1
|
Silva Ferreira MV, Soares CSP, Araujo-Filho JDAB, Dantas RN, Torres RVA, Morais TC, Avila LFR, Ishikawa W, Nomura CH, Rajiah PS, Parga Filho J. Mitral Annular Disease at Cardiac MRI: What to Know and Look For. Radiographics 2024; 44:e230156. [PMID: 38870043 DOI: 10.1148/rg.230156] [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] [Indexed: 06/15/2024]
Abstract
Accurate evaluation of the mitral valve (MV) apparatus is essential for understanding the mechanisms of MV disease across various clinical scenarios. The mitral annulus (MA) is a complex and crucial structure that supports MV function; however, conventional imaging techniques have limitations in fully capturing the entirety of the MA. Moreover, recognizing annular changes might aid in identifying patients who may benefit from advanced cardiac imaging and interventions. Multimodality cardiovascular imaging plays a major role in the diagnosis, prognosis, and management of MV disease. Transthoracic echocardiography is the first-line modality for evaluation of the MA, but it has limitations. Cardiac MRI (CMR) has emerged as a robust imaging modality for assessing annular changes, with distinct advantages over other imaging techniques, including accurate flow and volumetric quantification and assessment of variations in the measurements and shape of the MA during the cardiac cycle. Mitral annular disjunction (MAD) is defined as atrial displacement of the hinge point of the MV annulus away from the ventricular myocardium, a condition that is now more frequently diagnosed and studied owing to recent technical advances in cardiac imaging. However, several unresolved issues regarding MAD, such as the functional significance of pathologic disjunction and how this disjunction advances in the clinical course, require further investigation. The authors review the role of CMR in the assessment of MA disease, with a focus on MAD and its functional implications in MV prolapse and mitral regurgitation. ©RSNA, 2024 Supplemental material is available for this article. See the invited commentary by Stojanovska and Fujikura in this issue.
Collapse
Affiliation(s)
- Marcus Vinicius Silva Ferreira
- From the Department of Radiology, Hospital Sirio-Libanes, Rua Adma Jafet, 91, Sao Paulo, SP 01308-050, Brazil (M.V.S.F., C.S.P.S., J.dA.B.A.F., R.N.D., R.V.A.T., T.C.M., L.F.R.A., C.H.N., J.P.F.); Department of Radiology, Hospital Israelita Albert Einstein, Sao Paulo, SP 05652-900, Brazil (W.I.); and Department of Radiology, Mayo Clinic, Rochester, MN 55905 (P.S.R.)
| | - Clarice Santos Parreira Soares
- From the Department of Radiology, Hospital Sirio-Libanes, Rua Adma Jafet, 91, Sao Paulo, SP 01308-050, Brazil (M.V.S.F., C.S.P.S., J.dA.B.A.F., R.N.D., R.V.A.T., T.C.M., L.F.R.A., C.H.N., J.P.F.); Department of Radiology, Hospital Israelita Albert Einstein, Sao Paulo, SP 05652-900, Brazil (W.I.); and Department of Radiology, Mayo Clinic, Rochester, MN 55905 (P.S.R.)
| | - Jose de Arimateia Batista Araujo-Filho
- From the Department of Radiology, Hospital Sirio-Libanes, Rua Adma Jafet, 91, Sao Paulo, SP 01308-050, Brazil (M.V.S.F., C.S.P.S., J.dA.B.A.F., R.N.D., R.V.A.T., T.C.M., L.F.R.A., C.H.N., J.P.F.); Department of Radiology, Hospital Israelita Albert Einstein, Sao Paulo, SP 05652-900, Brazil (W.I.); and Department of Radiology, Mayo Clinic, Rochester, MN 55905 (P.S.R.)
| | - Roberto Nery Dantas
- From the Department of Radiology, Hospital Sirio-Libanes, Rua Adma Jafet, 91, Sao Paulo, SP 01308-050, Brazil (M.V.S.F., C.S.P.S., J.dA.B.A.F., R.N.D., R.V.A.T., T.C.M., L.F.R.A., C.H.N., J.P.F.); Department of Radiology, Hospital Israelita Albert Einstein, Sao Paulo, SP 05652-900, Brazil (W.I.); and Department of Radiology, Mayo Clinic, Rochester, MN 55905 (P.S.R.)
| | - Roberto Vitor Almeida Torres
- From the Department of Radiology, Hospital Sirio-Libanes, Rua Adma Jafet, 91, Sao Paulo, SP 01308-050, Brazil (M.V.S.F., C.S.P.S., J.dA.B.A.F., R.N.D., R.V.A.T., T.C.M., L.F.R.A., C.H.N., J.P.F.); Department of Radiology, Hospital Israelita Albert Einstein, Sao Paulo, SP 05652-900, Brazil (W.I.); and Department of Radiology, Mayo Clinic, Rochester, MN 55905 (P.S.R.)
| | - Thamara Carvalho Morais
- From the Department of Radiology, Hospital Sirio-Libanes, Rua Adma Jafet, 91, Sao Paulo, SP 01308-050, Brazil (M.V.S.F., C.S.P.S., J.dA.B.A.F., R.N.D., R.V.A.T., T.C.M., L.F.R.A., C.H.N., J.P.F.); Department of Radiology, Hospital Israelita Albert Einstein, Sao Paulo, SP 05652-900, Brazil (W.I.); and Department of Radiology, Mayo Clinic, Rochester, MN 55905 (P.S.R.)
| | - Luis Francisco Rodrigues Avila
- From the Department of Radiology, Hospital Sirio-Libanes, Rua Adma Jafet, 91, Sao Paulo, SP 01308-050, Brazil (M.V.S.F., C.S.P.S., J.dA.B.A.F., R.N.D., R.V.A.T., T.C.M., L.F.R.A., C.H.N., J.P.F.); Department of Radiology, Hospital Israelita Albert Einstein, Sao Paulo, SP 05652-900, Brazil (W.I.); and Department of Radiology, Mayo Clinic, Rochester, MN 55905 (P.S.R.)
| | - Walther Ishikawa
- From the Department of Radiology, Hospital Sirio-Libanes, Rua Adma Jafet, 91, Sao Paulo, SP 01308-050, Brazil (M.V.S.F., C.S.P.S., J.dA.B.A.F., R.N.D., R.V.A.T., T.C.M., L.F.R.A., C.H.N., J.P.F.); Department of Radiology, Hospital Israelita Albert Einstein, Sao Paulo, SP 05652-900, Brazil (W.I.); and Department of Radiology, Mayo Clinic, Rochester, MN 55905 (P.S.R.)
| | - Cesar Higa Nomura
- From the Department of Radiology, Hospital Sirio-Libanes, Rua Adma Jafet, 91, Sao Paulo, SP 01308-050, Brazil (M.V.S.F., C.S.P.S., J.dA.B.A.F., R.N.D., R.V.A.T., T.C.M., L.F.R.A., C.H.N., J.P.F.); Department of Radiology, Hospital Israelita Albert Einstein, Sao Paulo, SP 05652-900, Brazil (W.I.); and Department of Radiology, Mayo Clinic, Rochester, MN 55905 (P.S.R.)
| | - Prabhakar Shantha Rajiah
- From the Department of Radiology, Hospital Sirio-Libanes, Rua Adma Jafet, 91, Sao Paulo, SP 01308-050, Brazil (M.V.S.F., C.S.P.S., J.dA.B.A.F., R.N.D., R.V.A.T., T.C.M., L.F.R.A., C.H.N., J.P.F.); Department of Radiology, Hospital Israelita Albert Einstein, Sao Paulo, SP 05652-900, Brazil (W.I.); and Department of Radiology, Mayo Clinic, Rochester, MN 55905 (P.S.R.)
| | - Jose Parga Filho
- From the Department of Radiology, Hospital Sirio-Libanes, Rua Adma Jafet, 91, Sao Paulo, SP 01308-050, Brazil (M.V.S.F., C.S.P.S., J.dA.B.A.F., R.N.D., R.V.A.T., T.C.M., L.F.R.A., C.H.N., J.P.F.); Department of Radiology, Hospital Israelita Albert Einstein, Sao Paulo, SP 05652-900, Brazil (W.I.); and Department of Radiology, Mayo Clinic, Rochester, MN 55905 (P.S.R.)
| |
Collapse
|
2
|
Brissett S, Aurigemma GP, Parker MW. The Promise and Pitfalls of Three-Dimensional Vena Contracta for Mitral Regurgitation. J Am Soc Echocardiogr 2024; 37:599-602. [PMID: 38522487 DOI: 10.1016/j.echo.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 03/03/2024] [Indexed: 03/26/2024]
Affiliation(s)
- Shantel Brissett
- UMass Memorial Medical School and UMass Memorial Medical Center, Worcester, Massachusetts
| | - Gerard P Aurigemma
- UMass Memorial Medical School and UMass Memorial Medical Center, Worcester, Massachusetts
| | - Matthew W Parker
- UMass Memorial Medical School and UMass Memorial Medical Center, Worcester, Massachusetts.
| |
Collapse
|
3
|
Gorecka M, Craven TP, Jex N, Chew PG, Dobson LE, Brown LAE, Higgins DM, Thirunavukarasu S, Sharrack N, Javed W, Kotha S, Giannoudi M, Procter H, Parent M, Schlosshan D, Swoboda PP, Plein S, Levelt E, Greenwood JP. Mitral regurgitation assessment by cardiovascular magnetic resonance imaging during continuous in-scanner exercise: a feasibility study. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2024:10.1007/s10554-024-03141-8. [PMID: 38780711 DOI: 10.1007/s10554-024-03141-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 05/13/2024] [Indexed: 05/25/2024]
Abstract
PURPOSE Exercise imaging using current modalities can be challenging. This was patient focused study to establish the feasibility and reproducibility of exercise-cardiovascular magnetic resonance imaging (EX-CMR) acquired during continuous in-scanner exercise in asymptomatic patients with primary mitral regurgitation (MR). METHODS This was a prospective, feasibility study. Biventricular volumes/function, aortic flow volume, MR volume (MR-Rvol) and regurgitant fraction (MR-RF) were assessed at rest and during low- (Low-EX) and moderate-intensity exercise (Mod-EX) in asymptomatic patients with primary MR. RESULTS Twenty-five patients completed EX-CMR without complications. Whilst there were no significant changes in the left ventricular (LV) volumes, there was a significant increase in the LVEF (rest 63 ± 5% vs. Mod-EX 68 ± 6%;p = 0.01). There was a significant reduction in the right ventricular (RV) end-systolic volume (rest 68 ml(60-75) vs. Mod-EX 46 ml(39-59);p < 0.001) and a significant increase in the RV ejection fraction (rest 55 ± 5% vs. Mod-EX 65 ± 8%;p < 0.001). Whilst overall, there were no significant group changes in the MR-Rvol and MR-RF, individual responses were variable, with MR-Rvol increasing by ≥ 15 ml in 4(16%) patients and decreasing by ≥ 15 ml in 9(36%) of patients. The intra- and inter-observer reproducibility of LV volumes and aortic flow measurements were excellent, including at Mod-EX. CONCLUSION EX-CMR is feasible and reproducible in patients with primary MR. During exercise, there is an increase in the LV and RV ejection fraction, reduction in the RV end-systolic volume and a variable response of MR-Rvol and MR-RF. Understanding the individual variability in MR-Rvol and MR-RF during physiological exercise may be clinically important.
Collapse
Affiliation(s)
- Miroslawa Gorecka
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK
| | - Thomas P Craven
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK
| | - Nick Jex
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK
| | - Pei G Chew
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK
| | - Laura E Dobson
- Department of Cardiology, Wythenshawe Hospital, Manchester University NHS Trust, Manchester, UK
| | - Louise A E Brown
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK
| | | | - Sharmaine Thirunavukarasu
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK
| | - Noor Sharrack
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK
| | - Wasim Javed
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK
| | - Sindhoora Kotha
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK
| | - Marilena Giannoudi
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK
| | - Henry Procter
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK
| | - Martine Parent
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK
| | - Dominik Schlosshan
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK
| | - Peter P Swoboda
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK
| | - Sven Plein
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK
| | - Eylem Levelt
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK
| | - John P Greenwood
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK.
- Baker Heart and Diabetes Institute & Monash University, Melbourne, Australia.
| |
Collapse
|
4
|
Huttin O, Le Tourneau T, Filippetti L, Pace N, Sellal JM, Beaumont M, Mandry D, Marie PY, Selton-Suty C, Girerd N. A new evidence-based echocardiographic approach to predict cardiovascular events and myocardial fibrosis in mitral valve prolapse: The STAMP algorithm. Arch Cardiovasc Dis 2024; 117:173-176. [PMID: 38368159 DOI: 10.1016/j.acvd.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 01/09/2024] [Accepted: 01/10/2024] [Indexed: 02/19/2024]
Affiliation(s)
- Olivier Huttin
- Service de cardiologie, institut lorrain du cœur et des vaisseaux, CHRU de Nancy, 54500 Vandœuvre-lès-Nancy, France.
| | - Thierry Le Tourneau
- CIC 1413, université de Nantes, CHU de Nantes, 44000 Nantes, France; Inserm, CNRS, institut du thorax, université de Nantes, CHU de Nantes, 44000 Nantes, France
| | - Laure Filippetti
- Service de cardiologie, institut lorrain du cœur et des vaisseaux, CHRU de Nancy, 54500 Vandœuvre-lès-Nancy, France
| | - Nathalie Pace
- Service de cardiologie, institut lorrain du cœur et des vaisseaux, CHRU de Nancy, 54500 Vandœuvre-lès-Nancy, France
| | - Jean-Marc Sellal
- Service de cardiologie, institut lorrain du cœur et des vaisseaux, CHRU de Nancy, 54500 Vandœuvre-lès-Nancy, France
| | - Marine Beaumont
- U1433, CIC-IT, CHRU de Nancy, 54000 Vandœuvre-lès-Nancy, France; Inserm U1254, IADI, université de Lorraine, 54500 Vandœuvre-lès-Nancy, France
| | - Damien Mandry
- Service de cardiologie, institut lorrain du cœur et des vaisseaux, CHRU de Nancy, 54500 Vandœuvre-lès-Nancy, France; U1433, CIC-IT, CHRU de Nancy, 54000 Vandœuvre-lès-Nancy, France; Inserm U1254, IADI, université de Lorraine, 54500 Vandœuvre-lès-Nancy, France
| | - Pierre-Yves Marie
- Service de cardiologie, institut lorrain du cœur et des vaisseaux, CHRU de Nancy, 54500 Vandœuvre-lès-Nancy, France; U1433, CIC-IT, CHRU de Nancy, 54000 Vandœuvre-lès-Nancy, France; Inserm U1254, IADI, université de Lorraine, 54500 Vandœuvre-lès-Nancy, France
| | - Christine Selton-Suty
- Service de cardiologie, institut lorrain du cœur et des vaisseaux, CHRU de Nancy, 54500 Vandœuvre-lès-Nancy, France
| | - Nicolas Girerd
- Inserm, CIC 1433, université de Lorraine, CHRU de Nancy, 54000 Vandœuvre-lès-Nancy, France; Inserm U1116, université de Lorraine, 54505 Vandœuvre-lès-Nancy, France; Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists (INI-CRCT), F-CRIN, CHRU de Nancy, 54000 Nancy, France
| |
Collapse
|
5
|
Gerber BL. Review and critical appraisal of the indications for cardiac magnetic resonance imaging in the ESC guidelines. Acta Cardiol 2024; 79:5-19. [PMID: 37962294 DOI: 10.1080/00015385.2023.2279417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 10/30/2023] [Indexed: 11/15/2023]
Abstract
Cardiac MRI has made significant advances in the past decade, becoming an important technique for the evaluation of various cardiac pathologies. The aim of this document is to review the current indications for performing cardiac MRI based on the current ESC guidelines for STEMI, NSTEMI, chronic coronary artery disease, heart failure, arrhythmias, sudden cardiac death, valvular heart disease, pericardial disease and congenital heart disease. The review discusses the diagnostic and prognostic value of cMR for numerous cardiac diseases, and its important value in assessing structural heart disease and predicting arrhythmia risk. Additionally, it reflects upon the appropriateness of the guidelines and points out areas where the indications should be revised in future editions, based on the author's personal opinion. It is suggested that guideline criteria for the use of cMR should be more explicit to promote its use and lead to more specific reimbursements. However, further studies are needed to even better document the value of cMR in the future.
Collapse
Affiliation(s)
- Bernhard L Gerber
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc Woluwe St. Lambert, Belgium
- CARD Unit, Institut de Recherche Expérimentale et Clinique (IREC), UCLouvain, Brussels, Belgium
| |
Collapse
|
6
|
Delgado V, Ajmone Marsan N, Bonow RO, Hahn RT, Norris RA, Zühlke L, Borger MA. Degenerative mitral regurgitation. Nat Rev Dis Primers 2023; 9:70. [PMID: 38062018 DOI: 10.1038/s41572-023-00478-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/31/2023] [Indexed: 12/18/2023]
Abstract
Degenerative mitral regurgitation is a major threat to public health and affects at least 24 million people worldwide, with an estimated 0.88 million disability-adjusted life years and 34,000 deaths in 2019. Improving access to diagnostic testing and to timely curative therapies such as surgical mitral valve repair will improve the outcomes of many individuals. Imaging such as echocardiography and cardiac magnetic resonance allow accurate diagnosis and have provided new insights for a better definition of the most appropriate timing for intervention. Advances in surgical techniques allow minimally invasive treatment with durable results that last for ≥20 years. Transcatheter therapies can provide good results in select patients who are considered high risk for surgery and have a suitable anatomy; the durability of such repairs is up to 5 years. Translational science has provided new knowledge on the pathophysiology of degenerative mitral regurgitation and may pave the road to the development of medical therapies that could be used to halt the progression of the disease.
Collapse
Affiliation(s)
| | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Robert O Bonow
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Rebecca T Hahn
- Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Russell A Norris
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC, USA
| | - Liesl Zühlke
- South African Medical Research Council, Cape Town, South Africa
- Division of Paediatric Cardiology, Department of Paediatrics, Institute of Child Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Michael A Borger
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| |
Collapse
|
7
|
Maher T, Vegh A, Uretsky S. Mitral Regurgitation: Advanced Imaging Parameters and Changing Treatment Landscape. Heart Fail Clin 2023; 19:525-530. [PMID: 37714591 DOI: 10.1016/j.hfc.2023.05.001] [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] [Indexed: 09/17/2023]
Abstract
Mitral regurgitation is a common valvular heart disease with increasing prevalence due to the aging population. In degenerative (primary) mitral regurgitation, medical therapies are limited and the mainstay of treatment is mitral valve surgery. Patients are referred for mitral valve surgery based on the American College of Cardiology/American Heart Association guidelines, which recommend surgery in patients with severe mitral regurgitation. Echocardiography uses multiple parameters that lack reproducibility and accuracy. Studies comparing cardiovascular magnetic resonance (CMR) and echocardiography have shown that CMR is a better predictor of clinical outcome and postsurgical left ventricular remodeling than echocardiography.
Collapse
Affiliation(s)
- Thomas Maher
- Department of Medicine, Morristown Medical Center, Morristown, NJ, USA
| | - Andrea Vegh
- Department of Medicine, Morristown Medical Center, Morristown, NJ, USA
| | - Seth Uretsky
- Department of Cardiovascular Medicine, Gagnon Cardiovascular Institute, Morristown Medical Center/Atlantic Health System, 100 Madison Avenue, Morristown, NJ 07960, USA.
| |
Collapse
|
8
|
Huttin O, Girerd N, Jobbe-Duval A, Constant Dit Beaufils AL, Senage T, Filippetti L, Cueff C, Duarte K, Fraix A, Piriou N, Mandry D, Pace N, Le Scouarnec S, Capoulade R, Echivard M, Sellal JM, Marrec M, Beaumont M, Hossu G, Trochu JN, Sadoul N, Marie PY, Guenancia C, Schott JJ, Roussel JC, Serfaty JM, Selton-Suty C, Le Tourneau T. Machine Learning-Based Phenogrouping in MVP Identifies Profiles Associated With Myocardial Fibrosis and Cardiovascular Events. JACC Cardiovasc Imaging 2023; 16:1271-1284. [PMID: 37204382 DOI: 10.1016/j.jcmg.2023.03.009] [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] [Received: 06/21/2022] [Revised: 02/23/2023] [Accepted: 03/10/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Structural changes and myocardial fibrosis quantification by cardiac imaging have become increasingly important to predict cardiovascular events in patients with mitral valve prolapse (MVP). In this setting, it is likely that an unsupervised approach using machine learning may improve their risk assessment. OBJECTIVES This study used machine learning to improve the risk assessment of patients with MVP by identifying echocardiographic phenotypes and their respective association with myocardial fibrosis and prognosis. METHODS Clusters were constructed using echocardiographic variables in a bicentric cohort of patients with MVP (n = 429, age 54 ± 15 years) and subsequently investigated for their association with myocardial fibrosis (assessed by cardiac magnetic resonance) and cardiovascular outcomes. RESULTS Mitral regurgitation (MR) was severe in 195 (45%) patients. Four clusters were identified: cluster 1 comprised no remodeling with mainly mild MR, cluster 2 was a transitional cluster, cluster 3 included significant left ventricular (LV) and left atrial (LA) remodeling with severe MR, and cluster 4 included remodeling with a drop in LV systolic strain. Clusters 3 and 4 featured more myocardial fibrosis than clusters 1 and 2 (P < 0.0001) and were associated with higher rates of cardiovascular events. Cluster analysis significantly improved diagnostic accuracy over conventional analysis. The decision tree identified the severity of MR along with LV systolic strain <21% and indexed LA volume >42 mL/m2 as the 3 most relevant variables to correctly classify participants into 1 of the echocardiographic profiles. CONCLUSIONS Clustering enabled the identification of 4 clusters with distinct echocardiographic LV and LA remodeling profiles associated with myocardial fibrosis and clinical outcomes. Our findings suggest that a simple algorithm based on only 3 key variables (severity of MR, LV systolic strain, and indexed LA volume) may help risk stratification and decision making in patients with MVP. (Genetic and Phenotypic Characteristics of Mitral Valve Prolapse, NCT03884426; Myocardial Characterization of Arrhythmogenic Mitral Valve Prolapse [MVP STAMP], NCT02879825).
Collapse
Affiliation(s)
- Olivier Huttin
- Service de Cardiologie, Institut Lorrain du Coeur et des Vaisseaux, Centre Hospitalier Universitaire de Nancy, Nancy, France.
| | - Nicolas Girerd
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques-1433 and INSERM U1116, CHRU Nancy, French Clinical Research Infrastructure Network Investigation Network Initiative Cardiovascular and Renal Clinical Trialists (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Antoine Jobbe-Duval
- CHU Nantes, Université de Nantes, l'Institut du Thorax, Centre Investigation Clinique 1413, Nantes, France
| | | | - Thomas Senage
- CHU Nantes, Université de Nantes, l'Institut du Thorax, Centre Investigation Clinique 1413, Nantes, France; Department of Thoracic and CardioVascular Surgery, Thorax Institut, University of Nantes, Nantes, France
| | - Laura Filippetti
- Service de Cardiologie, Institut Lorrain du Coeur et des Vaisseaux, Centre Hospitalier Universitaire de Nancy, Nancy, France
| | - Caroline Cueff
- CHU Nantes, Université de Nantes, l'Institut du Thorax, Centre Investigation Clinique 1413, Nantes, France; Université de Nantes, CHU de Nantes, CNRS, INSERM, l'Institut du Thorax, Nantes, France
| | - Kevin Duarte
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques-1433 and INSERM U1116, CHRU Nancy, French Clinical Research Infrastructure Network Investigation Network Initiative Cardiovascular and Renal Clinical Trialists (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Antoine Fraix
- Service de Cardiologie, Institut Lorrain du Coeur et des Vaisseaux, Centre Hospitalier Universitaire de Nancy, Nancy, France
| | - Nicolas Piriou
- CHU Nantes, Université de Nantes, l'Institut du Thorax, Centre Investigation Clinique 1413, Nantes, France
| | - Damien Mandry
- Service de Cardiologie, Institut Lorrain du Coeur et des Vaisseaux, Centre Hospitalier Universitaire de Nancy, Nancy, France
| | - Nathalie Pace
- Service de Cardiologie, Institut Lorrain du Coeur et des Vaisseaux, Centre Hospitalier Universitaire de Nancy, Nancy, France
| | - Solena Le Scouarnec
- Université de Nantes, CHU de Nantes, CNRS, INSERM, l'Institut du Thorax, Nantes, France
| | - Romain Capoulade
- Université de Nantes, CHU de Nantes, CNRS, INSERM, l'Institut du Thorax, Nantes, France
| | - Matthieu Echivard
- Service de Cardiologie, Institut Lorrain du Coeur et des Vaisseaux, Centre Hospitalier Universitaire de Nancy, Nancy, France
| | - Jean Marc Sellal
- Service de Cardiologie, Institut Lorrain du Coeur et des Vaisseaux, Centre Hospitalier Universitaire de Nancy, Nancy, France
| | - Marie Marrec
- CHU Nantes, Université de Nantes, l'Institut du Thorax, Centre Investigation Clinique 1413, Nantes, France
| | | | - Gabriella Hossu
- CIC-IT, U1433, CHRU de Nancy, France; INSERM U1254, Imagerie Adaptative Diagnostique et Interventionnelle, Université de Lorraine, Nancy, France
| | - Jean-Noel Trochu
- CHU Nantes, Université de Nantes, l'Institut du Thorax, Centre Investigation Clinique 1413, Nantes, France; Université de Nantes, CHU de Nantes, CNRS, INSERM, l'Institut du Thorax, Nantes, France
| | - Nicolas Sadoul
- Service de Cardiologie, Institut Lorrain du Coeur et des Vaisseaux, Centre Hospitalier Universitaire de Nancy, Nancy, France
| | - Pierre-Yves Marie
- Service de Cardiologie, Institut Lorrain du Coeur et des Vaisseaux, Centre Hospitalier Universitaire de Nancy, Nancy, France
| | | | - Jean-Jacques Schott
- Université de Nantes, CHU de Nantes, CNRS, INSERM, l'Institut du Thorax, Nantes, France
| | - Jean-Christian Roussel
- CHU Nantes, Université de Nantes, l'Institut du Thorax, Centre Investigation Clinique 1413, Nantes, France; Université de Nantes, CHU de Nantes, CNRS, INSERM, l'Institut du Thorax, Nantes, France
| | - Jean-Michel Serfaty
- Université de Nantes, CHU de Nantes, CNRS, INSERM, l'Institut du Thorax, Nantes, France
| | - Christine Selton-Suty
- Service de Cardiologie, Institut Lorrain du Coeur et des Vaisseaux, Centre Hospitalier Universitaire de Nancy, Nancy, France
| | - Thierry Le Tourneau
- CHU Nantes, Université de Nantes, l'Institut du Thorax, Centre Investigation Clinique 1413, Nantes, France; Université de Nantes, CHU de Nantes, CNRS, INSERM, l'Institut du Thorax, Nantes, France
| |
Collapse
|
9
|
Zach V, Morris DA, Pieske B, Schneider-Reigbert M. Pitfalls of mitral regurgitation assessment in the presence of mitral valve prolapse. Echocardiography 2023; 40:862-865. [PMID: 37138500 DOI: 10.1111/echo.15583] [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: 09/27/2022] [Revised: 02/14/2023] [Accepted: 04/12/2023] [Indexed: 05/05/2023] Open
Abstract
Adequate grading of mitral regurgitation (MR) in patients with mitral valve prolapse (MVP) in the presence of mid-late systolic jets can represent a major challenge. In this entity, jets are commonly overestimated by echocardiography. Correct quantification is crucial and highly relevant for the further management and prognosis of these oftentimes young patients. This case points out potential pitfalls and underlines the importance to systematically include qualitative, quantitative, and semi-quantitative parameters into the echocardiographic assessment.
Collapse
Affiliation(s)
- Veronika Zach
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Berlin, DE, Germany
- DZHK (German Center for Cardiovascular Research) partner site Berlin, Berlin, DE, Germany
| | - Daniel Armando Morris
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Berlin, DE, Germany
| | | | - Matthias Schneider-Reigbert
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Berlin, DE, Germany
| |
Collapse
|
10
|
Craven TP, Chew PG, Dobson LE, Gorecka M, Parent M, Brown LAE, Saunderson CED, Das A, Chowdhary A, Jex N, Higgins DM, Dall'Armellina E, Levelt E, Schlosshan D, Swoboda PP, Plein S, Greenwood JP. Cardiac reverse remodeling in primary mitral regurgitation: mitral valve replacement vs. mitral valve repair. J Cardiovasc Magn Reson 2023; 25:43. [PMID: 37496072 PMCID: PMC10373289 DOI: 10.1186/s12968-023-00946-9] [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: 10/04/2022] [Accepted: 06/09/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND When feasible, guidelines recommend mitral valve repair (MVr) over mitral valve replacement (MVR) to treat primary mitral regurgitation (MR), based upon historic outcome studies and transthoracic echocardiography (TTE) reverse remodeling studies. Cardiovascular magnetic resonance (CMR) offers reference standard biventricular assessment with superior MR quantification compared to TTE. Using serial CMR in primary MR patients, we aimed to investigate cardiac reverse remodeling and residual MR post-MVr vs MVR with chordal preservation. METHODS 83 patients with ≥ moderate-severe MR on TTE were prospectively recruited. 6-min walk tests (6MWT) and CMR imaging including cine imaging, aortic/pulmonary through-plane phase contrast imaging, T1 maps and late-gadolinium-enhanced (LGE) imaging were performed at baseline and 6 months after mitral surgery or watchful waiting (control group). RESULTS 72 patients completed follow-up (Controls = 20, MVr = 30 and MVR = 22). Surgical groups demonstrated comparable baseline cardiac indices and co-morbidities. At 6-months, MVr and MVR groups demonstrated comparable improvements in 6MWT distances (+ 57 ± 54 m vs + 64 ± 76 m respectively, p = 1), reduced indexed left ventricular end-diastolic volumes (LVEDVi; - 29 ± 21 ml/m2 vs - 37 ± 22 ml/m2 respectively, p = 0.584) and left atrial volumes (- 23 ± 30 ml/m2 and - 39 ± 26 ml/m2 respectively, p = 0.545). At 6-months, compared with controls, right ventricular ejection fraction was poorer post-MVr (47 ± 6.1% vs 53 ± 8.0% respectively, p = 0.01) compared to post-MVR (50 ± 5.7% vs 53 ± 8.0% respectively, p = 0.698). MVR resulted in lower residual MR-regurgitant fraction (RF) than MVr (12 ± 8.0% vs 21 ± 11% respectively, p = 0.022). Baseline and follow-up indices of diffuse and focal myocardial fibrosis (Native T1 relaxation times, extra-cellular volume and quantified LGE respectively) were comparable between groups. Stepwise multiple linear regression of indexed variables in the surgical groups demonstrated baseline indexed mitral regurgitant volume as the sole multivariate predictor of left ventricular (LV) end-diastolic reverse remodelling, baseline LVEDVi as the most significant independent multivariate predictor of follow-up LVEDVi, baseline indexed LV end-systolic volume as the sole multivariate predictor of follow-up LV ejection fraction and undergoing MVR (vs MVr) as the most significant (p < 0.001) baseline multivariate predictor of lower residual MR. CONCLUSION In primary MR, MVR with chordal preservation may offer comparable cardiac reverse remodeling and functional benefits at 6-months when compared to MVr. Larger, multicenter CMR studies are required, which if the findings are confirmed could impact future surgical practice.
Collapse
Affiliation(s)
- Thomas P Craven
- Multidisciplinary Cardiovascular Research Centre & Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT, UK
| | - Pei G Chew
- Multidisciplinary Cardiovascular Research Centre & Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT, UK
| | - Laura E Dobson
- Department of Cardiology, Wythenshawe Hospital, Manchester University NHS Trust, Manchester, UK
| | - Miroslawa Gorecka
- Multidisciplinary Cardiovascular Research Centre & Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT, UK
| | - Martine Parent
- Multidisciplinary Cardiovascular Research Centre & Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT, UK
| | - Louise A E Brown
- Multidisciplinary Cardiovascular Research Centre & Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT, UK
| | - Christopher E D Saunderson
- Multidisciplinary Cardiovascular Research Centre & Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT, UK
| | - Arka Das
- Multidisciplinary Cardiovascular Research Centre & Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT, UK
| | - Amrit Chowdhary
- Multidisciplinary Cardiovascular Research Centre & Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT, UK
| | - Nicholas Jex
- Multidisciplinary Cardiovascular Research Centre & Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT, UK
| | | | - Erica Dall'Armellina
- Multidisciplinary Cardiovascular Research Centre & Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT, UK
| | - Eylem Levelt
- Multidisciplinary Cardiovascular Research Centre & Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT, UK
| | | | - Peter P Swoboda
- Multidisciplinary Cardiovascular Research Centre & Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT, UK
| | - Sven Plein
- Multidisciplinary Cardiovascular Research Centre & Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT, UK
| | - John P Greenwood
- Multidisciplinary Cardiovascular Research Centre & Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT, UK.
| |
Collapse
|
11
|
Uretsky S, Gillam LD. Reply: Misinterpretation of American Society of Echocardiography Mitral Regurgitation Algorithm? JACC Cardiovasc Imaging 2023; 16:569-570. [PMID: 37019602 DOI: 10.1016/j.jcmg.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/10/2023] [Accepted: 02/15/2023] [Indexed: 04/07/2023]
|
12
|
Baessato F, Fusini L, Muratori M, Tamborini G, Ghulam Ali S, Mantegazza V, Baggiano A, Mushtaq S, Pepi M, Patti G, Pontone G. Echocardiography vs. CMR in the Quantification of Chronic Mitral Regurgitation: A Happy Marriage or Stormy Divorce? J Cardiovasc Dev Dis 2023; 10:jcdd10040150. [PMID: 37103029 PMCID: PMC10145831 DOI: 10.3390/jcdd10040150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023] Open
Abstract
Quantification of chronic mitral regurgitation (MR) is essential to guide patients’ clinical management and define the need and appropriate timing for mitral valve surgery. Echocardiography represents the first-line imaging modality to assess MR and requires an integrative approach based on qualitative, semiquantitative, and quantitative parameters. Of note, quantitative parameters, such as the echocardiographic effective regurgitant orifice area, regurgitant volume (RegV), and regurgitant fraction (RegF), are considered the most reliable indicators of MR severity. In contrast, cardiac magnetic resonance (CMR) has demonstrated high accuracy and good reproducibility in quantifying MR, especially in cases with secondary MR; nonholosystolic, eccentric, and multiple jets; or noncircular regurgitant orifices, where quantification with echocardiography is an issue. No gold standard for MR quantification by noninvasive cardiac imaging has been defined so far. Only a moderate agreement has been shown between echocardiography, either with transthoracic or transesophageal approaches, and CMR in MR quantification, as supported by numerous comparative studies. A higher agreement is evidenced when echocardiographic 3D techniques are used. CMR is superior to echocardiography in the calculation of the RegV, RegF, and ventricular volumes and can provide myocardial tissue characterization. However, echocardiography remains fundamental in the pre-operative anatomical evaluation of the mitral valve and of the subvalvular apparatus. The aim of this review is to explore the accuracy of MR quantification provided by echocardiography and CMR in a head-to-head comparison between the two techniques, with insight into the technical aspects of each imaging modality.
Collapse
Affiliation(s)
- Francesca Baessato
- Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, 80636 Munich, Germany
- Department of Cardiology, Regional Hospital S. Maurizio, 39100 Bolzano, Italy
| | - Laura Fusini
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy
- Department of Electronics, Information and Biomedical Engineering, Politecnico di Milano, 20133 Milan, Italy
- Department of Translational Medicine, University of Eastern Piedmont, 28100 Novara, Italy
- Correspondence:
| | - Manuela Muratori
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy
| | - Gloria Tamborini
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy
| | - Sarah Ghulam Ali
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy
| | - Valentina Mantegazza
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy
| | - Andrea Baggiano
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy
| | - Saima Mushtaq
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy
| | - Mauro Pepi
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy
| | - Giuseppe Patti
- Department of Translational Medicine, University of Eastern Piedmont, 28100 Novara, Italy
- Division of Cardiology, Maggiore della Carità Hospital, 28100 Novara, Italy
| | - Gianluca Pontone
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, 2012 Milan, Italy
| |
Collapse
|
13
|
Altes A, Vermes E, Levy F, Vancraeynest D, Pasquet A, Vincentelli A, Gerber BL, Tribouilloy C, Maréchaux S. Quantification of primary mitral regurgitation by echocardiography: A practical appraisal. Front Cardiovasc Med 2023; 10:1107724. [PMID: 36970355 PMCID: PMC10036770 DOI: 10.3389/fcvm.2023.1107724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 02/20/2023] [Indexed: 03/12/2023] Open
Abstract
The accurate quantification of primary mitral regurgitation (MR) and its consequences on cardiac remodeling is of paramount importance to determine the best timing for surgery in these patients. The recommended echocardiographic grading of primary MR severity relies on an integrated multiparametric approach. It is expected that the large number of echocardiographic parameters collected would offer the possibility to check the measured values regarding their congruence in order to conclude reliably on MR severity. However, the use of multiple parameters to grade MR can result in potential discrepancies between one or more of them. Importantly, many factors beyond MR severity impact the values obtained for these parameters including technical settings, anatomic and hemodynamic considerations, patient's characteristics and echocardiographer' skills. Hence, clinicians involved in valvular diseases should be well aware of the respective strengths and pitfalls of each of MR grading methods by echocardiography. Recent literature highlighted the need for a reappraisal of the severity of primary MR from a hemodynamic perspective. The estimation of MR regurgitation fraction by indirect quantitative methods, whenever possible, should be central when grading the severity of these patients. The assessment of the MR effective regurgitant orifice area by the proximal flow convergence method should be used in a semi-quantitative manner. Furthermore, it is crucial to acknowledge specific clinical situations in MR at risk of misevaluation when grading severity such as late-systolic MR, bi-leaflet prolapse with multiple jets or extensive leak, wall-constrained eccentric jet or in older patients with complex MR mechanism. Finally, it is debatable whether the 4-grades classification of MR severity would be still relevant nowadays, since the indication for mitral valve (MV) surgery is discussed in clinical practice for patients with 3+ and 4+ primary MR based on symptoms, specific markers of adverse outcome and MV repair probability. Primary MR grading should be seen as a continuum integrating both quantification of MR and its consequences, even for patients with presumed “moderate” MR.
Collapse
Affiliation(s)
- Alexandre Altes
- GCS-Groupement des Hôpitaux de l’Institut Catholique de Lille/Lille Catholic Hospitals, Heart Valve Center, Cardiology Department, ETHICS EA 7446, Lille Catholic University, Lille, France
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium
| | | | - Franck Levy
- Department of Cardiology, Center Cardio-Thoracique de Monaco, Monaco, Monaco
| | - David Vancraeynest
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium
| | - Agnès Pasquet
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium
| | - André Vincentelli
- Cardiac Surgery Department, Centre Hospitalier Régional et Universitaire de Lille, Lille, France
| | - Bernhard L. Gerber
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium
| | | | - Sylvestre Maréchaux
- GCS-Groupement des Hôpitaux de l’Institut Catholique de Lille/Lille Catholic Hospitals, Heart Valve Center, Cardiology Department, ETHICS EA 7446, Lille Catholic University, Lille, France
- Correspondence: Sylvestre Maréchaux
| |
Collapse
|
14
|
Otemuyiwa BT, Lee EM, Sella E, Madamanchi C, Balasubramanian S, Ma T, Joshi A, Lu JC, Dorfman AL, Agarwal P. Effects of Mitral Valve Prolapse on Quantification of Mitral Regurgitation and Ejection Fraction Using Cardiac MRI. Radiol Cardiothorac Imaging 2023; 5:e220069. [PMID: 36860834 PMCID: PMC9969218 DOI: 10.1148/ryct.220069] [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: 04/03/2022] [Revised: 12/18/2022] [Accepted: 12/27/2022] [Indexed: 02/18/2023]
Abstract
Purpose To determine the impact of prolapsed volume on regurgitant volume (RegV), regurgitant fraction (RF), and left ventricular ejection fraction (LVEF) in patients with mitral valve prolapse (MVP) using cardiac MRI. Materials and Methods Patients with MVP and mitral regurgitation who underwent cardiac MRI from 2005 to 2020 were identified retrospectively from the electronic record. RegV is the difference between left ventricular stroke volume (LVSV) and aortic flow. Left ventricular end-systolic volume (LVESV) and LVSV were obtained from volumetric cine images, with prolapsed volume inclusion (LVESVp, LVSVp) and exclusion (LVESVa, LVSVa) providing two estimates of RegV (RegVp, RegVa), RF (RFp, RFa), and LVEF (LVEFa, LVEFp). Interobserver agreement for LVESVp was assessed using intraclass correlation coefficient (ICC). RegV was also calculated independently using measurements from mitral inflow and aortic net flow phase-contrast imaging as the reference standard (RegVg). Results The study included 19 patients (mean age, 28 years ± 16 [SD]; 10 male patients). Interobserver agreement for LVESVp was high (ICC, 0.98; 95% CI: 0.96, 0.99). Prolapsed volume inclusion resulted in higher LVESV (LVESVp: 95.4 mL ± 34.7 vs LVESVa: 82.4 mL ± 33.8; P < .001), lower LVSV (LVSVp: 100.5 mL ± 33.8 vs LVSVa: 113.5 mL ± 35.9; P < .001), and lower LVEF (LVEFp: 51.7% ± 5.7 vs LVEFa: 58.6% ± 6.3; P < .001). RegV was larger in magnitude when prolapsed volume was excluded (RegVa: 39.4 mL ± 21.0 vs RegVg: 25.8 mL ± 22.8; P = .02), with no evidence of a difference when including prolapsed volume (RegVp: 26.4 mL ± 16.4 vs RegVg: 25.8 mL ± 22.8; P > .99). Conclusion Measurements that included prolapsed volume most closely reflected mitral regurgitation severity, but inclusion of this volume resulted in a lower LVEF.Keywords: Cardiac, MRI© RSNA, 2023See also commentary by Lee and Markl in this issue.
Collapse
|
15
|
Lee J, Markl M. To Include or Not to Include: Quantification of Mitral Regurgitation in Patients with Mitral Valve Prolapse Using Cardiac MRI. Radiol Cardiothorac Imaging 2023; 5:e230007. [PMID: 36860841 PMCID: PMC9969204 DOI: 10.1148/ryct.230007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 01/23/2023] [Accepted: 01/23/2023] [Indexed: 02/18/2023]
Affiliation(s)
- Jeesoo Lee
- From the Department of Radiology, Northwestern University Feinberg School of Medicine, 737 N Michigan Ave, Suite 1600, Chicago, IL 60611 (J.L., M.M.); and Department of Biomedical Engineering, Northwestern University McCormick School of Engineering, Evanston, Ill (M.M.)
| | - Michael Markl
- From the Department of Radiology, Northwestern University Feinberg School of Medicine, 737 N Michigan Ave, Suite 1600, Chicago, IL 60611 (J.L., M.M.); and Department of Biomedical Engineering, Northwestern University McCormick School of Engineering, Evanston, Ill (M.M.)
| |
Collapse
|
16
|
Welker CC, Huang J, Khromava M, Boswell MR, Gil IJN, Ramakrishna H. Analysis of the 2021 European Society of Cardiology/European Association for Cardio-Thoracic Surgery Guidelines for the Management of Valvular Heart Disease. J Cardiothorac Vasc Anesth 2023; 37:803-811. [PMID: 36775745 DOI: 10.1053/j.jvca.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 01/05/2023] [Indexed: 01/11/2023]
Affiliation(s)
- Carson C Welker
- Division of Anesthesia and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Jeffrey Huang
- Division of Critical Care Medicine, Mayo Clinic, Rochester, MN
| | | | | | - Iván J Núñez Gil
- Interventional Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain; Biomedical Science Faculty, Universidad Europea de Madrid, Madrid, Spain
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic, Rochester, MN; Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
| |
Collapse
|
17
|
Vermes E, Altes A, Iacuzio L, Levy F, Bohbot Y, Renard C, Grigioni F, Maréchaux S, Tribouilloy C. The evolving role of cardiovascular magnetic resonance in the assessment of mitral valve prolapse. Front Cardiovasc Med 2023; 10:1093060. [PMID: 36937904 PMCID: PMC10020178 DOI: 10.3389/fcvm.2023.1093060] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 02/13/2023] [Indexed: 03/06/2023] Open
Abstract
Mitral valve prolapse (MVP), characterized by a displacement > 2 mm above the mitral annulus of one or both bileaflets, with or without leaflet thickening, is a common valvular heart disease, with a prevalence of approximately 2% in western countries. Although this population has a generally good overall prognosis, MVP can be associated with mitral regurgitation (MR), left ventricular (LV) remodeling leading to heart failure, ventricular arrhythmia, and, the most devastating complication, sudden cardiac death, especially in myxomatous bileaflet prolapse (Barlow's disease). Among several prognostic factors reported in the literature, LV fibrosis and mitral annular disjunction may act as an arrhythmogenic substrate in this population. Cardiac magnetic resonance (CMR) has emerged as a reliable tool for assessing MVP, MR severity, LV remodeling, and fibrosis. Indeed, CMR is the gold standard imaging modality to assess ventricular volume, function, and wall motion abnormalities; it allows accurate calculation of the regurgitant volume and regurgitant fraction in MR using a combination of LV volumetric measurement and aortic flow quantification, independent of regurgitant jet morphology and valid in cases of multiple valvulopathies. Moreover, CMR is a unique imaging modality that can assess non-invasively focal and diffuse fibrosis using late gadolinium enhancement sequences and, more recently, T1 mapping. This review describes the use of CMR in patients with MVP and its role in identifying patients at high risk of ventricular arrhythmia.
Collapse
Affiliation(s)
- Emmanuelle Vermes
- Department of Cardiology, Amiens University Hospital, Amiens, France
- *Correspondence: Emmanuelle Vermes
| | - Alexandre Altes
- Department of Cardiology, Heart Valve Center, Lille Catholic Hospitals, GCS-Groupement des Hôpitaux de l'Institut Catholique de Lille, Lille Catholic University, Lille, France
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université catholique de Louvain, Brussels, Belgium
| | - Laura Iacuzio
- Department of Cardiology, Centre Cardio-Thoracique de Monaco, Monaco, Monaco
| | - Franck Levy
- Department of Cardiology, Centre Cardio-Thoracique de Monaco, Monaco, Monaco
| | - Yohann Bohbot
- Department of Cardiology, Amiens University Hospital, Amiens, France
- UR UPJV 7517, Jules Verne University of Picardie, Amiens, France
| | - Cédric Renard
- Department of Radiology, Amiens University Hospital, Amiens, France
| | - Francesco Grigioni
- Division of Cardiology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma and Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Sylvestre Maréchaux
- Department of Cardiology, Heart Valve Center, Lille Catholic Hospitals, GCS-Groupement des Hôpitaux de l'Institut Catholique de Lille, Lille Catholic University, Lille, France
| | - Christophe Tribouilloy
- Department of Cardiology, Amiens University Hospital, Amiens, France
- UR UPJV 7517, Jules Verne University of Picardie, Amiens, France
| |
Collapse
|
18
|
Ajmone Marsan N, Delgado V, Shah DJ, Pellikka P, Bax JJ, Treibel T, Cavalcante JL. Valvular heart disease: shifting the focus to the myocardium. Eur Heart J 2023; 44:28-40. [PMID: 36167923 PMCID: PMC9805407 DOI: 10.1093/eurheartj/ehac504] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 07/12/2022] [Accepted: 08/26/2022] [Indexed: 01/05/2023] Open
Abstract
Adverse cardiac remodelling is the main determinant of patient prognosis in degenerative valvular heart disease (VHD). However, to give an indication for valvular intervention, current guidelines include parameters of cardiac chamber dilatation or function which are subject to variability, do not directly reflect myocardial structural changes, and, more importantly, seem to be not sensitive enough in depicting early signs of myocardial dysfunction before irreversible myocardial damage has occurred. To avoid irreversible myocardial dysfunction, novel biomarkers are advocated to help refining indications for intervention and risk stratification. Advanced echocardiographic modalities, including strain analysis, and magnetic resonance imaging have shown to be promising in providing new tools to depict the important switch from adaptive to maladaptive myocardial changes in response to severe VHD. This review, therefore, summarizes the current available evidence on the role of these new imaging biomarkers in degenerative VHD, aiming at shifting the clinical perspective from a valve-centred to a myocardium-focused approach for patient management and therapeutic decision-making.
Collapse
Affiliation(s)
- Nina Ajmone Marsan
- Department of Cardiology, Leiden Univesity Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Victoria Delgado
- Department of Cardiology, Leiden Univesity Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
- Department of Cardiology, Germans Trias i Pujol Hospital, Carretera de Canyet s/n. 08916 Badalona, Barcelona, Spain
| | - Dipan J Shah
- Division of Cardiovascular Imaging, Weill Cornell Medical College, Houston Methodist DeBakey Heart & Vascular Center, 6565 Fannin St, Houston, TX 77030, USA
| | - Patricia Pellikka
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Jeroen J Bax
- Department of Cardiology, Leiden Univesity Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Thomas Treibel
- Department of Cardiology, Barts Heart Centre and University College London, West Smithfield, London EC1A 7BE, UK
| | - João L Cavalcante
- Department of Cardiology, Minneapolis Heart Institute at Abbott Northwestern Hospital, 800 E 28th St, Minneapolis, MN 55407, USA
| |
Collapse
|
19
|
Faza NN, Chebrolu LB, El-Tallawi KC, Zoghbi WA. An Integrative, Multiparametric Approach to Mitral Regurgitation Evaluation. JACC Case Rep 2022; 4:1231-1241. [PMID: 36406912 PMCID: PMC9666750 DOI: 10.1016/j.jaccas.2022.07.013] [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: 02/17/2022] [Revised: 06/29/2022] [Accepted: 07/07/2022] [Indexed: 11/06/2022]
Abstract
Echocardiography is the first-line modality for assessing mitral regurgitation (MR). In addition to evaluation of the MR jet characteristics, echocardiography can provide quantitative parameters of MR severity. This case series illustrates the importance of integrating multiple parameters in the evaluation of MR and the role of multimodality imaging. (Level of Difficulty: Advanced.)
Collapse
Affiliation(s)
| | | | | | - William A. Zoghbi
- Address for correspondence: Dr William A Zoghbi, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, 6550 Fannin Street, Suite 1801, Houston, Texas 77030, USA. @WilliamZoghbi
| |
Collapse
|
20
|
Gorecka M, Bissell MM, Higgins DM, Garg P, Plein S, Greenwood JP. Rationale and clinical applications of 4D flow cardiovascular magnetic resonance in assessment of valvular heart disease: a comprehensive review. J Cardiovasc Magn Reson 2022; 24:49. [PMID: 35989320 PMCID: PMC9394062 DOI: 10.1186/s12968-022-00882-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 08/04/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Accurate evaluation of valvular pathology is crucial in the timing of surgical intervention. Whilst transthoracic echocardiography is widely available and routinely used in the assessment of valvular heart disease, it is bound by several limitations. Although cardiovascular magnetic resonance (CMR) imaging can overcome many of the challenges encountered by echocardiography, it also has a number of limitations. MAIN TEXT 4D Flow CMR is a novel technique, which allows time-resolved, 3-dimensional imaging. It enables visualisation and direct quantification of flow and peak velocities of all valves simultaneously in one simple acquisition, without any geometric assumptions. It also has the unique ability to measure advanced haemodynamic parameters such as turbulent kinetic energy, viscous energy loss rate and wall shear stress, which may add further diagnostic and prognostic information. Although 4D Flow CMR acquisition can take 5-10 min, emerging acceleration techniques can significantly reduce scan times, making 4D Flow CMR applicable in contemporary clinical practice. CONCLUSION 4D Flow CMR is an emerging CMR technique, which has the potential to become the new reference-standard method for the evaluation of valvular lesions. In this review, we describe the clinical applications, advantages and disadvantages of 4D Flow CMR in the assessment of valvular heart disease.
Collapse
Affiliation(s)
- Miroslawa Gorecka
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT, UK
| | - Malenka M Bissell
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT, UK
| | | | - Pankaj Garg
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Sven Plein
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT, UK
| | - John P Greenwood
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT, UK.
| |
Collapse
|
21
|
Galusko V, Sekar B, Ricci F, Wong K, Bhattacharyya S, Mullen M, Gallina S, Ionescu A, Khanji MY. Mitral regurgitation management: a systematic review of clinical practice guidelines and recommendations. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2022; 8:481-495. [PMID: 34878118 DOI: 10.1093/ehjqcco/qcab082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 11/08/2021] [Indexed: 12/29/2022]
Abstract
Multiple guidelines exist for the diagnosis and management of mitral regurgitation (MR), the second most common valvular heart disease in high-income countries, with recommendations that do not always match. We systematically reviewed guidelines on diagnosis and management of MR, highlighting similarities and differences to guide clinical decision-making. We searched national and international guidelines in MEDLINE and EMBASE (1 June 2010 to 1 September 2021), the Guidelines International Network, National Guideline Clearinghouse, National Library for Health Guidelines Finder, Canadian Medical Association Clinical Practice Guidelines Infobase, and websites of relevant organizations. Two reviewers independently screened the abstracts and identified articles of interest. Guidelines that were rigorously developed (as assessed with the Appraisal of Guidelines for Research and Evaluation II instrument) were retained for analysis. Five guidelines were retained. There was consensus on a multidisciplinary approach from the heart team and for the definition and grading of severe primary MR. There was general agreement on the thresholds for intervention in symptomatic and asymptomatic primary MR; however, discrepancies were present. There was agreement on optimization of medical therapy in severe secondary MR and intervention in patients symptomatic despite optimal medical therapy, but no consensus on the choice of intervention (surgical repair/replacement vs. transcatheter approach). Cut-offs for high-risk intervention in MR, risk stratification of progressive MR, and guidance on mixed valvular disease were sparse.
Collapse
Affiliation(s)
- Victor Galusko
- Department of Cardiology, King's College Hospital, London SE5 9RS, UK
| | - Baskar Sekar
- Department of Cardiology, Gloucestershire Hospitals NHS Foundation Trust, Gloucester GL1 3NN, UK
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, Institute of Advanced Biomedical Technologies, G.d'Annunzio University, 66100 Chieti, Italy.,Department of Clinical Sciences, Lund University, Jan Waldenströms gata 35-205, Malmö 22100, Sweden.,Department of Cardiology, Casa di Cura Villa Serena, 65013 Città Sant'Angelo, Pescara, Italy
| | - Kit Wong
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
| | - Sanjeev Bhattacharyya
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK.,NIHR Barts Biomedical Research Centre, William Harvey Research Institute, Queen Mary University of London, London EC1A 7BE, UK
| | - Michael Mullen
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
| | - Sabina Gallina
- Department of Neuroscience, Imaging and Clinical Sciences, Institute of Advanced Biomedical Technologies, G.d'Annunzio University, 66100 Chieti, Italy
| | - Adrian Ionescu
- Department of Cardiology, Morriston Cardiac Regional Centre, Swansea Bay Health Board, Swansea SA6 6NL, UK
| | - Mohammed Yunus Khanji
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK.,NIHR Barts Biomedical Research Centre, William Harvey Research Institute, Queen Mary University of London, London EC1A 7BE, UK.,Department of Cardiology, Newham University Hospital, Barts Health NHS Trust, Glen Road, London E13 8SL, UK
| |
Collapse
|
22
|
Vermes E, Iacuzio L, Levy F, Bohbot Y, Renard C, Gerber B, Maréchaux S, Tribouilloy C. Role of Cardiovascular Magnetic Resonance in Native Valvular Regurgitation: A Comprehensive Review of Protocols, Grading of Severity, and Prediction of Valve Surgery. Front Cardiovasc Med 2022; 9:881141. [PMID: 35872899 PMCID: PMC9300884 DOI: 10.3389/fcvm.2022.881141] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 06/07/2022] [Indexed: 11/15/2022] Open
Abstract
Valvular regurgitation is common in developed countries with an increasing prevalence due to the aging of the population and more accurate diagnostic imaging methods. Echocardiography is the gold standard method for the assessment of the severity of valvular heart regurgitation. Nonetheless, cardiovascular magnetic resonance (CMR) has emerged as an additional tool for assessing mainly the severity of aortic and mitral valve regurgitation in the setting of indeterminate findings by echocardiography. Moreover, CMR is a valuable imaging modality to assess ventricular volume and flow, which are useful in the calculation of regurgitant volume and regurgitant fraction of mitral valve regurgitation, aortic valve regurgitation, tricuspid valve regurgitation, and pulmonary valve regurgitation. Notwithstanding this, reference values and optimal thresholds to determine the severity and prognosis of valvular heart regurgitation have been studied lesser by CMR than by echocardiography. Hence, further larger studies are warranted to validate the potential prognostic relevance of the severity of valvular heart regurgitation determined by CMR. The present review describes, analyzes, and discusses the use of CMR to determine the severity of valvular heart regurgitation in clinical practice.
Collapse
Affiliation(s)
- Emmanuelle Vermes
- Department of Cardiology, Amiens University Hospital, Amiens, France
- *Correspondence: Emmanuelle Vermes,
| | - Laura Iacuzio
- Department of Cardiology, Center Cardio-Thoracique de Monaco, Monaco, Monaco
| | - Franck Levy
- Department of Cardiology, Center Cardio-Thoracique de Monaco, Monaco, Monaco
| | - Yohann Bohbot
- Department of Cardiology, Amiens University Hospital, Amiens, France
- UR UPJV 7517, Jules Verne University of Picardie, Amiens, France
| | - Cédric Renard
- Department of Radiology, Amiens University Hospital, Amiens, France
| | - Bernhard Gerber
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université catholique de Louvain, Brussels, Belgium
| | - Sylvestre Maréchaux
- Department of Cardiology, Heart Valve Center, Lille Catholic University Hospital, Lille, France
| | - Christophe Tribouilloy
- Department of Cardiology, Amiens University Hospital, Amiens, France
- UR UPJV 7517, Jules Verne University of Picardie, Amiens, France
- Christophe Tribouilloy,
| |
Collapse
|
23
|
Ribeyrolles S, Monin JL, Rohnean A, Diakov C, Caussin C, Monnot S, Berrebi A, Paul JF. Grading mitral regurgitation using 4D flow CMR: Comparison to transthoracic echocardiography. Echocardiography 2022; 39:783-793. [PMID: 35536700 DOI: 10.1111/echo.15364] [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: 11/15/2021] [Revised: 02/22/2022] [Accepted: 04/25/2022] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES To determine the 4D Flow Cardiac Magnetic Resonance (CMR) thresholds that achieve the best agreement with transthoracic echocardiography (TTE) for grading mitral regurgitation (MR). METHODS We conducted a single-center prospective study of patients evaluated for chronic primary MR in 2016-2020. MR was evaluated blindly by TTE and 4D Flow CMR, respectively by two cardiologists and two radiologists with decades of experience. MR was graded with both methods as mild, moderate, or severe. 4D Flow CMR measurements included MR regurgitant volume per beat (RV) and mitral anterograde flow per beat (MF). RF was obtained as the ratio RV/MF. Additionally, MF was compared to left ventricular stroke volume (LVSV) by cine-CMR. RESULTS We included 33 patients in the initial cohort and 33 in the validation cohort. Inter-observer agreement was excellent for 4D Flow CMR ICC = .94 (95% CI, .86-.97, p < 0.0001). Using recommended TTE thresholds (30 ml, 60 ml, 30%, 50%), agreement was moderate for RV and RF. The best agreement between 4D Flow CMR and TTE was obtained with CMR thresholds of 20 and 40 ml for RV (κ = .93; 95% CI, .8-1) and 20% and 37% for RF (κ = .90; 95% CI, .7-.9). In the validation cohort, agreement between TTE and 4D Flow CMR was good with the optimal thresholds (κ = .78; 95% CI, .61-.94). CONCLUSION We propose CMR thresholds that provide a good agreement between TTE and CMR for grading MR. Further studies are needed to fully validate 4D-Flow CMR accuracy for primary MR quantification.
Collapse
Affiliation(s)
- Sophie Ribeyrolles
- Department of Cardiovascular Medicine, Institut Mutualiste Montsouris, Paris, France
| | - Jean-Luc Monin
- Department of Cardiovascular Medicine, Institut Mutualiste Montsouris, Paris, France
| | - Adela Rohnean
- Department of Cardiovascular Imaging, Institut Mutualiste Montsouris, Paris, France
| | - Christelle Diakov
- Department of Cardiovascular Medicine, Institut Mutualiste Montsouris, Paris, France
| | - Christophe Caussin
- Department of Cardiovascular Medicine, Institut Mutualiste Montsouris, Paris, France
| | - Sebastien Monnot
- Department of Cardiovascular Imaging, Institut Mutualiste Montsouris, Paris, France
| | - Alain Berrebi
- Department of Cardiovascular Medicine, Institut Mutualiste Montsouris, Paris, France
| | - Jean-François Paul
- Department of Cardiovascular Imaging, Institut Mutualiste Montsouris, Paris, France
| |
Collapse
|
24
|
Marwick TH, Chandrashekhar Y. Quantification and Selective Use of Multimodality Imaging in the Assessment of Valvular Regurgitation. JACC Cardiovasc Imaging 2022; 15:957-959. [PMID: 35512965 DOI: 10.1016/j.jcmg.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
25
|
Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Rafael Sádaba J, Tribouilloy C, Wojakowski W. Guía ESC/EACTS 2021 sobre el diagnóstico y tratamiento de las valvulopatías. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
26
|
Uretsky S, Animashaun IB, Sakul S, Aldaia L, Marcoff L, Koulogiannis K, Argulian E, Rosenthal M, Wolff SD, Gillam LD. American Society of Echocardiography Algorithm for Degenerative Mitral Regurgitation: Comparison With CMR. JACC. CARDIOVASCULAR IMAGING 2022; 15:747-760. [PMID: 35324429 DOI: 10.1016/j.jcmg.2021.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 10/08/2021] [Accepted: 10/13/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The purpose of this study was to compare the American Society of Echocardiography (ASE) algorithm for assessing mitral regurgitation (MR) to cardiac magnetic resonance (CMR) and left ventricular (LV) remodeling following mitral intervention. BACKGROUND The ASE recommends integrating multiple echocardiographic parameters for assessing MR. The ASE guidelines include an algorithm that weighs the parameters and highlights those considered indicative of definitely mild or definitely severe MR. METHODS We prospectively enrolled 152 (age 62 ± 13 years; 59% male) patients with degenerative MR who underwent ASE algorithm-guided echocardiographic and CMR grading of MR severity. Using the ASE algorithm, patients were graded as definitely mild, grade I, grade II, grade III, grade IV, or definitely severe MR. CMR MR volume was graded as mild (<30 mL), grade II moderate (30-44 mL), grade III moderate (45-59 mL), or severe (≥60 mL). A subgroup of 63 patients underwent successful mitral intervention, of whom 48 had postintervention CMR. RESULTS Only 52% of patients with definitely severe MR by the ASE algorithm had severe MR by CMR, and 10% had mild MR by CMR. There was an increase in post mitral intervention LV reverse remodeling with worsening MR severity using CMR (P < 0.0001) but not the ASE algorithm (P = 0.07). Severe MR by CMR was an independent predictor of post mitral intervention LV reverse remodeling and definitely severe MR by the ASE algorithm was not. CONCLUSIONS In patients with degenerative MR, agreement between CMR and the ASE algorithm was suboptimal. Severe MR by CMR was an independent predictor of post mitral intervention LV reverse remodeling, whereas definitely severe MR by the ASE algorithm was not. These findings suggest an important role for CMR in surgical decision making in degenerative MR. (Comparison Study of Echocardiography and Cardiovascular Magnetic Resonance Imaging in the Assessment of Mitral and Aortic Regurgitation; NCT04038879).
Collapse
Affiliation(s)
- Seth Uretsky
- Department of Cardiovascular Medicine, Gagnon Cardiovascular Institute, Morristown Medical Center/Atlantic Health System, Morristown, New Jersey, USA.
| | - Islamiyat Babs Animashaun
- Department of Cardiovascular Medicine, Gagnon Cardiovascular Institute, Morristown Medical Center/Atlantic Health System, Morristown, New Jersey, USA
| | - Sakul Sakul
- Department of Medicine, Division of Cardiology, Mount Sinai St. Luke's Hospital, Mount Sinai School of Medicine, New York, New York, USA
| | - Lillian Aldaia
- Department of Cardiovascular Medicine, Gagnon Cardiovascular Institute, Morristown Medical Center/Atlantic Health System, Morristown, New Jersey, USA
| | - Leo Marcoff
- Department of Cardiovascular Medicine, Gagnon Cardiovascular Institute, Morristown Medical Center/Atlantic Health System, Morristown, New Jersey, USA
| | - Konstantinos Koulogiannis
- Department of Cardiovascular Medicine, Gagnon Cardiovascular Institute, Morristown Medical Center/Atlantic Health System, Morristown, New Jersey, USA
| | - Edgar Argulian
- Department of Medicine, Division of Cardiology, Mount Sinai St. Luke's Hospital, Mount Sinai School of Medicine, New York, New York, USA
| | - Mark Rosenthal
- Department of Cardiovascular Medicine, Gagnon Cardiovascular Institute, Morristown Medical Center/Atlantic Health System, Morristown, New Jersey, USA
| | | | - Linda D Gillam
- Department of Cardiovascular Medicine, Gagnon Cardiovascular Institute, Morristown Medical Center/Atlantic Health System, Morristown, New Jersey, USA
| |
Collapse
|
27
|
Challenges and Opportunities in Evaluating Severity of Degenerative Mitral Regurgitation: Details Matter. JACC Cardiovasc Imaging 2022; 15:761-765. [PMID: 35131204 DOI: 10.1016/j.jcmg.2022.01.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 01/13/2022] [Indexed: 12/16/2022]
|
28
|
Pype LL, Bertrand PB, Paelinck BP, Heidbuchel H, Van Craenenbroeck EM, Van De Heyning CM. Left Ventricular Remodeling in Non-syndromic Mitral Valve Prolapse: Volume Overload or Concomitant Cardiomyopathy? Front Cardiovasc Med 2022; 9:862044. [PMID: 35498019 PMCID: PMC9039519 DOI: 10.3389/fcvm.2022.862044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 03/07/2022] [Indexed: 01/11/2023] Open
Abstract
Mitral valve prolapse (MVP) is a common valvular disorder that can be associated with mitral regurgitation (MR), heart failure, ventricular arrhythmias and sudden cardiac death. Given the prognostic impact of these conditions, it is important to evaluate not only mitral valve morphology and regurgitation, but also the presence of left ventricular (LV) function and remodeling. To date, several possible hypotheses have been proposed regarding the underlying mechanisms of LV remodeling in the context of non-syndromic MVP, but the exact pathophysiological explanation remains elusive. Overall, volume overload related to severe MR is considered the main cause of LV dilatation in MVP. However, significant LV remodeling has been observed in patients with MVP and no/mild MR, particularly in patients with bileaflet MVP or Barlow’s disease, generating several new hypotheses. Recently, the concept of “prolapse volume” was introduced, adding a significant volume load to the LV on top of the transvalvular MR volume. Another possible hypothesis is the existence of a concomitant cardiomyopathy, supported by the link between MVP and myocardial fibrosis. The origin of this cardiomyopathy could be either genetic, a second hit (e.g., on top of genetic predisposition) and/or frequent ventricular ectopic beats. This review provides an overview of the different mechanisms and remaining questions regarding LV remodeling in non-syndromic MVP. Since technical specifications of imaging modalities impact the evaluation of MR severity and LV remodeling, and therefore might influence clinical decision making in these patients, this review will also discuss assessment of MVP using different imaging modalities.
Collapse
Affiliation(s)
- Lobke L. Pype
- Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
- Genetics, Pharmacology and Physiopathology of Heart, Vasculature and Skeleton (GENCOR) Research Group, University of Antwerp, Antwerp, Belgium
| | - Philippe B. Bertrand
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Cardio and Organ Systems (COST) Resarch Group, Hasselt University, Hasselt, Belgium
| | - Bernard P. Paelinck
- Genetics, Pharmacology and Physiopathology of Heart, Vasculature and Skeleton (GENCOR) Research Group, University of Antwerp, Antwerp, Belgium
- Department of Cardiac Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - Hein Heidbuchel
- Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
- Genetics, Pharmacology and Physiopathology of Heart, Vasculature and Skeleton (GENCOR) Research Group, University of Antwerp, Antwerp, Belgium
| | - Emeline M. Van Craenenbroeck
- Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
- Genetics, Pharmacology and Physiopathology of Heart, Vasculature and Skeleton (GENCOR) Research Group, University of Antwerp, Antwerp, Belgium
| | - Caroline M. Van De Heyning
- Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
- Genetics, Pharmacology and Physiopathology of Heart, Vasculature and Skeleton (GENCOR) Research Group, University of Antwerp, Antwerp, Belgium
- *Correspondence: Caroline M. Van De Heyning,
| |
Collapse
|
29
|
Malignant Mitral Valve Prolapse: Risk and Prevention of Sudden Cardiac Death. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2022; 24:61-86. [PMID: 35784809 PMCID: PMC9241643 DOI: 10.1007/s11936-022-00956-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Purpose of review The purpose of this review is to explore the prevalence and risk factors for a malignant phenotype in mitral valve prolapse (MVP) characterized by life-threatening ventricular arrhythmias and sudden cardiac arrest and death (SCD), including mechanistic and pathophysiologic findings and mechanism-based potential therapies. Recent findings A malignant phenotype in MVP characterized by life-threatening arrhythmias has long been recognized, although MVP is often benign. Efforts to identify this malignant phenotype have revealed potential risk factors for SCD that include elongated, myxomatous leaflets, ECG changes and complex ventricular ectopy. More recently, malignant MVP has been associated with myocardial fibrosis in the papillary muscles and inferobasal left ventricular wall. This localization suggests a central role of prolapse-induced mechanical forces on the myocardium in creating an arrhythmogenic substrate and triggering life-threatening arrhythmias. This mechanism for fibrosis is also consistent with imaging evidence of prolapse-induced mechanical changes in the papillary muscles and inferobasal left ventricular wall. Currently, no therapy to prevent SCD in malignant MVP has been established and limited clinical data are available. Mechanistic information and prospective study have the potential to identify patients at risk of SCD and preventive strategies. Summary Malignant MVP relates to unique properties and mechanical abnormalities in the mitral valve apparatus and adjacent myocardium. Increased understanding of disease mechanisms and determinants of arrhythmias is needed to establish effective therapies.
Collapse
|
30
|
Altes A, Levy F, Iacuzio L, Dumortier H, Toledano M, Tartar J, Tribouilloy C, Maréchaux S. Comparison of mitral regurgitant volume assessment between proximal flow convergence and volumetric methods in patients with significant primary mitral regurgitation: an echocardiographic and CMR study. J Am Soc Echocardiogr 2022; 35:671-681. [DOI: 10.1016/j.echo.2022.03.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 03/04/2022] [Accepted: 03/04/2022] [Indexed: 11/25/2022]
|
31
|
Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. EUROINTERVENTION 2022; 17:e1126-e1196. [PMID: 34931612 PMCID: PMC9725093 DOI: 10.4244/eij-e-21-00009] [Citation(s) in RCA: 106] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
32
|
Characterization of Primary Mitral Regurgitation With Flail Leaflet and/or Wall-Impinging Flow. J Am Coll Cardiol 2021; 78:2537-2546. [PMID: 34915984 DOI: 10.1016/j.jacc.2021.09.1382] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/27/2021] [Accepted: 09/28/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Echocardiography guidelines note that a flail leaflet is a specific criterion for severe mitral regurgitation (MR) and that regurgitant severity is underestimated in wall-impinging jets (Coandă effect). Both findings are often considered to be pathognomonic of severe MR. OBJECTIVES In this study, the authors sought to determine the association of flail leaflet and Coandă effect with MR severity quantified by means of cardiac magnetic resonance (CMR). METHODS The authors enrolled 158 consecutive patients with primary MR according to echocardiography and CMR. The presence of a flail leaflet or Coandă was determined for each patient. CMR regurgitant volume (RV) and regurgitant fraction (RF) were quantified for all patients. RESULTS There were 55 patients (35%) with a flail leaflet, 52 (33%) with Coandă, and 22 (14%) with a flail leaflet and Coandă. The mean CMR mitral RV and RF progressively increased in patients without a Coandă or flail, a Coandă, a flail, or a Coandă and a flail (RV: 28 ± 21 mL vs 43 ± 23 mL vs 58 ± 29 mL vs 64 ± 25 mL [P < 0.001]; RF: 25% ± 16% vs 34% ± 14% vs 41% ± 12% vs 45% ± 12% [P < 0.001]). With the use of CMR RV, 35%, 46%, and 59% of patients had severe MR with the presence of a Coandă, flail leaflet, or both, respectively. With the use of CMR RF, 25%, 31%, and 40% of patients had severe MR with the presence of a Coandă, flail leaflet, or both, respectively. CONCLUSIONS While the presence of a flail leaflet and Coandă effect on echocardiography are associated with higher regurgitant volumes and fractions, they are frequently not associated with severe MR as assessed by means of CMR. (Comparison Study of Echocardiography and Cardiovascular Magnetic Resonance Imaging in the Assessment of Mitral and Aortic Regurgitation; NCT04038879).
Collapse
|
33
|
Hasin T, Mann D, Welt M, Barrett O, Shalev A, Godfrey M, Kovacs A, Bogot N, Carasso S, Glikson M, Wolak A. Loss of left ventricular rotation is a significant determinant of functional mitral regurgitation. Int J Cardiol 2021; 345:143-149. [PMID: 34626742 DOI: 10.1016/j.ijcard.2021.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/25/2021] [Accepted: 10/04/2021] [Indexed: 11/19/2022]
Abstract
AIM To evaluate insufficient rotational movement of the left ventricle (LV) as a potential novel mechanism for functional regurgitation of the mitral valve (FMR). METHODS AND RESULTS We compared reference subjects and patients with LV dysfunction (LVD, ejection fraction EF < 50%) with and without FMR (regurgitant volume RVol>10 ml). Subjects without structural mitral valve pathology undergoing cardiac MRI were evaluated. Delayed enhancement, global LV remodeling parameters, systolic twist and torsion were measured (using manual and novel automated cardiac MRI tissue-tracking). The study included 117 subjects with mean ± SD age 50.4 ± 17.8 years, of which 30.8% were female. Compared to subjects with LVD without FMR (n = 31), those with FMR (n = 37) had similar clinical characteristics, diagnoses, delayed enhancement, EF, and longitudinal strain. Subjects with FMR had significantly larger left ventricles (EDVi:136.6 ± 41.8 vs 97.5 ± 26.2 ml/m, p < 0.0001) with wider separation between papillary muscles (21.1 ± 7.6 vs 17.2 ± 5.7 mm, p = 0.023). Notably, they had lower apical (p < 0.0001) but not basal rotation and lower peak systolic twist (3.1 ± 2.4° vs 5.5 ± 2.5°, p < 0.0001) and torsion (0.56 ± 0.38°/cm vs 0.88 ± 0.52°/cm, p = 0.004). In a multivariate model for RVol including age, gender, twist, LV end-diastolic volume, sphericity index and separation between papillary muscles, only gender, volume and twist were significant. Twist was the most powerful correlate (beta -2.23, CI -3.26 to -1.23 p < 0.001). In patients with FMR, peak systolic twist negatively correlates with RVol (r = -0.73, p < 0.0001). CONCLUSION Reduced rotational systolic LV motion is significantly and independently associated with RVol among patients with FMR, suggesting a novel pathophysiological mechanism and a potential therapeutic target.
Collapse
Affiliation(s)
- Tal Hasin
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel; Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Daniel Mann
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Michael Welt
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel; Department of Cardiology, The Edith Wolfson Medical Center, Holon, Israel
| | - Orit Barrett
- Department of Cardiology, Soroka University Medical Center, Beer Sheva, Israel
| | - Aryeh Shalev
- Department of Cardiology, Soroka University Medical Center, Beer Sheva, Israel
| | - Max Godfrey
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Andras Kovacs
- Department of Cardiology, Hungarian Defense Forces Medical Center, Budapest, Hungary
| | - Naama Bogot
- Department of Radiology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Shemy Carasso
- Department of Cardiology, Padeh Poria Medical Center, Poria, Israel
| | - Michael Glikson
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Arik Wolak
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel.
| |
Collapse
|
34
|
Musella F, Azzu A, Antonopoulos AS, La Mura L, Mohiaddin RH. Comprehensive mitral valve prolapse assessment by cardiovascular MRI. Clin Radiol 2021; 77:e120-e129. [PMID: 34895911 DOI: 10.1016/j.crad.2021.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 11/05/2021] [Indexed: 12/07/2022]
Abstract
Mitral valve (MV) prolapse (MVP) is a not fully understood common MV disorder. The development of sophisticated cardiovascular magnetic resonance imaging (CMRI) sequences over the last decades has allowed a more detailed assessment and provided better understanding of the pathophysiology of MVP to guide management, interventions, and risk stratification of patients affected. This review provides an overview of the most recent insights about this multifaceted pathology, particularly regarding the emerging concepts of mitral annular disjunction (MAD), and risk of arrhythmia and sudden death associated with myocardial fibrosis. We describe the emerging role of CMRI in both diagnosis and, more importantly, risk assessment of this disease, aiming to provide a comprehensive protocol for the assessment of MVP, which could represent a practical guide to clinicians and MRI practitioners working in the field.
Collapse
Affiliation(s)
- F Musella
- Department of Advanced Biomedical Sciences, University Federico II of Naples. Naples, Italy.
| | - A Azzu
- Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, UK; National Heart and Lung Institute, Imperial College London, UK
| | - A S Antonopoulos
- 1st Cardiology Department, Athens School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - L La Mura
- Department of Advanced Biomedical Sciences, University Federico II of Naples. Naples, Italy
| | - R H Mohiaddin
- Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, UK; National Heart and Lung Institute, Imperial College London, UK.
| |
Collapse
|
35
|
Lee J, Gupta AN, Ma LE, Scott MB, Mason OR, Wu E, Thomas JD, Markl M. Valvular regurgitation flow jet assessment using in vitro 4D flow MRI: Implication for mitral regurgitation. Magn Reson Med 2021; 87:1923-1937. [PMID: 34783383 DOI: 10.1002/mrm.29082] [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: 06/25/2021] [Revised: 10/01/2021] [Accepted: 10/25/2021] [Indexed: 11/11/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the accuracy of four-dimensional (4D) flow MRI for direct assessment of peak velocity, flow volume, and momentum of a mitral regurgitation (MR) flow jets using an in vitro pulsatile jet flow phantom. We systematically investigated the impact of spatial resolution and quantification location along the jet on flow quantities with Doppler ultrasound as a reference for peak velocity. METHODS Four-dimensional flow MRI data of a pulsatile jet through a circular, elliptical, and 3D-printed patient-specific MR orifice model was acquired with varying spatial resolution (1.5-5 mm isotropic voxel). Flow rate and momentum of the jet were quantified at various axial distances (x = 0-50 mm) and integrated over time to calculate Voljet and MTIjet . In vivo assessment of Voljet and MTIjet was performed on 3 MR patients. RESULTS Peak velocities were comparable to Doppler ultrasound (3% error, 1.5 mm voxel), but underestimated with decreasing spatial resolution (-40% error, 5 mm voxel). Voljet was similar to regurgitant volume (RVol) within 5 mm, and then increased linearly with the axial distance (19%/cm) because of flow entrainment. MTIjet remained steady throughout the jet (2%/cm) as theoretically predicted. Four and 9 voxels across the jet were required to measure flow volume and momentum-time-integral within 10% error, respectively. CONCLUSION Four-dimensional flow MRI detected accurate peak velocity, flow rate, and momentum for in vitro MR-mimicking flow jets. Spatial resolution significantly impacted flow quantitation, which otherwise followed predictions of flow entrainment and momentum conservation. This study provides important preliminary information for accurate in vivo MR assessment using 4D flow MRI.
Collapse
Affiliation(s)
- Jeesoo Lee
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Aakash N Gupta
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Liliana E Ma
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Michel B Scott
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - O'Neil R Mason
- Division of Cardiology, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Erik Wu
- Division of Cardiology, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - James D Thomas
- Division of Cardiology, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Michael Markl
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA.,Department of Biomedical Engineering, Northwestern University, McCormick School of Engineering, Evanston, Illinois, USA
| |
Collapse
|
36
|
Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur J Cardiothorac Surg 2021; 60:727-800. [PMID: 34453161 DOI: 10.1093/ejcts/ezab389] [Citation(s) in RCA: 299] [Impact Index Per Article: 99.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
|
37
|
House CM, Xi M, Moriarty KA, Nelson WB. Gender differences in primary mitral regurgitant volumes at specific regurgitant fractions as assessed by magnetic resonance imaging. Int J Cardiovasc Imaging 2021; 38:663-671. [PMID: 34669058 DOI: 10.1007/s10554-021-02449-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/12/2021] [Indexed: 10/20/2022]
Abstract
Guidelines suggest using a regurgitant fraction of 50% and regurgitant volume of 60 ml for determination of severe mitral insufficiency. Recent MRI data has suggested that a regurgitant fraction of 40% defines severe primary mitral insufficiency. We sought to determine whether there were gender differences in primary mitral regurgitant volumes for regurgitant fractions of 40% and 50%. A database search identified 394 patients that had MRI with a mitral regurgitant volume ≥ 10 ml or a study indication of mitral insufficiency. Chart review identified 97 patients with primary mitral insufficiency. Of these patients, 53 (54%) were women. Men had significantly larger left ventricular volumes, myocardial mass, stroke volumes and mitral regurgitant volumes (37 ± 25 ml vs. 24 ± 12 ml). The difference in regurgitant fraction between genders was not significant (27 ± 14% vs. 24 ± 11%; p-value = 0.24). Regurgitant fraction and regurgitant volume had a strong linear correlation in both men (r = .95) and women (r = .92). Despite similar linear correlations, the slope-intercept equations differed significantly between men and women (p < .001). A regurgitant fraction of 40% correlated with a regurgitant volume of 59 ml in men and 39.5 ml in women, while a regurgitant fraction of 50% correlated with a regurgitant volume of 76.2 ml in men and 49.6 ml in women. Regurgitant fraction, determined by cardiac MRI, provides a gender independent assessment of primary mitral insufficiency, and suggests that regurgitant volume thresholds for severe primary mitral insufficiency may be lower in women.
Collapse
Affiliation(s)
- Chad M House
- Regions Hospital Heart Center, 640 Jackson Street, Mail Stop 11102M, St. Paul, MN, 55101, USA. .,HealthPartners Medical Group, Bloomington, MN, USA.
| | - Min Xi
- HealthPartners Institute for Education and Research, Bloomington, MN, USA
| | - Katie A Moriarty
- Regions Hospital Heart Center, 640 Jackson Street, Mail Stop 11102M, St. Paul, MN, 55101, USA.,HealthPartners Medical Group, Bloomington, MN, USA.,University of Minnesota Medical School, Minneapolis, MN, USA
| | - William B Nelson
- Regions Hospital Heart Center, 640 Jackson Street, Mail Stop 11102M, St. Paul, MN, 55101, USA.,HealthPartners Medical Group, Bloomington, MN, USA.,University of Minnesota Medical School, Minneapolis, MN, USA
| |
Collapse
|
38
|
Comparison of mitral regurgitation severity assessments based on magnetic resonance imaging and echocardiography in patients with hypertrophic cardiomyopathy. Sci Rep 2021; 11:19902. [PMID: 34615936 PMCID: PMC8494871 DOI: 10.1038/s41598-021-99446-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 09/27/2021] [Indexed: 12/23/2022] Open
Abstract
Mitral regurgitation (MR), which is one of the factors responsible for heart failure symptoms and the development of atrial fibrillation, is an important feature of hypertrophic cardiomyopathy (HCM), and its presence affects which treatment options are chosen. Although cardiac magnetic resonance imaging (MRI) is considered the reference standard for assessing the regurgitant volume (RV) and fraction (RF), echocardiography is the most common method for assessing MR severity. Accordingly, the aim of this study was to compare the results of echocardiography and cardiac MRI for assessing MR severity in a cohort of patients with HCM. MR severity was assessed in 53 patients using cardiac MRI by determining the mitral RV (MRV) and mitral RF (MRF). The results were graded according to thresholds recommended in current guidelines. MR severity assessed by echocardiography was graded by integrating indices of severity. Greater than mild MR, as assessed using echocardiography, was present in 22 patients (41.5%) with HCM and in none of the control patients (p = 0.001). In all, 31 patients (58.5%) had no more than mild MR. When MR severity was assessed using different methods, either moderate (kappa = 0.44, 95% confidence interval = 0.21–0.67), poor or no agreement was found between MRI-derived and echocardiography-derived grades. HCM patients with echocardiography-derived moderate and severe MR had similar median MRVs and MRFs (p = 0.59 and p = 0.11, respectively). In HCM patients, cardiac MRI and echocardiography were at most in modest agreement in assessing MR severity. Importantly, echocardiography-derived moderate and severe MR were not distinguishable by either MRV or MRF.
Collapse
|
39
|
Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J 2021; 43:561-632. [PMID: 34453165 DOI: 10.1093/eurheartj/ehab395] [Citation(s) in RCA: 1963] [Impact Index Per Article: 654.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
|
40
|
Francone M, Aquaro GD, Barison A, Castelletti S, de Cobelli F, de Lazzari M, Esposito A, Focardi M, di Renzi P, Indolfi C, Lanzillo C, Lovato L, Maestrini V, Mercuro G, Natale L, Mantini C, Polizzi G, Rabbat M, Secchi F, Secinaro A, di Cesare E, Pontone G. Appropriate use criteria for cardiovascular MRI: SIC - SIRM position paper Part 2 (myocarditis, pericardial disease, cardiomyopathies and valvular heart disease). J Cardiovasc Med (Hagerstown) 2021; 22:515-529. [PMID: 34076599 DOI: 10.2459/jcm.0000000000001170] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Cardiovascular magnetic resonance (CMR) has emerged as an accurate diagnostic technique for the evaluation of patients with cardiac disease in the majority of clinical settings, thanks to an established additional diagnostic and prognostic value. This document has been developed by a joined group of experts of the Italian Society of Cardiology (SIC) and Italian Society of Radiology (SIRM) to provide a summary about the current state of technology and clinical applications of CMR, to improve the clinical diagnostic pathways and to promote its inclusion in clinical practice. The writing committee consisted of members and experts of both societies in order to develop a more integrated approach in the field of cardiac imaging. This section 2 will cover myocarditis, pericardial disease, cardiomyopathies and valvular heart disease.
Collapse
Affiliation(s)
- Marco Francone
- Department of Radiological, Oncological and Pathological Sciences, Policlinico Umberto I, Sapienza University of Rome, Rome
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan
| | | | | | - Silvia Castelletti
- Istituto Auxologico Italiano IRCCS, Center for the Cardiac Arrhythmias of Genetic Origin
| | - Francesco de Cobelli
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy Department of Radiology, IRCCS San Raffaele Scientific Institute, Milan
| | - Manuel de Lazzari
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Italy
| | - Antonio Esposito
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy Department of Radiology, IRCCS San Raffaele Scientific Institute, Milan
| | - Marta Focardi
- Department of Cardiology, Azienda Ospedaliera Universitaria Senese, Siena
| | - Paolo di Renzi
- U.O.C. Radiologia, Ospedale 'San Giovanni Calibita' Fatebenefratelli - Isola Tiberina - Rome
| | - Ciro Indolfi
- Division of Cardiology, University Magna Graecia, Italy and Mediterranea Cardiocentro, Naples
| | | | - Luigi Lovato
- Cardiovascular Radiology Unit, Department of Imaging S.Orsola-Malpighi University Hospital, Bologna
| | - Viviana Maestrini
- Department of Clinical Internal, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Giuseppe Mercuro
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari
| | - Luigi Natale
- Department of Diagnostic Imaging, Oncological Radiotherapy, and Hematology - Diagnostic Imaging Area
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS
- Universita ' Cattolica del Sacro Cuore, Rome
| | - Cesare Mantini
- Department of Neuroscience, Imaging and Clinical Sciences, 'G. d'Annunzio' University, Chieti
| | - Gesualdo Polizzi
- Unit of Radiodiagnostics II, University Hospital 'Policlinico-Vittorio Emanuele', Catania, Italy
| | - Mark Rabbat
- Loyola University of Chicago, Chicago
- Edward Hines Jr. VA Hospital, Hines, Illinois, USA
| | - Francesco Secchi
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan
- Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese
| | - Aurelio Secinaro
- Advanced Cardiovascular Imaging Unit, Department of Imaging, Bambino Gesù Children's Hospital, Rome
| | - Ernesto di Cesare
- Department of Life, Healt and Enviromental Sciences, University of L'Aquila, L'Aquila
| | | |
Collapse
|
41
|
Computational Analysis of Virtual Echocardiographic Assessment of Functional Mitral Regurgitation for Validation of Proximal Isovelocity Surface Area Methods. J Am Soc Echocardiogr 2021; 34:1211-1223. [PMID: 34214636 DOI: 10.1016/j.echo.2021.06.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 06/14/2021] [Accepted: 06/16/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Mitral regurgitation (MR) quantification by the proximal isovelocity surface area (PISA) method remains challenging. Using computer models, the authors evaluated the accuracy of different PISA methods and quantified their errors. METHODS Five functional MR computer models of different geometric and tethering abnormalities were created, validated, and treated as phantom models, from which the reference values were directly obtained. Virtual two-dimensional (2D) PISA and three-dimensional (3D) PISA (both peak and integrated values) were performed on these phantom models. By comparing virtual PISA results with reference values, the accuracy of different PISA methods was evaluated, and their sources of errors were quantified. RESULTS Compared with reference values of regurgitant flow rate, excellent correlations were found for true PISA (r = 0.99, bias = 32.3 ± 35.3 mL/sec), 3D PISA (r = 0.97, bias = -24.4 ± 55.5 mL/sec), followed by multiplane 2D hemicylindrical PISA (r = 0.88, bias = -24.1 ± 85.4 mL/sec) and hemiellipsoidal PISA (r = 0.91, bias = -55.7 ± 96.6 mL/sec). Weaker correlations were found for single-plane 2D hemispherical PISA (parasternal long-axis: r = 0.71, bias = -77.6 ± 124.5 mL/sec; apical two-chamber: r = 0.69, bias = -52.0 ± 122.0 mL/sec; apical four-chamber: r = 0.82, bias = -65.5 ± 107.3 mL/sec). For regurgitant volume quantification, integrated PISA was more accurate than peak PISA. The bias of 3D PISA improved from -12.7 ± 7.8 mL (peak PISA) to -2.1 ± 5.3 mL (integrated PISA). CONCLUSIONS For functional MR quantification, 2D hemispherical PISA had significant underestimation, multiplane 2D hemiellipsoidal and hemicylindrical PISA showed improved accuracy, and 3D PISA was the most accurate. The PISA method is subject to both systematic underestimation due to the Doppler angle effect and systematic overestimation when regurgitant flow is not perpendicular to PISA contour. Integrated PISA is able to capture dynamic MR and is therefore more accurate than peak PISA. The sum of regurgitant flow rates is the most feasible way to perform integrated PISA.
Collapse
|
42
|
Reid A, Blanke P, Bax JJ, Leipsic J. Multimodality imaging in valvular heart disease: how to use state-of-the-art technology in daily practice. Eur Heart J 2021; 42:1912-1925. [PMID: 33186469 DOI: 10.1093/eurheartj/ehaa768] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 06/15/2020] [Accepted: 09/08/2020] [Indexed: 12/16/2022] Open
Abstract
Our understanding of the complexities of valvular heart disease (VHD) has evolved in recent years, primarily because of the increased use of multimodality imaging (MMI). Whilst echocardiography remains the primary imaging technique, the contemporary evaluation of patients with VHD requires comprehensive analysis of the mechanism of valvular dysfunction, accurate quantification of severity, and active exclusion extravalvular consequences. Furthermore, advances in surgical and percutaneous therapies have driven the need for meticulous multimodality imaging to aid in patient and procedural selection. Fundamental decision-making regarding whom, when, and how to treat patients with VHD has become more complex. There has been rapid technological advancement in MMI; many techniques are now available in routine clinical practice, and their integration into has the potential to truly individualize management strategies. This review provides an overview of the current evidence for the use of MMI in VHD, and how various techniques within each modality can be used practically to answer clinical conundrums.
Collapse
Affiliation(s)
- Anna Reid
- Department of Radiology and Cardiology, Center for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver V6Z1Y6, BC, Canada
| | - Philipp Blanke
- Department of Radiology and Cardiology, Center for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver V6Z1Y6, BC, Canada
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands
| | - Jonathon Leipsic
- Department of Radiology and Cardiology, Center for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver V6Z1Y6, BC, Canada
| |
Collapse
|
43
|
Eyharts D, Lavie-Badie Y, Cazalbou S, Fournier P, Cariou E, Pascal P, Campelo-Parada F, Marcheix B, Galinier M, Berry I, Carrié D, Lairez O. Quantitative assessment of tricuspid regurgitation using right and left ventricular stroke volumes obtained from tomographic equilibrium radionuclide ventriculography. J Nucl Cardiol 2021; 28:864-872. [PMID: 31201690 DOI: 10.1007/s12350-019-01781-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 05/30/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Quantitative assessment of valve regurgitation using volumetric method by comparing right and left ventricular stroke volumes is still under investigations. AIMS To investigate the accuracy of tomographic equilibrium radionuclide ventriculography (t-ERV) for the quantification of tricuspid regurgitation (TR). METHODS AND RESULTS Sixty-one patients (44 men; mean age 59 ± 12 years) who underwent both t-ERV and transthoracic echocardiography (TTE) studies within 2 weeks for right ventricular systolic function assessment were eligible for inclusion. A sub-group of 22 patients underwent both t-ERV and CMR. Patients with mitral/aortic regurgitation by TTE were excluded of the study. TR regurgitant volume (RVol) was calculated using the proximal isovelocity surface area (PISA) method from TTE and the volumetric method (right ventricular stroke volume minus left ventricular stroke volume) from t-ERV. There was a significant correlation between RVol as assess by ERV and by TTE (R = 0.95, P < 0.0001). Intraclass correlation coefficient between TTE and ERV for TR quantification was 0.95 (P < 0.0001). Among patients who underwent CMR, the correlation between RVol obtained by TTE and by t-ERV and CMR were R = 0.81 and R = 0.75, respectively (all P < 0.0001). CONCLUSION TR assessment using the t-ERV correlates well with PISA from TTE in patients referred for right ventricular systolic function assessment.
Collapse
Affiliation(s)
- Damien Eyharts
- Department of Cardiology, Rangueil University Hospital, Toulouse, France
- Cardiac Imaging Center, Toulouse University Hospital, Toulouse, France
- Heart Valve Center, Toulouse University Hospital, Toulouse, France
| | - Yoan Lavie-Badie
- Department of Cardiology, Rangueil University Hospital, Toulouse, France
- Cardiac Imaging Center, Toulouse University Hospital, Toulouse, France
- Department of Nuclear Medicine, Rangueil University Hospital, Toulouse, France
- Heart Valve Center, Toulouse University Hospital, Toulouse, France
| | - Stéphanie Cazalbou
- Department of Cardiology, Rangueil University Hospital, Toulouse, France
- Cardiac Imaging Center, Toulouse University Hospital, Toulouse, France
- Heart Valve Center, Toulouse University Hospital, Toulouse, France
| | - Pauline Fournier
- Department of Cardiology, Rangueil University Hospital, Toulouse, France
- Cardiac Imaging Center, Toulouse University Hospital, Toulouse, France
- Heart Valve Center, Toulouse University Hospital, Toulouse, France
| | - Eve Cariou
- Department of Cardiology, Rangueil University Hospital, Toulouse, France
- Cardiac Imaging Center, Toulouse University Hospital, Toulouse, France
- Medical School of Rangueil, University Paul Sabatier, Toulouse, France
- Heart Valve Center, Toulouse University Hospital, Toulouse, France
| | - Pierre Pascal
- Cardiac Imaging Center, Toulouse University Hospital, Toulouse, France
- Department of Nuclear Medicine, Rangueil University Hospital, Toulouse, France
| | - Francisco Campelo-Parada
- Department of Cardiology, Rangueil University Hospital, Toulouse, France
- Heart Valve Center, Toulouse University Hospital, Toulouse, France
| | - Bertrand Marcheix
- Medical School of Rangueil, University Paul Sabatier, Toulouse, France
- Heart Valve Center, Toulouse University Hospital, Toulouse, France
- Department of Cardiac Surgery, Rangueil University Hospital, Toulouse, France
| | - Michel Galinier
- Department of Cardiology, Rangueil University Hospital, Toulouse, France
- Cardiac Imaging Center, Toulouse University Hospital, Toulouse, France
- Medical School of Rangueil, University Paul Sabatier, Toulouse, France
- Heart Valve Center, Toulouse University Hospital, Toulouse, France
| | - Isabelle Berry
- Cardiac Imaging Center, Toulouse University Hospital, Toulouse, France
- Department of Nuclear Medicine, Rangueil University Hospital, Toulouse, France
- Medical School of Rangueil, University Paul Sabatier, Toulouse, France
| | - Didier Carrié
- Department of Cardiology, Rangueil University Hospital, Toulouse, France
- Cardiac Imaging Center, Toulouse University Hospital, Toulouse, France
- Medical School of Purpan, University Paul Sabatier, Toulouse, France
- Heart Valve Center, Toulouse University Hospital, Toulouse, France
| | - Olivier Lairez
- Department of Cardiology, Rangueil University Hospital, Toulouse, France.
- Cardiac Imaging Center, Toulouse University Hospital, Toulouse, France.
- Department of Nuclear Medicine, Rangueil University Hospital, Toulouse, France.
- Medical School of Rangueil, University Paul Sabatier, Toulouse, France.
- Heart Valve Center, Toulouse University Hospital, Toulouse, France.
| |
Collapse
|
44
|
Zheng R, Kusunose K. Review: application of current imaging modalities in the management of left-sided valvular heart disease. Cardiovasc Diagn Ther 2021; 11:793-803. [PMID: 34295706 DOI: 10.21037/cdt.2020.02.04] [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: 11/25/2019] [Accepted: 01/31/2020] [Indexed: 11/06/2022]
Abstract
In terms of valvular heart disease (VHD) imaging, transthoracic echocardiography (TTE) is the preferred first choice because of its widespread availability. Other modalities, such as transesophageal echocardiography, computed tomography and magnetic resonance imaging, have played a supplementary role in diagnosis for severity, deciding the timing/type of treatment, detection of post procedural complications, and prognostic predictions. However, there are few consensuses on how to employ these modalities, as the evidence is not extensive as that for TTE. On the other hand, these imaging modalities also have their own unique strengths. If employed properly, these modalities have the potential to play a more prominent role in clinical decision making. In this review, we focus on the potential, limitations and application of current imaging modalities in the management of left-sided VHD.
Collapse
Affiliation(s)
- Robert Zheng
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Kenya Kusunose
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan
| |
Collapse
|
45
|
Abstract
Purpose of Review The purpose of this review is to summarize the application of cardiac magnetic resonance (CMR) in the diagnostic and prognostic evaluation of patients with heart failure (HF). Recent Findings CMR is an important non-invasive imaging modality in the assessment of ventricular volumes and function and in the analysis of myocardial tissue characteristics. The information derived from CMR provides a comprehensive evaluation of HF. Its unique ability of tissue characterization not only helps to reveal the underlying etiologies of HF but also offers incremental prognostic information. Summary CMR is a useful non-invasive tool for the diagnosis and assessment of prognosis in patients suffering from heart failure.
Collapse
Affiliation(s)
- Chuanfen Liu
- Cardiovascular Division, Department of Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA USA
- Department of Cardiology, Peking University People’s Hospital, Beijing, China
| | - Victor A. Ferrari
- Cardiovascular Division, Department of Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA USA
| | - Yuchi Han
- Cardiovascular Division, Department of Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA USA
| |
Collapse
|
46
|
Garcia J, Beckie K, Hassanabad AF, Sojoudi A, White JA. Aortic and mitral flow quantification using dynamic valve tracking and machine learning: Prospective study assessing static and dynamic plane repeatability, variability and agreement. JRSM Cardiovasc Dis 2021; 10:2048004021999900. [PMID: 33717471 PMCID: PMC7923984 DOI: 10.1177/2048004021999900] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/02/2021] [Accepted: 02/08/2021] [Indexed: 11/15/2022] Open
Abstract
Background Blood flow is a crucial measurement in the assessment of heart valve disease. Time-resolved flow using magnetic resonance imaging (4 D flow MRI) can provide a comprehensive assessment of heart valve hemodynamics but it relies in manual plane analysis. In this study, we aimed to demonstrate the feasibility of automate the detection and tracking of aortic and mitral valve planes to assess blood flow from 4 D flow MRI. Methods In this prospective study, a total of n = 106 subjects were enrolled: 19 patients with mitral disease, 65 aortic disease patients and 22 healthy controls. Machine learning was employed to detect aortic and mitral location and motion in a cine three-chamber plane and a perpendicular projection was co-registered to the 4 D flow MRI dataset to quantify flow volume, regurgitant fraction, and a peak velocity. Static and dynamic plane association and agreement were evaluated. Intra- and inter-observer, and scan-rescan reproducibility were also assessed. Results Aortic regurgitant fraction was elevated in aortic valve disease patients as compared with controls and mitral valve disease patients (p < 0.05). Similarly, mitral regurgitant fraction was higher in mitral valve patients (p < 0.05). Both aortic and mitral total flow were high in aortic patients. Static and dynamic were good (r > 0.6, p < 0.005) for aortic total flow and peak velocity, and mitral peak velocity and regurgitant fraction. All measurements showed good inter- and intra-observer, and scan-rescan reproducibility. Conclusion We demonstrated that aortic and mitral hemodynamics can efficiently be quantified from 4 D flow MRI using assisted valve detection with machine learning.
Collapse
Affiliation(s)
- Julio Garcia
- Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada.,Department of Radiology, University of Calgary, Calgary, AB, Canada.,Stephenson Cardiac Imaging Centre, University of Calgary, AB, Canada.,Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada.,Alberta Children's Hospital Research Institute, Calgary, AB, Canada
| | - Kailey Beckie
- Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada.,Department of Radiology, University of Calgary, Calgary, AB, Canada.,Stephenson Cardiac Imaging Centre, University of Calgary, AB, Canada.,Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
| | - Ali F Hassanabad
- Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada.,Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Alireza Sojoudi
- Circle Cardiovascular Imaging, Advanced Technologies, Calgary, AB, Canada
| | - James A White
- Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada.,Stephenson Cardiac Imaging Centre, University of Calgary, AB, Canada
| |
Collapse
|
47
|
Quantification of regurgitation in mitral valve prolapse with automated real time echocardiographic 3D proximal isovelocity surface area: multimodality consistency and role of eccentricity index. Int J Cardiovasc Imaging 2021; 37:1947-1959. [PMID: 33616785 PMCID: PMC8255267 DOI: 10.1007/s10554-021-02179-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 01/30/2021] [Indexed: 10/25/2022]
Abstract
Three-dimensional transthoracic echocardiography (3D-TTE) provides a semi-automated proximal isovelocity surface area method (3D-PISA) to obtain quantitative parameters. Data assessing regurgitation severity in mitral valve prolapse (MVP) are scarce, so we assessed the 3D-PISA method compared with 2D-PISA and cardiovascular magnetic resonance (CMR) and the role of an eccentricity index. We evaluated the 3D-PISA method for assessing MR in 54 patients with MVP (57 ± 14 years; 42 men; 12 mild/mild-moderate; 12 moderate-severe; and 30 severe MR). Role of an asymmetric (i.e. eccentricity index ≥ 1.25) flow convergence region (FCR) and inter-modality consistency were then assessed. 3D-PISA derived regurgitant volume (RVol) showed a good correlation with 2D-PISA and CMR derived parameters (r = 0.86 and r = 0.81, respectively). The small mean differences with 2D-PISA derived RVol did not reach statistical significance in overall population (5.7 ± 23 ml, 95% CI - 0.6 to 12; p = 0.08) but differed in those with asymmetric 3D-FCR (n = 21; 2D-PISA: 72 ± 36 ml vs. 3D-PISA: 93 ± 47 ml; p = 0.001). RVol mean values were higher using PISA methods (CMR 57 ± 33 ml; 2D-PISA 73 ± 39 ml; and 3D-PISA 79 ± 45 ml) and an overestimation was observed when CMR was used as reference (2D-PISA vs. CMR: mean difference: 15.8 ml [95% CI 10-22, p < 0.001]; and 3D-PISA vs. CMR: 21.5 ml [95% CI 14-29, p < 0.001]). Intra- and inter-observer reliability was excellent (ICC 0.91-0.99), but with numerically lower coefficient of variation for 3D-PISA (8%-10% vs. 2D-PISA: 12%-16%). 3D-PISA method for assessing regurgitation in MVP may enable analogous evaluation compared to standard 2D-PISA, but with overestimation in case of asymmetric FCR or when CMR is used as reference method.
Collapse
|
48
|
Lopes BBC, Kwon DH, Shah DJ, Lesser JR, Bapat V, Enriquez-Sarano M, Sorajja P, Cavalcante JL. Importance of Myocardial Fibrosis in Functional Mitral Regurgitation: From Outcomes to Decision-Making. JACC Cardiovasc Imaging 2021; 14:867-878. [PMID: 33582069 DOI: 10.1016/j.jcmg.2020.10.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/19/2020] [Accepted: 10/08/2020] [Indexed: 12/27/2022]
Abstract
Functional mitral regurgitation (FMR) is a common and complex valve disease, in which severity and risk stratification is still a conundrum. Although risk increases with FMR severity, it is modulated by subjacent left ventricular (LV) disease. The extent of LV remodeling and dysfunction is traditionally evaluated by echocardiography, but a growing body of evidence shows that myocardial fibrosis (MF) assessment by cardiac magnetic resonance (CMR) may complement risk stratification and inform treatment decisions. This review summarizes the current knowledge on the comprehensive evaluation that CMR can provide for patients with FMR, in particular for the assessment of MF and its potential impact in clinical decision-making.
Collapse
Affiliation(s)
- Bernardo B C Lopes
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Deborah H Kwon
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Dipan J Shah
- Houston Methodist Debakey Heart & Vascular Center, Houston, Texas, USA
| | - John R Lesser
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA; Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Vinayak Bapat
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA; Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Maurice Enriquez-Sarano
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA; Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Paul Sorajja
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA; Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - João L Cavalcante
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA; Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA; Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA.
| |
Collapse
|
49
|
Fidock B, Archer G, Barker N, Elhawaz A, Al-Mohammad A, Rothman A, Hose R, Hall IR, Grech E, Briffa N, Lewis N, van der Geest RJ, Zhang JM, Zhong L, Swift AJ, Wild JM, De Gárate E, Bucciarelli-Ducci C, Bax JJ, Plein S, Myerson S, Garg P. Standard and emerging CMR methods for mitral regurgitation quantification. Int J Cardiol 2021; 331:316-321. [PMID: 33548381 PMCID: PMC8040969 DOI: 10.1016/j.ijcard.2021.01.066] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 01/04/2021] [Accepted: 01/27/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND There are several methods to quantify mitral regurgitation (MR) by cardiovascular magnetic resonance (CMR). The interoperability of these methods and their reproducibility remains undetermined. OBJECTIVE To determine the agreement and reproducibility of different MR quantification methods by CMR across all aetiologies. METHODS Thirty-five patients with MR were recruited (primary MR = 12, secondary MR = 10 and MVR = 13). Patients underwent CMR, including cines and four-dimensional flow (4D flow). Four methods were evaluated: MRStandard (left ventricular stroke volume - aortic forward flow by phase contrast), MRLVRV (left ventricular stroke volume - right ventricular stroke volume), MRJet (direct jet quantification by 4D flow) and MRMVAV (mitral forward flow by 4D flow - aortic forward flow by 4D flow). For all cases and MR types, 520 MR volumes were recorded by these 4 methods for intra-/inter-observer tests. RESULTS In primary MR, MRMVAV and MRLVRV were comparable to MRStandard (P > 0.05). MRJet resulted in significantly higher MR volumes when compared to MRStandard (P < 0.05) In secondary MR and MVR cases, all methods were comparable. In intra-observer tests, MRMVAV demonstrated least bias with best limits of agreement (bias = -0.1 ml, -8 ml to 7.8 ml, P = 0.9) and best concordance correlation coefficient (CCC = 0.96, P < 0.01). In inter-observer tests, for primary MR and MVR, least bias and highest CCC were observed for MRMVAV. For secondary MR, bias was lowest for MRJet (-0.1 ml, PNS). CONCLUSION CMR methods of MR quantification demonstrate agreement in secondary MR and MVR. In primary MR, this was not observed. Across all types of MR, MRMVAV quantification demonstrated the highest reproducibility and consistency.
Collapse
Affiliation(s)
| | | | | | | | - Abdallah Al-Mohammad
- University of Sheffield, Sheffield, UK; Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - Rod Hose
- University of Sheffield, Sheffield, UK
| | - Ian R Hall
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Ever Grech
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Norman Briffa
- University of Sheffield, Sheffield, UK; Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Nigel Lewis
- University of Sheffield, Sheffield, UK; Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | | | | | | | | | | | | | - Jeroen J Bax
- Leiden University Medical Centre, Leiden, the Netherlands
| | | | | | | |
Collapse
|
50
|
Cardiovascular Magnetic Resonance in Valvular Heart Disease-Related Heart Failure. Heart Fail Clin 2021; 17:103-108. [PMID: 33220879 DOI: 10.1016/j.hfc.2020.09.002] [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] [Indexed: 11/23/2022]
Abstract
Patients with valvular heart disease-related heart failure are unable to pump enough blood to meet the body's needs. Magnetic resonance imaging (MRI) can play an important role by identifying these patients and distinguishing them from patients whose valvular disease is not the cause of their heart failure. Heart failure is a major public health problem, with a prevalence of 5.8 million people in the United States and more than 223 million people worldwide. This article focuses on the diagnostic and prognostic value of MRI patients with valvular causes of heart failure.
Collapse
|