche des Cordeliers, Paris, France
- AP-HP, Department of Endocrinology, Diabetes and Nutrition, Fibrosis, Inflammation, Remodeling in Cardiovascular, Respiratory and Renal Diseases (FIRE) Department Hospital University, Bichat Hospital, Paris, France
| | - Emelia J Benjamin
- Framingham Heart Study, Population Sciences Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, US National Institutes of Health, Framingham, Massachusetts, USA
- Department of Medicine (Cardiovascular Division), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Fabrice Bonnet
- INSERM, Clinical Investigation Centre (CIC) 0203, University Hospital of Pontchaillou, Rennes, France
- Department of Endocrinology, University Hospital, Rennes, France
| | - Su Hao Lo
- Department of Biochemistry and Molecular Medicine, School of Medicine, University of California, Davis, Davis, California, USA
| | - Elena Dolmatova
- Cardiovascular Research Center, Massachusetts General Hospital, Charlestown, Massachusetts, USA
| | - Floriane Simonet
- INSERM Unité Mixte de Recherche (UMR) 1087, Centre National de la Recherche Scientifique (CNRS) UMR 6291, Institut du Thorax, Nantes, France
| | - Simon Lecointe
- INSERM Unité Mixte de Recherche (UMR) 1087, Centre National de la Recherche Scientifique (CNRS) UMR 6291, Institut du Thorax, Nantes, France
- Centre Hospitalier Universitaire (CHU) Nantes, Université de Nantes, Nantes, France
| | - Florence Kyndt
- INSERM Unité Mixte de Recherche (UMR) 1087, Centre National de la Recherche Scientifique (CNRS) UMR 6291, Institut du Thorax, Nantes, France
- Centre Hospitalier Universitaire (CHU) Nantes, Université de Nantes, Nantes, France
| | - Richard Redon
- INSERM Unité Mixte de Recherche (UMR) 1087, Centre National de la Recherche Scientifique (CNRS) UMR 6291, Institut du Thorax, Nantes, France
- Centre Hospitalier Universitaire (CHU) Nantes, Université de Nantes, Nantes, France
| | - Hervé Le Marec
- INSERM Unité Mixte de Recherche (UMR) 1087, Centre National de la Recherche Scientifique (CNRS) UMR 6291, Institut du Thorax, Nantes, France
- Centre Hospitalier Universitaire (CHU) Nantes, Université de Nantes, Nantes, France
| | - Philippe Froguel
- CNRS UMR 8199, Lille Pasteur Institute, Lille 2 University, European Genomic Institute for Diabetes (EGID), Lille, France
- Department of Genomics of Common Disease, School of Public Health, Imperial College London, London, UK
| | - Patrick T Ellinor
- Cardiovascular Research Center, Massachusetts General Hospital, Charlestown, Massachusetts, USA
- Program in Medical and Population Genetics, Broad Institute, Cambridge, Massachusetts, USA
| | - Ramachandran S Vasan
- Framingham Heart Study, Population Sciences Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, US National Institutes of Health, Framingham, Massachusetts, USA
| | - Patrick Bruneval
- INSERM UMR 970, Paris Cardiovascular Research Center, Paris, France
- Paris Descartes University, Paris Sorbonne Cité, Paris, France
- AP-HP, Department of Pathology, Hôpital Européen Georges Pompidou, Paris, France
| | - Roger R Markwald
- Department of Regenerative Medicine and Cell Biology, Cardiovascular Developmental Biology Center, Children's Research Institute, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Russell A Norris
- Department of Regenerative Medicine and Cell Biology, Cardiovascular Developmental Biology Center, Children's Research Institute, Medical University of South Carolina, Charleston, South Carolina, USA
| | - David J Milan
- Cardiovascular Research Center, Massachusetts General Hospital, Charlestown, Massachusetts, USA
| | - Susan A Slaugenhaupt
- Center for Human Genetic Research, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Robert A Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jean-Jacques Schott
- INSERM Unité Mixte de Recherche (UMR) 1087, Centre National de la Recherche Scientifique (CNRS) UMR 6291, Institut du Thorax, Nantes, France
- Centre Hospitalier Universitaire (CHU) Nantes, Université de Nantes, Nantes, France
| | - Albert A Hagege
- INSERM UMR 970, Paris Cardiovascular Research Center, Paris, France
- AP-HP, Department of Cardiology, Hôpital Européen Georges Pompidou, Paris, France
| | - Xavier Jeunemaitre
- INSERM UMR 970, Paris Cardiovascular Research Center, Paris, France
- Paris Descartes University, Paris Sorbonne Cité, Paris, France
- AP-HP, Department of Genetics, Hôpital Européen Georges Pompidou, Paris, France
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11
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Wan S, Lee APW, Jin CN, Wong RHL, Chan HHM, Ng CSH, Wan IYP, Underwood MJ. The choice of mitral annuloplastic ring-beyond "surgeon's preference". Ann Cardiothorac Surg 2015; 4:261-5. [PMID: 26309828 DOI: 10.3978/j.issn.2225-319x.2015.01.05] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Accepted: 12/15/2014] [Indexed: 11/14/2022]
Affiliation(s)
- Song Wan
- 1 Division of Cardiothoracic Surgery, Department of Surgery, 2 Division of Cardiology, Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Alex P W Lee
- 1 Division of Cardiothoracic Surgery, Department of Surgery, 2 Division of Cardiology, Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Chun-Na Jin
- 1 Division of Cardiothoracic Surgery, Department of Surgery, 2 Division of Cardiology, Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Randolph H L Wong
- 1 Division of Cardiothoracic Surgery, Department of Surgery, 2 Division of Cardiology, Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Herman H M Chan
- 1 Division of Cardiothoracic Surgery, Department of Surgery, 2 Division of Cardiology, Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Calvin S H Ng
- 1 Division of Cardiothoracic Surgery, Department of Surgery, 2 Division of Cardiology, Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Innes Y P Wan
- 1 Division of Cardiothoracic Surgery, Department of Surgery, 2 Division of Cardiology, Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Malcolm J Underwood
- 1 Division of Cardiothoracic Surgery, Department of Surgery, 2 Division of Cardiology, Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
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12
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Hagège AA, Carpentier A, Levine RA. Dynamic changes of the mitral valve annulus: new look at mitral valve diseases. Circ Cardiovasc Imaging 2015; 8:CIRCIMAGING.115.003539. [PMID: 25956923 DOI: 10.1161/circimaging.115.003539] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Albert A Hagège
- From the Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, Paris, France (A.A.H., A.C., R.A.L.); INSERM U970, Paris Cardiovascular Research Center, Hôpital Européen Georges Pompidou, Paris, France (A.A.H.); Department of Cardiology (A.A.H.) and Department of Cardiovascular Surgery (A.C.), Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France; and Cardiac Ultrasound Laboratory, Massachusetts General Hospital and Harvard Medical School, Boston, MA (R.A.L.).
| | - Alain Carpentier
- From the Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, Paris, France (A.A.H., A.C., R.A.L.); INSERM U970, Paris Cardiovascular Research Center, Hôpital Européen Georges Pompidou, Paris, France (A.A.H.); Department of Cardiology (A.A.H.) and Department of Cardiovascular Surgery (A.C.), Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France; and Cardiac Ultrasound Laboratory, Massachusetts General Hospital and Harvard Medical School, Boston, MA (R.A.L.)
| | - Robert A Levine
- From the Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, Paris, France (A.A.H., A.C., R.A.L.); INSERM U970, Paris Cardiovascular Research Center, Hôpital Européen Georges Pompidou, Paris, France (A.A.H.); Department of Cardiology (A.A.H.) and Department of Cardiovascular Surgery (A.C.), Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France; and Cardiac Ultrasound Laboratory, Massachusetts General Hospital and Harvard Medical School, Boston, MA (R.A.L.)
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13
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Dal-Bianco JP, Inglessis I, Melnitchouk S, Daher M, Palacios IF. Percutaneous Mitral Valve Edge-to-Edge Repair for Degenerative Mitral Regurgitation. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2015; 17:389. [PMID: 26070587 DOI: 10.1007/s11936-015-0389-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OPINION STATEMENT Surgical mitral valve (MV) repair remains the gold standard to treat patients with significant degenerative mitral regurgitation (DMR). Medical therapy was the only option for patients found to be not appropriate for MV surgery until the development of percutaneous/transcatheter MV repair options that now allow to reduce MR less invasively and safely. This article discusses the basic mechanisms of MR and the rationale for MR intervention and offers a detailed review on percutaneous/transcatheter MV repair with the MitraClip.
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Affiliation(s)
- Jacob P Dal-Bianco
- Cardiology Division, Department of Medicine, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Yawkey 5B, Boston, MA, 02114, USA,
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14
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Abstract
Mitral regurgitation is one of the most common forms of heart valve disorder, which may result in heart failure. Due to the rapid ageing of the population, surgical repair and replacement treatments, which have represented an effective treatment in the past, are now unsuitable for about half of symptomatic patients, who are judged high-risk. Encouraged by the positive experience with transcatheter aortic valves and percutaneous reconstructive mitral treatments, a number of research groups are currently engaged in the development of minimally invasive approaches for the functional replacement of the mitral valve. The first experiences have clearly demonstrated that the approach is feasible and promising, though significant progress is still required in the prostheses design and implantation procedures before the treatment can establish as a safe and effective solution. This review analyses the devices currently at a most advanced stage of development, describing their main features and the technical solutions that they adopt in order to respond to the functional requirements of the most challenging of the heart valves.
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15
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Normal mitral annulus dynamics and its relationships with left ventricular and left atrial function. Int J Cardiovasc Imaging 2014; 31:279-90. [DOI: 10.1007/s10554-014-0547-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 10/03/2014] [Indexed: 01/08/2023]
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16
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Mihăilă S, Muraru D, Piasentini E, Miglioranza MH, Peluso D, Cucchini U, Iliceto S, Vinereanu D, Badano LP. Quantitative Analysis of Mitral Annular Geometry and Function in Healthy Volunteers Using Transthoracic Three-Dimensional Echocardiography. J Am Soc Echocardiogr 2014; 27:846-57. [DOI: 10.1016/j.echo.2014.04.017] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Indexed: 10/25/2022]
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17
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Dal-Bianco JP, Beaudoin J, Handschumacher MD, Levine RA. Basic mechanisms of mitral regurgitation. Can J Cardiol 2014; 30:971-81. [PMID: 25151282 DOI: 10.1016/j.cjca.2014.06.022] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Revised: 06/16/2014] [Accepted: 06/22/2014] [Indexed: 12/17/2022] Open
Abstract
Any structural or functional impairment of the mitral valve (MV) apparatus that exhausts MV tissue redundancy available for leaflet coaptation will result in mitral regurgitation (MR). The mechanism responsible for MV malcoaptation and MR can be dysfunction or structural change of the left ventricle, the papillary muscles, the chordae tendineae, the mitral annulus, and the MV leaflets. The rationale for MV treatment depends on the MR mechanism and therefore it is essential to identify and understand normal and abnormal MV and MV apparatus function.
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Affiliation(s)
- Jacob P Dal-Bianco
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan Beaudoin
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Department of Cardiology, Québec City, Québec, Canada
| | - Mark D Handschumacher
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert A Levine
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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18
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Abstract
Transesophageal echocardiography provides excellent visualization of the posteriorly located mitral valve. Over the last decade, 3-dimensional transesophageal echocardiography (3D TEE) has emerged as an exciting imaging modality, particularly of the mitral valve. The current generation matrix array technology allows the operator to perform 2D and 3D imaging with a single transducer. 3D TEE affords the unique ability to view the mitral valve and its surrounding structures "en face" in real time (RT), and provide contextual anatomical guidance during surgical and transcatheter interventions. Additionally, offline quantification has made significant contributions to our mechanistic understanding of the normal and diseased mitral valve, and alterations induced by therapeutic intervention such as surgical repair. This review will address recent advances in the incremental role of 3D TEE in mitral valve imaging.
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19
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Muller DWM, Jansz P. A clip in time--selecting interventions for severe mitral valve regurgitation. Heart Lung Circ 2014; 23:493-5. [PMID: 24810159 DOI: 10.1016/j.hlc.2014.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Accepted: 02/19/2014] [Indexed: 10/25/2022]
Affiliation(s)
- David W M Muller
- Cardiology and Cardiothoracic Surgery Depts, St Vincent's Hospital, Victoria St, Darlinghurst, NSW 2010, Australia.
| | - Paul Jansz
- Cardiology and Cardiothoracic Surgery Depts, St Vincent's Hospital, Victoria St, Darlinghurst, NSW 2010, Australia
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20
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Wan S. Invited commentary. Ann Thorac Surg 2014; 97:497-8. [PMID: 24484791 DOI: 10.1016/j.athoracsur.2013.10.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Revised: 10/19/2013] [Accepted: 10/22/2013] [Indexed: 10/25/2022]
Affiliation(s)
- Song Wan
- Division of Cardiothoracic Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong, China.
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21
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Abstract
The mitral valve apparatus is a complex 3-dimensional (3D) functional unit that is critical to unidirectional heart pump function. This review details the normal anatomy, histology, and function of the main mitral valve apparatus components: mitral annulus, mitral valve leaflets, chordae tendineae, and papillary muscles. Two-dimensional and 3D echocardiography is ideally suited to examine the mitral valve apparatus and has provided important insights into the mechanism of mitral valve disease. An overview of standardized echocardiography image acquisition and interpretation is provided. Understanding normal mitral valve apparatus function is essential to comprehend alterations in mitral valve disease and the rationale for repair strategies.
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