1
|
Mangini F, Scarcia M, Biederman RWW, Calbi R, Spinelli F, Casavecchia G, Brunetti ND, Gravina M, Fiore C, Suma S, Milo M, Turchetti C, Pesce E, Caramia R, Lombardi F, Grimaldi M. Cardiac magnetic resonance imaging in the evaluation and management of mitral valve prolapse - a comprehensive review. Echocardiography 2024; 41:e15894. [PMID: 39078395 DOI: 10.1111/echo.15894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Revised: 07/01/2024] [Accepted: 07/05/2024] [Indexed: 07/31/2024] Open
Abstract
Mitral valve prolapse is a common valve disorder that usually has a benign prognosis unless there is significant regurgitation or LV impairment. However, a subset of patients are at an increased risk of ventricular arrhythmias and sudden cardiac death, which has led to the recognition of "arrhythmic mitral valve prolapse" as a clinical entity. Emerging risk factors include mitral annular disjunction and myocardial fibrosis. While echocardiography remains the primary method of evaluation, cardiac magnetic resonance has become crucial in managing this condition. Cine magnetic resonance sequences provide accurate characterization of prolapse and annular disjunction, assessment of ventricular volumes and function, identification of early dysfunction and remodeling, and quantitative assessment of mitral regurgitation when integrated with flow imaging. However, the unique strength of magnetic resonance lies in its ability to identify tissue changes. T1 mapping sequences identify diffuse fibrosis, in turn related to early ventricular dysfunction and remodeling. Late gadolinium enhancement sequences detect replacement fibrosis, an independent risk factor for ventricular arrhythmias and sudden cardiac death. There are consensus documents and reviews on the use of cardiac magnetic resonance specifically in arrhythmic mitral valve prolapse. However, in this article, we propose an algorithm for the broader use of cardiac magnetic resonance in managing this condition in various scenarios. Future advancements may involve implementing techniques for tissue characterization and flow analysis, such as 4D flow imaging, to identify patients with ventricular dysfunction and remodeling, increased arrhythmic risk, and more accurate grading of mitral regurgitation, ultimately benefiting patient selection for surgical therapy.
Collapse
Affiliation(s)
- Francesco Mangini
- Department of Cardiology, Ospedale Regionale "Miulli", Acquaviva delle Fonti, BA, Italy
| | - Maria Scarcia
- Department of Cardiology, Ospedale Regionale "Miulli", Acquaviva delle Fonti, BA, Italy
| | - Robert W W Biederman
- Cardiology Department, Roper St Francis Healthcare, Charleston, South Carolina, USA
| | - Roberto Calbi
- Department of Cardiology, Ospedale Regionale "Miulli", Acquaviva delle Fonti, BA, Italy
| | - Francesco Spinelli
- Department of Cardiology, Ospedale Regionale "Miulli", Acquaviva delle Fonti, BA, Italy
| | | | | | - Matteo Gravina
- Radiology Department, University of Foggia, Foggia, Italy
| | - Corrado Fiore
- Department of Cardiology, Citta di Lecce Hospital, Novoli (Lecce), Puglia, Italy
| | - Sergio Suma
- Department of Cardiology, Azienda Ospedaliero Universitaria di Parma, Parma, Italy
| | - Maria Milo
- Department of Cardiology, Ospedale "Di Summa - Perrino," ASL Br, Brindisi, Italy
| | | | - Ernesto Pesce
- Madonna della Bruna Outpatients Clinic, Matera, Italy
| | - Remo Caramia
- Department of Anesthesiology, Ospedale "Camberlingo," ASL Br, Francavilla Fontana, Italy
| | - Francesca Lombardi
- Department of Cardiovascular Sciences, Università Cattolica del Sacro Cuore, Milano, Lombardia, Italy
| | - Massimo Grimaldi
- Department of Cardiology, Ospedale Regionale "Miulli", Acquaviva delle Fonti, BA, Italy
| |
Collapse
|
2
|
Esposito A, Gatti M, Trivieri MG, Agricola E, Peretto G, Gallone G, Catapano F, Pradella S, Devesa A, Bruno E, Fiore G, Francone M, Palmisano A. Imaging for the assessment of the arrhythmogenic potential of mitral valve prolapse. Eur Radiol 2024; 34:4243-4260. [PMID: 38078997 PMCID: PMC11164824 DOI: 10.1007/s00330-023-10413-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 10/04/2023] [Accepted: 10/09/2023] [Indexed: 05/18/2024]
Abstract
Mitral valve prolapse (MVP) is the most common valve disease in the western world and recently emerged as a possible substrate for sudden cardiac death (SCD). It is estimated an annual risk of sudden cardiac death of 0.2 to 1.9% mostly caused by complex ventricular arrhythmias (VA). Several mechanisms have been recognized as potentially responsible for arrhythmia onset in MVP, resulting from the combination of morpho-functional abnormality of the mitral valve, structural substrates (regional myocardial hypertrophy, fibrosis, Purkinje fibers activity, inflammation), and mechanical stretch. Echocardiography plays a central role in MVP diagnosis and assessment of severity of regurgitation. Several abnormalities detectable by echocardiography can be prognostic for the occurrence of VA, from morphological alteration including leaflet redundancy and thickness, mitral annular dilatation, and mitral annulus disjunction (MAD), to motion abnormalities detectable with "Pickelhaube" sign. Additionally, speckle-tracking echocardiography may identify MVP patients at higher risk for VA by detection of increased mechanical dispersion. On the other hand, cardiac magnetic resonance (CMR) has the capability to provide a comprehensive risk stratification combining the identification of morphological and motion alteration with the detection of myocardial replacement and interstitial fibrosis, making CMR an ideal method for arrhythmia risk stratification in patients with MVP. Finally, recent studies have suggested a potential role in risk stratification of new techniques such as hybrid PET-MR and late contrast enhancement CT. The purpose of this review is to provide an overview of the mitral valve prolapse syndrome with a focus on the role of imaging in arrhythmic risk stratification. CLINICAL RELEVANCE STATEMENT: Mitral valve prolapse is the most frequent valve condition potentially associated with arrhythmias. Imaging has a central role in the identification of anatomical, functional, mechanical, and structural alterations potentially associated with a higher risk of developing complex ventricular arrhythmia and sudden cardiac death. KEY POINTS: • Mitral valve prolapse is a common valve disease potentially associated with complex ventricular arrhythmia and sudden cardiac death. • The mechanism of arrhythmogenesis in mitral valve prolapse is complex and multifactorial, due to the interplay among multiple conditions including valve morphological alteration, mechanical stretch, myocardial structure remodeling with fibrosis, and inflammation. • Cardiac imaging, especially echocardiography and cardiac magnetic resonance, is crucial in the identification of several features associated with the potential risk of serious cardiac events. In particular, cardiac magnetic resonance has the advantage of being able to detect myocardial fibrosis which is currently the strongest prognosticator.
Collapse
Affiliation(s)
- Antonio Esposito
- Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Milan, Italy.
- School of Medicine, Università Vita-Salute San Raffaele, Milan, Italy.
| | - Marco Gatti
- Radiology Unit, Department of Surgical Sciences, AOU Città Della Salute E Della Scienza Di Torino, University of Turin, Turin, Italy
| | - Maria Giovanna Trivieri
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Eustachio Agricola
- School of Medicine, Università Vita-Salute San Raffaele, Milan, Italy
- Cardiovascular Imaging Unit, Cardiothoracic Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Peretto
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Guglielmo Gallone
- Città Della Salute E Della Scienza, University of Turin, Turin, Italy
| | - Federica Catapano
- IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Silvia Pradella
- Department of Emergency Radiology, University Hospital Careggi, Florence, Italy
| | - Ana Devesa
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Elisa Bruno
- School of Medicine, Università Vita-Salute San Raffaele, Milan, Italy
| | - Giorgio Fiore
- Cardiovascular Imaging Unit, Cardiothoracic Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Francone
- IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Anna Palmisano
- Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Università Vita-Salute San Raffaele, Milan, Italy
| |
Collapse
|
3
|
Tang X, Fan W. The Association Between Late Gadolinium Enhancement by Cardiac Magnetic Resonance and Ventricular Arrhythmia in Patients With Mitral Valve Prolapse: A Systematic Review and Meta-Analysis. Clin Cardiol 2024; 47:e24316. [PMID: 38958255 PMCID: PMC11220671 DOI: 10.1002/clc.24316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 06/08/2024] [Accepted: 06/18/2024] [Indexed: 07/04/2024] Open
Abstract
INTRODUCTION Malignant ventricular arrhythmia (VA) and sudden cardiac death (SCD) have been reported in patients with mitral valve prolapse (MVP); however, effective risk stratification methods are still lacking. Myocardial fibrosis is thought to play an important role in the development of VA; however, observational studies have produced contradictory findings regarding the relationship between VA and late gadolinium enhancement (LGE) in MVP patients. The aim of this meta-analysis and systematic review of observational studies was to investigate the association between left ventricular LGE and VA in patients with MVP. METHODS We searched the PubMed, Embase, and Web of Science databases from 1993 to 2023 to identify case-control, cross-sectional, and cohort studies that compared the incidence of VA in patients with MVP who had left ventricular LGE and those without left ventricular LGE. RESULTS A total of 1464 subjects with MVP from 12 observational studies met the eligibility criteria. Among them, VA episodes were reported in 221 individuals (15.1%). Meta-analysis demonstrated that the presence of left ventricular LGE was significantly associated with an increased risk of VA (pooled risk ratio 2.96, 95% CI: 2.26-3.88, p for heterogeneity = 0.07, I2 = 40%). However, a meta-regression analysis of the prevalence of mitral regurgitation (MR) showed that the severity of MR did not significantly affect the association between the occurrence of LGE and VA (p = 0.079). CONCLUSION The detection of LGE could be helpful for stratifying the risk of VA in patients with MVP.
Collapse
Affiliation(s)
- Xiaofu Tang
- The Second Affiliated Hospital, Jiangxi Medical CollegeNanchang UniversityNanchangJiangxiChina
| | - Weiguo Fan
- Department of Cardiovascular Medicine, The Second Affiliated Hospital, Jiangxi Medical CollegeNanchang UniversityNanchangJiangxiChina
| |
Collapse
|
4
|
Azzola Guicciardi N, Ascione G, Alfieri O, Maisano F, De Bonis M. When annuloplasty is not enough: a case report of ventricular arrhythmias stepwise abolition after mitral valve re-repair. Eur Heart J Case Rep 2024; 8:ytae305. [PMID: 39006214 PMCID: PMC11245692 DOI: 10.1093/ehjcr/ytae305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/09/2024] [Accepted: 06/04/2024] [Indexed: 07/16/2024]
Abstract
Background Some patients affected by mitral valve (MV) prolapse (MVP) are at higher risk of ventricular arrhythmias (VAs), but the underlying pathogenesis, as well as the effects of surgery on VA, remain not fully understood. Mitral valve repair, however, represents a privileged point of view to deepen the understanding of arrhythmogenesis in this context. Hence, we report an interesting case of MV re-repair. Case summary A 52-year-old man was referred to our institution for severe mitral regurgitation (MR) due to P2 prolapse in the context of myxomatous MV degeneration. Pre-operative imaging showed systolic mitral annular disjunction, left ventricular (LV) wall curling, Pickelhaube's sign, and a prolapsing tricuspid valve (TV) with only mild regurgitation. Twenty-four-hour electrocardiogram (ECG) Holter revealed a significant burden of premature ventricular contractions (PVCs), most of them originating from anterior papillary muscle (APM), posterior papillary muscle (PPM), and mitral annulus (MA). Quadrangular resection of P2 and mitral annuloplasty were performed. One year later, relapse of severe MR due to a residual P2M1 prolapse occurred. Twenty-four-hour ECG Holter showed no PVCs from PPM and MA, while those from APM persisted. A central edge-to-edge repair was effectively used to fix the residual prolapse. After 1 year from REDO surgery, a third ECG Holter confirmed the absence of any remaining LV PVCs, but still few ectopic beats originating from TV were recorded. Discussion Here, we report a case of VA resolution after specific, anatomical triggers addressing surgical gestures. Our experience confirms that MV surgery may have a role in MVP patients' arrhythmias correction.
Collapse
Affiliation(s)
- Nicolò Azzola Guicciardi
- Department of Cardiac Surgery-Valve Center-IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy
| | - Guido Ascione
- Department of Cardiac Surgery-Valve Center-IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy
| | - Ottavio Alfieri
- Department of Cardiac Surgery-Valve Center-IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy
| | - Francesco Maisano
- Department of Cardiac Surgery-Valve Center-IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy
| | - Michele De Bonis
- Department of Cardiac Surgery-Valve Center-IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy
| |
Collapse
|
5
|
Brugiatelli L, Rolando M, Lofiego C, Fogante M, Capodaglio I, Patani F, Tofoni P, Maurizi K, Nazziconi M, Massari A, Furlani G, Signore G, Esposto Pirani P, Schicchi N, Dello Russo A, Di Eusanio M, Vagnarelli F. Transcatheter Mitral Valve Intervention: Current and Future Role of Multimodality Imaging for Device Selection and Periprocedural Guidance. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1082. [PMID: 39064511 PMCID: PMC11278759 DOI: 10.3390/medicina60071082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2024] [Revised: 06/26/2024] [Accepted: 06/29/2024] [Indexed: 07/28/2024]
Abstract
Mitral regurgitation (MR) is a broadly diffuse valvular heart disease (VHD) with a significant impact on the healthcare system and patient prognosis. Transcatheter mitral valve interventions (TMVI) are now well-established techniques included in the therapeutic armamentarium for managing patients with mitral regurgitation, either primary or functional MR. Even if the guidelines give indications regarding the correct management of this VHD, the wide heterogeneity of patients' clinical backgrounds and valvular and heart anatomies make each patient a unique case, in which the appropriate device's selection requires a multimodal imaging evaluation and a multidisciplinary discussion. Proper pre-procedural evaluation plays a pivotal role in judging the feasibility of TMVI, while a cooperative work between imagers and interventionalist is also crucial for procedural success. This manuscript aims to provide an exhaustive overview of the main parameters that need to be evaluated for appropriate device selection, pre-procedural planning, intra-procedural guidance and post-operative assessment in the setting of TMVI. In addition, it tries to give some insights about future perspectives for structural cardiovascular imaging.
Collapse
Affiliation(s)
- Leonardo Brugiatelli
- “G.M. Lancisi” Cardiovascular Center, 60126 Ancona, Italy
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60121 Ancona, Italy
| | - Marco Rolando
- “G.M. Lancisi” Cardiovascular Center, 60126 Ancona, Italy
| | - Carla Lofiego
- “G.M. Lancisi” Cardiovascular Center, 60126 Ancona, Italy
| | - Marco Fogante
- Maternal-Child, Senological, Cardiological Radiology and Outpatient Ultrasound, Department of Radiological Sciences, University Hospital of Marche, 60126 Ancona, Italy
| | | | | | - Paolo Tofoni
- “G.M. Lancisi” Cardiovascular Center, 60126 Ancona, Italy
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60121 Ancona, Italy
| | - Kevin Maurizi
- “G.M. Lancisi” Cardiovascular Center, 60126 Ancona, Italy
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60121 Ancona, Italy
| | - Marco Nazziconi
- “G.M. Lancisi” Cardiovascular Center, 60126 Ancona, Italy
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60121 Ancona, Italy
| | - Arianna Massari
- “G.M. Lancisi” Cardiovascular Center, 60126 Ancona, Italy
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60121 Ancona, Italy
| | - Giulia Furlani
- “G.M. Lancisi” Cardiovascular Center, 60126 Ancona, Italy
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60121 Ancona, Italy
| | - Giovanni Signore
- Department of Transalational Medical Sciences, University of Campania “Luigi Vanvitelli”, 80131 Naples, Italy
| | - Paolo Esposto Pirani
- Maternal-Child, Senological, Cardiological Radiology and Outpatient Ultrasound, Department of Radiological Sciences, University Hospital of Marche, 60126 Ancona, Italy
| | - Nicolò Schicchi
- Cardiovascular Radiological Diagnostics, Department of Radiological Sciences, University Hospital of Marche, 60126 Ancona, Italy
| | - Antonio Dello Russo
- “G.M. Lancisi” Cardiovascular Center, 60126 Ancona, Italy
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60121 Ancona, Italy
| | - Marco Di Eusanio
- Cardiac Surgery Department, Polytechnic University of Marche, AOU delle Marche, 60121 Ancona, Italy
| | | |
Collapse
|
6
|
Badau Riebel CI, Agoston-Coldea L. Left Ventricular Fibrosis by Cardiac Magnetic Resonance Tissue Characterization in Chronic Mitral Regurgitation Patients. J Clin Med 2024; 13:3877. [PMID: 38999443 PMCID: PMC11242255 DOI: 10.3390/jcm13133877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 06/20/2024] [Accepted: 06/26/2024] [Indexed: 07/14/2024] Open
Abstract
Background: Left ventricular remodeling in chronic mitral regurgitation (MR) encompasses two types of myocardial fibrosis: replacement fibrosis, identified by late gadolinium enhancement (LGE), and diffuse interstitial fibrosis, assessed by pre- and postcontrast T1 mapping techniques. These may explain irreversible LV dysfunction after MR correction. We aimed to assess the presence of myocardial fibrosis in patients with moderate and severe MR with no criteria for surgery versus mild MR controls. Methods: We enrolled 137 patients with chronic primary MR and 130 controls; all underwent cardiac magnetic resonance, and were followed up in a median of 2.9 years to assess mortality and the need for mitral valve replacement. Results: Patients in the study group displayed significantly higher degrees of LGE (28.4% vs 7.69%, p < 0.05), higher native T1 values (1167 ± 58.5 versus 971 ± 51.4 (p < 0.05)), and higher extracellular volumes compared to controls (32.3% ± 3.5 versus 23.9 ± 2.2, (p < 0.05)). The composite outcome occurred in 28 patients in the study group (20.4%), and significantly higher with LGE+ (78.5%). Replacement fibrosis (HR = 1.83, 95% CI, p < 0.01) and interstitial fibrosis (HR = 1.61, 95% CI, p < 0.01) were independent predictors for the composite outcome. Conclusions: Patients with moderate and severe MR with no criteria for surgery still exhibit a significant degree of both replacement and interstitial fibrosis, with prognostic implications.
Collapse
Affiliation(s)
| | - Lucia Agoston-Coldea
- Department of Cardiology, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400347 Cluj Napoca, Romania;
- Department of Internal Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400347 Cluj Napoca, Romania
| |
Collapse
|
7
|
Darwish A, Bersali A, Saeed M, Dhore A, Maragiannis D, El-Tallawi KC, Shah DJ. Assessing Regurgitation Severity, Adverse Remodeling, and Fibrosis with CMR in Primary Mitral Regurgitation. Curr Cardiol Rep 2024; 26:705-715. [PMID: 38748329 DOI: 10.1007/s11886-024-02069-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2024] [Indexed: 07/11/2024]
Abstract
PURPOSE OF REVIEW This review offers an evidence-based analysis of established and emerging cardiovascular magnetic resonance (CMR) techniques used to assess the severity of primary mitral regurgitation (MR), identify adverse cardiac remodeling and its prognostic effect. The aim is to provide different insights regarding clinical decision-making and enhance the clinical outcomes of patients with MR. RECENT FINDINGS Cardiac remodeling and myocardial replacement fibrosis are observed frequently in the presence of substantial LV volume overload, particularly in cases with severe primary MR. CMR serves as a useful diagnostic imaging modality in assessing mitral regurgitation severity, early detection of cardiac remodeling, myocardial dysfunction, and myocardial fibrosis, enabling timely intervention before irreversible damage ensues. Incorporating myocardial remodeling in terms of left ventricular (LV) dilatation and myocardial fibrosis with quantitative MR severity assessment by CMR may assist in defining optimal timing of intervention.
Collapse
Affiliation(s)
- Amr Darwish
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin, suite 1801, Houston, TX, 77030, USA
| | - Akila Bersali
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin, suite 1801, Houston, TX, 77030, USA
| | - Mujtaba Saeed
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin, suite 1801, Houston, TX, 77030, USA
| | - Aneesh Dhore
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin, suite 1801, Houston, TX, 77030, USA
| | - Dimitrios Maragiannis
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin, suite 1801, Houston, TX, 77030, USA
| | - K Carlos El-Tallawi
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin, suite 1801, Houston, TX, 77030, USA
| | - Dipan J Shah
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin, suite 1801, Houston, TX, 77030, USA.
| |
Collapse
|
8
|
Sabbag A, Aabel EW, Castrini AI, Siontis KC, Laredo M, Nizard J, Duthoit G, Asirvatham S, Sehrawat O, Kirkels FP, van Rosendael PJ, Beinart R, Acha MR, Peichl P, Lim HS, Sohns C, Martins R, Font J, Truong NNK, Estensen M, Haugaa KH. Mitral valve prolapse: arrhythmic risk during pregnancy and postpartum. Eur Heart J 2024; 45:1831-1839. [PMID: 38740526 PMCID: PMC11129793 DOI: 10.1093/eurheartj/ehae224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 02/02/2024] [Accepted: 03/26/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND AND AIMS Arrhythmic mitral valve prolapse (AMVP) is linked to life-threatening ventricular arrhythmias (VAs), and young women are considered at high risk. Cases of AMVP in women with malignant VA during pregnancy have emerged, but the arrhythmic risk during pregnancy is unknown. The authors aimed to describe features of women with high-risk AMVP who developed malignant VA during the perinatal period and to assess if pregnancy and the postpartum period were associated with a higher risk of malignant VA. METHODS This retrospective international multi-centre case series included high-risk women with AMVP who experienced malignant VA and at least one pregnancy. Malignant VA included ventricular fibrillation, sustained ventricular tachycardia, or appropriate shock from an implantable cardioverter defibrillator. The authors compared the incidence of malignant VA in non-pregnant periods and perinatal period; the latter defined as occurring during pregnancy and within 6 months after delivery. RESULTS The authors included 18 women with AMVP from 11 centres. During 7.5 (interquartile range 5.8-16.6) years of follow-up, 37 malignant VAs occurred, of which 18 were pregnancy related occurring in 13 (72%) unique patients. Pregnancy and 6 months after delivery showed increased incidence rate of malignant VA compared to the non-pregnancy period (univariate incidence rate ratio 2.66, 95% confidence interval 1.23-5.76). CONCLUSIONS The perinatal period could impose increased risk of malignant VA in women with high-risk AMVP. The data may provide general guidance for pre-conception counselling and for nuanced shared decision-making between patients and clinicians.
Collapse
Affiliation(s)
- Avi Sabbag
- Sheba Medical Centre, Ramat-Gan, affiliated with the School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eivind W Aabel
- ProCardio Center for Research Based Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, and University of Oslo, Sognsvannsveien 20, 0372 Oslo, Norway
| | - Anna Isotta Castrini
- ProCardio Center for Research Based Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, and University of Oslo, Sognsvannsveien 20, 0372 Oslo, Norway
| | | | - Mikael Laredo
- Sorbonne Université, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Jacky Nizard
- Sorbonne Université, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Guillaume Duthoit
- Sorbonne Université, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Samuel Asirvatham
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ojasay Sehrawat
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Feddo P Kirkels
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | | | - Roy Beinart
- Sheba Medical Centre, Ramat-Gan, affiliated with the School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Rav Acha
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Petr Peichl
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Han S Lim
- Austin and Northern Health, University of Melbourne, Melbourne, Australia
| | - Christian Sohns
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | | | - Jonaz Font
- LTSI, Rennes University Hospital, Rennes, France
| | - Nguyen N K Truong
- Department of Interventional Cardiology, Medical University Center of Ho Chi Minh City, Ho Chi Minh, Vietnam
| | - Mette Estensen
- ProCardio Center for Research Based Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, and University of Oslo, Sognsvannsveien 20, 0372 Oslo, Norway
| | - Kristina H Haugaa
- ProCardio Center for Research Based Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, and University of Oslo, Sognsvannsveien 20, 0372 Oslo, Norway
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
9
|
Holte E, Podlesnikar T, Carvalho F, Demirkiran A, Manka R, Martínez GG, Michalski B, Pasquet A, Separovic Hanzevacki J, Soliman-Aboumarie H, Shruti JS, Haugaa KH, Dweck MR. European Association of Cardiovascular Imaging survey on the evaluation of mitral regurgitation. Eur Heart J Cardiovasc Imaging 2024; 25:573-578. [PMID: 38387435 PMCID: PMC11057920 DOI: 10.1093/ehjci/jeae053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 02/24/2024] Open
Abstract
AIMS To evaluate the diagnosis and imaging of patients with mitral regurgitation (MR) and the management in routine clinical practice across Europe, the European Association of Cardiovascular Imaging Scientific Initiatives Committee performed a survey across European centres. In particular, the routine use of echocardiography, advanced imaging modalities, heart valve clinics, and heart valve teams was explored. METHODS AND RESULTS A total of 61 responders, mainly from tertiary centres or university hospitals, from 26 different countries responded to the survey, which consisted of 22 questions. For most questions related to echocardiography and advanced imaging, the answers were relatively homogeneous and demonstrated good adherence to current recommendations. In particular, the centres used a multi-parametric echocardiographic approach and selected the effective regurgitant orifice and vena contracta width as their preferred assessments. 2D measurements are still the most widely used parameters to assess left ventricular structure; however, the majority use 3D trans-oesophageal echocardiography (TOE) to evaluate valve morphology in severe MR. The majority of centres reported the onsite availability and clinical use of ergometric stress echocardiography, cardiac computed tomography (CCT), and cardiac magnetic resonance (CMR) imaging. Heart valve clinics and heart valve teams were also widely prevalent. CONCLUSION Consistent with current guidelines, echocardiography (transthoracic echocardiography and TOE) remains the first-line and central imaging modality for the assessment of MR although the complementary use of 3D TOE, CCT, and CMR appears to be growing. Heart valve clinics and heart valve teams are now widely prevalent.
Collapse
Affiliation(s)
- Espen Holte
- Clinic of Cardiology, St. Olavs Hospital, Postboks 3250 Torgarden, Trondheim 7006, Norway
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology NTNU, Postboks 8905, Trondheim 7491, Norway
| | - Tomaž Podlesnikar
- University Medical Centre Maribor, Slovenia
- University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Fontes Carvalho
- Cardiovascular Research and Development Unit (UnIC), Faculty of Medicine, University of Porto, Porto, Portugal
| | - Ahmet Demirkiran
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081 HV, The Netherlands
- Department of Cardiology, Kocaeli Şehir Medical Center, Tavşantepe, İzmit/Kocaeli 41060, Türkiye
| | - Robert Manka
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Gabriela Guzmán Martínez
- Department of Cardiology, Department of Medicine, Faculty of Biomedical and Health Sciences, Universidad Europea de Madrid, Madrid, Spain
| | - Błażej Michalski
- Department of Cardiology, Medical University of Lodz, Lodz, Poland
| | - Agnès Pasquet
- Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, IREC/CARD UCLouvain, Brussels B-1200, Belgium
| | - Jadranka Separovic Hanzevacki
- Department of Cardiovascular Diseases, Clinical Hospital Centre Zagreb, School of Medicine, University of Zagreb, Croatia
| | - Hatem Soliman-Aboumarie
- Department of Cardiothoracic Critical Care, Transplantation and Mechanical Circulatory Support, Royal Brompton and Harefield Hospitals, London, UK
- School of Cardiovascular and Metabolic Medicine and Sciences, King’s College London, London, UK
| | - Joshi S Shruti
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Kristina H Haugaa
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Postboks 4950 Nydalen, Oslo 0424, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Marc R Dweck
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| |
Collapse
|
10
|
Perazzolo Marra M, Cecere A, Cipriani A, Migliore F, Zorzi A, De Lazzari M, Lorenzoni G, Cecchetto A, Brunetti G, Graziano F, Pittorru R, Motta R, De Conti G, Bauce B, Corrado D, Gregori D, Iliceto S. Determinants of Ventricular Arrhythmias in Mitral Valve Prolapse. JACC Clin Electrophysiol 2024; 10:670-681. [PMID: 38340116 DOI: 10.1016/j.jacep.2023.12.007] [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: 07/28/2023] [Revised: 10/04/2023] [Accepted: 12/04/2023] [Indexed: 02/12/2024]
Abstract
BACKGROUND Mitral valve prolapse (MVP) may be associated with ventricular arrhythmias (VA) even in the absence of significant valvular regurgitation. Curling, mitral annulus disjunction (MAD) and myocardial fibrosis (late gadolinium enhancement [LGE]) may account for arrhythmogenesis. OBJECTIVES This study investigated the determinants of VA in patients with MVP without significant regurgitation. METHODS This study included 108 patients with MVP (66 female; median age: 48 years) without valve regurgitation. All patients underwent 12-lead electrocardiography, 12-lead 24-hour electrocardiographic Holter monitoring, exercise stress test, and cardiac magnetic resonance. Patients were divided into 2 groups (arrhythmic and no-arrhythmic MVP), according to the presence of VA with a right bundle branch block pattern. RESULTS The 62 patients (57%) with arrhythmic MVP showed: 1) higher MAD (median length: 6.0 vs 3.2 mm; P = 0.017); 2) higher prevalence of curling (79% vs 52%; P = 0.012); and 3) higher prevalence of left ventricular LGE (79% vs 52%; P = 0.012). Mediation analysis showed that curling had both a direct (P = 0.03) and indirect effect mediated by LGE (P = 0.04) on VA, whereas the association between MAD and VA was completely mediated by LGE. Patients with severe VA showed more pronounced morphofunctional alterations, in terms of MAD (7.0 vs 4.6 mm; P = 0.004) and presence and severity of curling (respectively, 91% vs 64%; P = 0.010; and 4 vs 3 mm; P = 0.004), compared to those without severe VA. CONCLUSIONS In patients with MVP the occurrence of VA with right bundle branch block morphology is the expression of more severe morphologic, mechanical, and tissue alterations. Curling has both a direct and an indirect effect on VA.
Collapse
Affiliation(s)
- Martina Perazzolo Marra
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padua, Padua, Italy.
| | - Annagrazia Cecere
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Alberto Cipriani
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Federico Migliore
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Alessandro Zorzi
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Manuel De Lazzari
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Giulia Lorenzoni
- Unit of Biostatistics, Epidemiology, and Public Health, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | - Antonella Cecchetto
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Giulia Brunetti
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Francesca Graziano
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Raimondo Pittorru
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Raffaella Motta
- Radiology Unit, University of Padua-Azienda Ospedaliera, Padua, Italy
| | - Giorgio De Conti
- Radiology Unit, University of Padua-Azienda Ospedaliera, Padua, Italy
| | - Barbara Bauce
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Domenico Corrado
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Dario Gregori
- Unit of Biostatistics, Epidemiology, and Public Health, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | - Sabino Iliceto
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| |
Collapse
|
11
|
Oda S. Preprocedural Evaluation of Ventricular Functional Mitral Regurgitation Upon Transcatheter Edge-to-Edge Repair by Noninvasive Imaging - An Emerging Clinical Standard. Circ J 2024; 88:528-530. [PMID: 38432902 DOI: 10.1253/circj.cj-24-0150] [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] [Indexed: 03/05/2024]
Affiliation(s)
- Seitaro Oda
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University
| |
Collapse
|
12
|
Bawaskar P, Thomas N, Ismail K, Guo Y, Chhikara S, Athwal PSS, Ranum A, Jadhav A, Mendez AH, Nadkarni I, Frerichs D, Velangi P, Ergando T, Akram H, Kanda A, Shenoy C. Nonischemic or Dual Cardiomyopathy in Patients With Coronary Artery Disease. Circulation 2024; 149:807-821. [PMID: 37929565 PMCID: PMC10951941 DOI: 10.1161/circulationaha.123.067032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 11/02/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Randomized trials in obstructive coronary artery disease (CAD) have largely shown no prognostic benefit from coronary revascularization. Although there are several potential reasons for the lack of benefit, an underexplored possible reason is the presence of coincidental nonischemic cardiomyopathy (NICM). We investigated the prevalence and prognostic significance of NICM in patients with CAD (CAD-NICM). METHODS We conducted a registry study of consecutive patients with obstructive CAD on coronary angiography who underwent contrast-enhanced cardiovascular magnetic resonance imaging for the assessment of ventricular function and scar at 4 hospitals from 2004 to 2020. We identified the presence and cause of cardiomyopathy using cardiovascular magnetic resonance imaging and coronary angiography data, blinded to clinical outcomes. The primary outcome was a composite of all-cause death or heart failure hospitalization, and secondary outcomes were all-cause death, heart failure hospitalization, and cardiovascular death. RESULTS Among 3023 patients (median age, 66 years; 76% men), 18.2% had no cardiomyopathy, 64.8% had ischemic cardiomyopathy (CAD+ICM), 9.3% had CAD+NICM, and 7.7% had dual cardiomyopathy (CAD+dualCM), defined as both ICM and NICM. Thus, 16.9% had CAD+NICM or dualCM. During a median follow-up of 4.8 years (interquartile range, 2.9, 7.6), 1116 patients experienced the primary outcome. In Cox multivariable analysis, CAD+NICM or dualCM was independently associated with a higher risk of the primary outcome compared with CAD+ICM (adjusted hazard ratio, 1.23 [95% CI, 1.06-1.43]; P=0.007) after adjustment for potential confounders. The risks of the secondary outcomes of all-cause death and heart failure hospitalization were also higher with CAD+NICM or dualCM (hazard ratio, 1.21 [95% CI, 1.02-1.43]; P=0.032; and hazard ratio, 1.37 [95% CI, 1.11-1.69]; P=0.003, respectively), whereas the risk of cardiovascular death did not differ from that of CAD+ICM (hazard ratio, 1.15 [95% CI, 0.89-1.48]; P=0.28). CONCLUSIONS In patients with CAD referred for clinical cardiovascular magnetic resonance imaging, NICM or dualCM was identified in 1 of every 6 patients and was associated with worse long-term outcomes compared with ICM. In patients with obstructive CAD, coincidental NICM or dualCM may contribute to the lack of prognostic benefit from coronary revascularization.
Collapse
Affiliation(s)
- Parag Bawaskar
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Nicholas Thomas
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Khaled Ismail
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Yugene Guo
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Sanya Chhikara
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Pal Satyajit Singh Athwal
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Alison Ranum
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Achal Jadhav
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Abel Hooker Mendez
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Ishan Nadkarni
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Dominic Frerichs
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Pratik Velangi
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Tesfatsiyon Ergando
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Hassan Akram
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Adinan Kanda
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Chetan Shenoy
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| |
Collapse
|
13
|
Malhotra P, Han D, Chakravarty T, Thomson L, Dey D, Nakamura M, Patel D, Harutyunyan I, Tamarappoo B, Skaf S, Singh S, Rader F, Siegel R, Friedman J, Makkar R, Berman D. Increased CT angiography-derived extracellular volume fraction predicts less benefit in left ventricular remodeling and ejection fraction after transcatheter edge to edge repair for severe mitral regurgitation. J Cardiovasc Comput Tomogr 2024; 18:217-218. [PMID: 38302390 DOI: 10.1016/j.jcct.2024.01.002] [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: 09/19/2023] [Revised: 12/28/2023] [Accepted: 01/05/2024] [Indexed: 02/03/2024]
Affiliation(s)
- Pankaj Malhotra
- Mark Taper Imaging Center, Cedars Sinai Medical Center, Los Angeles, CA, USA; Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Donghee Han
- Mark Taper Imaging Center, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Tarun Chakravarty
- Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Louise Thomson
- Mark Taper Imaging Center, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Damini Dey
- Mark Taper Imaging Center, Cedars Sinai Medical Center, Los Angeles, CA, USA; Biomedical Imaging Research Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Mamoo Nakamura
- Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Dhairya Patel
- Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | | | - Balaji Tamarappoo
- Department of Cardiology, Indiana University Health, Indianapolis, IN, USA
| | - Sabah Skaf
- Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Siddharth Singh
- Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Florian Rader
- Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Robert Siegel
- Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - John Friedman
- Mark Taper Imaging Center, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Raj Makkar
- Mark Taper Imaging Center, Cedars Sinai Medical Center, Los Angeles, CA, USA; Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel Berman
- Mark Taper Imaging Center, Cedars Sinai Medical Center, Los Angeles, CA, USA; Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA.
| |
Collapse
|
14
|
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
|
15
|
Wang M, Yan M, Tan L, Zhao X, Liu G, Zhang Z, Zhang J, Gao H, Qin W. Non-coding RNAs: targets for Chinese herbal medicine in treating myocardial fibrosis. Front Pharmacol 2024; 15:1337623. [PMID: 38476331 PMCID: PMC10928947 DOI: 10.3389/fphar.2024.1337623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 02/07/2024] [Indexed: 03/14/2024] Open
Abstract
Cardiovascular diseases have become the leading cause of death in urban and rural areas. Myocardial fibrosis is a common pathological manifestation at the adaptive and repair stage of cardiovascular diseases, easily predisposing to cardiac death. Non-coding RNAs (ncRNAs), RNA molecules with no coding potential, can regulate gene expression in the occurrence and development of myocardial fibrosis. Recent studies have suggested that Chinese herbal medicine can relieve myocardial fibrosis through targeting various ncRNAs, mainly including microRNAs (miRNAs), long non-coding RNAs (lncRNAs), and circular RNAs (circRNAs). Thus, ncRNAs are novel drug targets for Chinese herbal medicine. Herein, we summarized the current understanding of ncRNAs in the pathogenesis of myocardial fibrosis, and highlighted the contribution of ncRNAs to the therapeutic effect of Chinese herbal medicine on myocardial fibrosis. Further, we discussed the future directions regarding the potential applications of ncRNA-based drug screening platform to screen drugs for myocardial fibrosis.
Collapse
Affiliation(s)
- Minghui Wang
- School of Pharmacy, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
- School of Pharmacy, Jining Medical University, Rizhao, Shandong, China
| | - Maocai Yan
- School of Pharmacy, Jining Medical University, Rizhao, Shandong, China
| | - Liqiang Tan
- Department of Nasopharyngeal Carcinoma, Sun Yat-Sen University Cancer Center, Guangzhou, Guangdong, China
| | - Xiaona Zhao
- School of Pharmacy, Jining Medical University, Rizhao, Shandong, China
- School of Pharmacy, Weifang Medical University, Weifang, Shandong, China
| | - Guoqing Liu
- School of Pharmacy, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
- School of Pharmacy, Jining Medical University, Rizhao, Shandong, China
| | - Zejin Zhang
- School of Pharmacy, Jining Medical University, Rizhao, Shandong, China
- School of Pharmacy, Binzhou Medical University, Yantai, Shandong, China
| | - Jing Zhang
- School of Pharmacy, Jining Medical University, Rizhao, Shandong, China
| | - Honggang Gao
- School of Pharmacy, Jining Medical University, Rizhao, Shandong, China
| | - Wei Qin
- School of Pharmacy, Jining Medical University, Rizhao, Shandong, China
| |
Collapse
|
16
|
Compagnucci P, Selimi A, Cipolletta L, Volpato G, Gasperetti A, Valeri Y, Parisi Q, Curcio A, Natale A, Dello Russo A, Casella M. Arrhythmic Mitral Valve Prolapse and Sports Activity: Pathophysiology, Risk Stratification, and Sports Eligibility Assessment. J Clin Med 2024; 13:1350. [PMID: 38592178 PMCID: PMC10932446 DOI: 10.3390/jcm13051350] [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: 01/09/2024] [Revised: 02/16/2024] [Accepted: 02/20/2024] [Indexed: 04/10/2024] Open
Abstract
Although mitral valve prolapse (MVP) is the most prevalent valvular abnormality in Western countries and generally carries a good prognosis, a small subset of patients is exposed to a significant risk of malignant ventricular arrhythmias (VAs) and sudden cardiac death (SCD), the so-called arrhythmic MVP (AMVP) syndrome. Recent work has emphasized phenotypical risk features of severe AMVP and clarified its pathophysiology. However, the appropriate assessment and risk stratification of patients with suspected AMVP remains a clinical conundrum, with the possibility of both overestimating and underestimating the risk of malignant VAs, with the inappropriate use of advanced imaging and invasive electrophysiology study on one hand, and the catastrophic occurrence of SCD on the other. Furthermore, the sports eligibility assessment of athletes with AMVP remains ill defined, especially in the grey zone of intermediate arrhythmic risk. The definition, epidemiology, pathophysiology, risk stratification, and treatment of AMVP are covered in the present review. Considering recent guidelines and expert consensus statements, we propose a comprehensive pathway to facilitate appropriate counseling concerning the practice of competitive/leisure-time sports, envisioning shared decision making and the multidisciplinary "sports heart team" evaluation of borderline cases. Our final aim is to encourage an active lifestyle without compromising patients' safety.
Collapse
Affiliation(s)
- Paolo Compagnucci
- Cardiology and Arrhythmology Clinic, Marche University Hospital, 60126 Ancona, Italy; (A.S.); (L.C.); (G.V.); (Y.V.); (Q.P.); (A.D.R.)
| | - Adelina Selimi
- Cardiology and Arrhythmology Clinic, Marche University Hospital, 60126 Ancona, Italy; (A.S.); (L.C.); (G.V.); (Y.V.); (Q.P.); (A.D.R.)
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60121 Ancona, Italy;
| | - Laura Cipolletta
- Cardiology and Arrhythmology Clinic, Marche University Hospital, 60126 Ancona, Italy; (A.S.); (L.C.); (G.V.); (Y.V.); (Q.P.); (A.D.R.)
| | - Giovanni Volpato
- Cardiology and Arrhythmology Clinic, Marche University Hospital, 60126 Ancona, Italy; (A.S.); (L.C.); (G.V.); (Y.V.); (Q.P.); (A.D.R.)
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60121 Ancona, Italy;
| | - Alessio Gasperetti
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60121 Ancona, Italy;
- Department of Cardiology, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Yari Valeri
- Cardiology and Arrhythmology Clinic, Marche University Hospital, 60126 Ancona, Italy; (A.S.); (L.C.); (G.V.); (Y.V.); (Q.P.); (A.D.R.)
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60121 Ancona, Italy;
| | - Quintino Parisi
- Cardiology and Arrhythmology Clinic, Marche University Hospital, 60126 Ancona, Italy; (A.S.); (L.C.); (G.V.); (Y.V.); (Q.P.); (A.D.R.)
| | - Antonio Curcio
- Division of Cardiology, Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, 87036 Rende, Italy
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St David’s Medical Center, Austin, TX 78705, USA;
- Interventional Electrophysiology, Scripps Clinic, San Diego, CA 92037, USA
- Department of Internal Medicine, Metro Health Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH 44195, USA
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, Marche University Hospital, 60126 Ancona, Italy; (A.S.); (L.C.); (G.V.); (Y.V.); (Q.P.); (A.D.R.)
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60121 Ancona, Italy;
| | - Michela Casella
- Cardiology and Arrhythmology Clinic, Marche University Hospital, 60126 Ancona, Italy; (A.S.); (L.C.); (G.V.); (Y.V.); (Q.P.); (A.D.R.)
- Department of Medical, Special and Dental Sciences, Marche Polytechnic University, 60121 Ancona, Italy
| |
Collapse
|
17
|
Malagoli A, Albini A, Benfari G, Ilardi F, Lisi M, Mandoli GE, Pastore MC, Sperlongano S, Cameli M, D'Andrea A. Arrhythmic mitral valve prolapse: a practical approach for asymptomatic patients. Eur Heart J Cardiovasc Imaging 2024; 25:293-301. [PMID: 38061000 DOI: 10.1093/ehjci/jead332] [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: 10/20/2023] [Revised: 11/24/2023] [Accepted: 11/28/2023] [Indexed: 02/24/2024] Open
Abstract
Mitral valve prolapse (MVP) is usually regarded as a benign condition though the proportion of patients with a life-threatening arrhythmic MVP form remains undefined. Recently, an experts' consensus statement on arrhythmic MVP has proposed approaches for risk stratification across the spectrum of clinical manifestation. However, sudden cardiac death may be the first presentation, making clinicians focused to early unmasking this subset of asymptomatic patients. Growing evidence on the role of cardiac imaging in the in-deep stratification pathway has emerged in the last decade. Pathology findings have suggested the fibrosis of papillary muscles and inferobasal left ventricular wall as the malignant hallmark. Cardiac magnetic resonance, while of limited availability, allows the identification of this arrhythmogenic substrate. Therefore, speckle-tracking echocardiography may be a gateway to prompt referring patients to further advanced imaging investigation. Our review aims to summarize the phenotypic features linked to the arrhythmic risk and to propose an image-based algorithm intended to help stratifying asymptomatic MVP patients.
Collapse
Affiliation(s)
- Alessandro Malagoli
- Division of Cardiology, Nephro-Cardiovascular Department, Baggiovara Hospital, University of Modena and Reggio Emilia, 1355 Pietro Giardini Street, Modena 41126, Italy
| | - Alessandro Albini
- Division of Cardiology, Department of Cardiac, Thoracic and Vascular diseases, IRCCS San Gerardo dei Tintori Foundation, Monza, Italy
| | - Giovanni Benfari
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Federica Ilardi
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Matteo Lisi
- Department of Cardiovascular Disease-AUSL Romagna, Division of Cardiology, Ospedale S. Maria delle Croci, Ravenna, Italy
| | - Giulia Elena Mandoli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Maria Concetta Pastore
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Simona Sperlongano
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Matteo Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Antonello D'Andrea
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
- Department of Cardiology, Umberto I Hospital, Nocera Inferiore, Italy
| |
Collapse
|
18
|
Vancheri F, Longo G, Henein MY. Left ventricular ejection fraction: clinical, pathophysiological, and technical limitations. Front Cardiovasc Med 2024; 11:1340708. [PMID: 38385136 PMCID: PMC10879419 DOI: 10.3389/fcvm.2024.1340708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 01/12/2024] [Indexed: 02/23/2024] Open
Abstract
Risk stratification of cardiovascular death and treatment strategies in patients with heart failure (HF), the optimal timing for valve replacement, and the selection of patients for implantable cardioverter defibrillators are based on an echocardiographic calculation of left ventricular ejection fraction (LVEF) in most guidelines. As a marker of systolic function, LVEF has important limitations being affected by loading conditions and cavity geometry, as well as image quality, thus impacting inter- and intra-observer measurement variability. LVEF is a product of shortening of the three components of myocardial fibres: longitudinal, circumferential, and oblique. It is therefore a marker of global ejection performance based on cavity volume changes, rather than directly reflecting myocardial contractile function, hence may be normal even when myofibril's systolic function is impaired. Sub-endocardial longitudinal fibers are the most sensitive layers to ischemia, so when dysfunctional, the circumferential fibers may compensate for it and maintain the overall LVEF. Likewise, in patients with HF, LVEF is used to stratify subgroups, an approach that has prognostic implications but without a direct relationship. HF is a dynamic disease that may worsen or improve over time according to the underlying pathology. Such dynamicity impacts LVEF and its use to guide treatment. The same applies to changes in LVEF following interventional procedures. In this review, we analyze the clinical, pathophysiological, and technical limitations of LVEF across a wide range of cardiovascular pathologies.
Collapse
Affiliation(s)
- Federico Vancheri
- Department of Internal Medicine, S.Elia Hospital, Caltanissetta, Italy
| | - Giovanni Longo
- Cardiovascular and Interventional Department, S.Elia Hospital, Caltanissetta, Italy
| | - Michael Y. Henein
- Institute of Public Health and Clinical Medicine, Umea University, Umea, Sweden
| |
Collapse
|
19
|
Cecere A, Cipriani A, De Lazzari M, Graziano F, Brunetti G, De Conti G, Motta R, Ravagnin A, Lorenzoni G, Gregori D, Basso C, Tona F, Lee YJ, Delling FN, Iliceto S, Marra MP. Left ventricular fibrosis in arrhythmic mitral valve prolapse: quantification and comparison of semi-automated techniques assessed by cardiac magnetic resonance. Int J Cardiovasc Imaging 2024; 40:275-285. [PMID: 38141098 PMCID: PMC10884156 DOI: 10.1007/s10554-023-03006-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 11/03/2023] [Indexed: 12/24/2023]
Abstract
PURPOSE Left ventricular (LV) fibrosis has a key role in arrhythmogenesis in patients with mitral valve prolapse (MVP). Cardiac magnetic resonance identifies LV fibrosis by using late gadolinium enhancement (LGE) technique. LGE assessment and quantification in patients with MVP lacks of standardization protocols. METHODS 66 MVP patients with normal systolic function and without significant regurgitation were enrolled. Semi-automated gray-scale thresholding techniques using full width at half maximum (FWHM) and 2, 3 and 5 standard deviation (SD) above the remote myocardium were used and compared with the visual assessment, considered as the gold standard. RESULTS LGE was identified in 41 MVP patients (62%) and quantified. The mean quantity of LGE visually assessed was 2.40 ± 1.07% or 1.40 ± 0.82 g. With FWHM, LGE resulted 3.56 ± 1.23% or 1.99 ± 1.13 g. Using thresholding, the mean LGE quantity was 9.2 ± 3.1% or 4.82 ± 2.28 g for 2-SD, 5.72 ± 1.75% or 3.06 ± 1.47 g for 3-SD and 2.36 ± 0.99% or 1.29 ± 0.79 g for 5-SD. The 5-SD measurement in percentage demonstrated a good correlation with LGE quantification visually assessed (2.40 ± 1.07 vs. 2.363 ± 0.9909, p = 0.543). When compared with the gold standard, the 5-SD threshold quantification, both in percentage and in grams, revealed the least intra-observer (respectively, ICC: 0.976 and 0.966) and inter-observer variability (respectively ICC: 0.948 and 0.935). CONCLUSION The 5-SD gray-scale threshold technique in percentage revealed the best correlation with the visual assessment and an optimal reproducibility in MVP patient.
Collapse
Affiliation(s)
- Annagrazia Cecere
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua-Azienda Ospedaliera, Via Giustiniani, 2, 35128, Padua, Italy
| | - Alberto Cipriani
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua-Azienda Ospedaliera, Via Giustiniani, 2, 35128, Padua, Italy
| | - Manuel De Lazzari
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua-Azienda Ospedaliera, Via Giustiniani, 2, 35128, Padua, Italy
| | - Francesca Graziano
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua-Azienda Ospedaliera, Via Giustiniani, 2, 35128, Padua, Italy
| | - Giulia Brunetti
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua-Azienda Ospedaliera, Via Giustiniani, 2, 35128, Padua, Italy
| | - Giorgio De Conti
- Radiology Unit, University of Padua-Azienda Ospedaliera, Padua, Italy
| | - Raffaella Motta
- Department of Medicine, University of Padua-Azienda Ospedaliera, Padua, Italy
| | - Alberto Ravagnin
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua-Azienda Ospedaliera, Via Giustiniani, 2, 35128, Padua, Italy
| | - Giulia Lorenzoni
- Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, Unit of Biostatistics, Epidemiology and Public Health, University of Padova, Padova, Italy
| | - Dario Gregori
- Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, Unit of Biostatistics, Epidemiology and Public Health, University of Padova, Padova, Italy
| | - Cristina Basso
- Cardiovascular Pathology Unit, University Hospital of Padua, Padua, Italy
| | - Francesco Tona
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua-Azienda Ospedaliera, Via Giustiniani, 2, 35128, Padua, Italy
| | - Yoo Jin Lee
- Clinical Radiology, Cardiac and Pulmonary Imaging, University of California, San Francisco, CA, USA
| | - Francesca Nesta Delling
- Department of Medicine (Cardiovascular Division), University of California San Francisco, San Francisco, CA, USA
| | - Sabino Iliceto
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua-Azienda Ospedaliera, Via Giustiniani, 2, 35128, Padua, Italy
| | - Martina Perazzolo Marra
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua-Azienda Ospedaliera, Via Giustiniani, 2, 35128, Padua, Italy.
| |
Collapse
|
20
|
Spampinato RA, Marin-Cuartas M, van Kampen A, Fahr F, Sieg F, Strotdrees E, Jahnke C, Klaeske K, Wiesner K, Morningstar JE, Nagata Y, Izquierdo-Garcia D, Dieterlen MT, Norris RA, Levine RA, Paetsch I, Borger MA. Left ventricular fibrosis and CMR tissue characterization of papillary muscles in mitral valve prolapse patients. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2024; 40:213-224. [PMID: 37891450 DOI: 10.1007/s10554-023-02985-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 10/11/2023] [Indexed: 10/29/2023]
Abstract
PURPOSE Mitral valve prolapse (MVP) is associated with left ventricle (LV) fibrosis, including the papillary muscles (PM), which is in turn linked to malignant arrhythmias. This study aims to evaluate comprehensive tissue characterization of the PM by cardiovascular magnetic resonance (CMR) imaging and its association with LV fibrosis observed by intraoperative biopsies. METHODS MVP patients with indication for surgery due to severe mitral regurgitation (n = 19) underwent a preoperative CMR with characterization of the PM: dark-appearance on cine, T1 mapping, conventional bright blood (BB) and dark blood (DB) late gadolinium enhancement (LGE). CMR T1 mapping was performed on 21 healthy volunteers as controls. LV inferobasal myocardial biopsies were obtained in MVP patients and compared to CMR findings. RESULTS MVP patients (54 ± 10 years old, 14 male) had a dark-appearance of the PM with higher native T1 and extracellular volume (ECV) values compared with healthy volunteers (1096 ± 78ms vs. 994 ± 54ms and 33.9 ± 5.6% vs. 25.9 ± 3.1%, respectively, p < 0.001). Seventeen MVP patients (89.5%) had fibrosis by biopsy. BB-LGE + in LV and PM was identified in 5 (26.3%) patients, while DB-LGE + was observed in LV in 9 (47.4%) and in PM in 15 (78.9%) patients. DB-LGE + in PM was the only technique that showed no difference with detection of LV fibrosis by biopsy. Posteromedial PM was more frequently affected than the anterolateral (73.7% vs. 36.8%, p = 0.039) and correlated with biopsy-proven LV fibrosis (Rho 0.529, p = 0.029). CONCLUSIONS CMR imaging in MVP patients referred for surgery shows a dark-appearance of the PM with higher T1 and ECV values compared with healthy volunteers. The presence of a positive DB-LGE at the posteromedial PM by CMR may serve as a better predictor of biopsy-proven LV inferobasal fibrosis than conventional CMR techniques.
Collapse
Affiliation(s)
- Ricardo A Spampinato
- Department of Cardiac Surgery, University, Leipzig Heart Center, Struempellstrasse 39, 04289, Leipzig, Germany.
| | - Mateo Marin-Cuartas
- Department of Cardiac Surgery, University, Leipzig Heart Center, Struempellstrasse 39, 04289, Leipzig, Germany
| | - Antonia van Kampen
- Department of Cardiac Surgery, University, Leipzig Heart Center, Struempellstrasse 39, 04289, Leipzig, Germany
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Florian Fahr
- Department of Cardiac Surgery, University, Leipzig Heart Center, Struempellstrasse 39, 04289, Leipzig, Germany
| | - Franz Sieg
- Department of Cardiac Surgery, University, Leipzig Heart Center, Struempellstrasse 39, 04289, Leipzig, Germany
| | - Elfriede Strotdrees
- Department of Cardiac Surgery, University, Leipzig Heart Center, Struempellstrasse 39, 04289, Leipzig, Germany
| | - Cosima Jahnke
- Department of Cardiology and Electrophysiology, Leipzig Heart Center, Leipzig, Germany
| | - Kristin Klaeske
- Department of Cardiac Surgery, University, Leipzig Heart Center, Struempellstrasse 39, 04289, Leipzig, Germany
| | - Karoline Wiesner
- Department of Cardiac Surgery, University, Leipzig Heart Center, Struempellstrasse 39, 04289, Leipzig, Germany
| | - Jordan E Morningstar
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC, USA
| | - Yasufumi Nagata
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - David Izquierdo-Garcia
- The Institute for Innovation in Imaging, Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Maja-Theresa Dieterlen
- Department of Cardiac Surgery, University, Leipzig Heart Center, Struempellstrasse 39, 04289, Leipzig, Germany
| | - Russell A Norris
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC, USA
| | - Robert A Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ingo Paetsch
- Department of Cardiology and Electrophysiology, Leipzig Heart Center, Leipzig, Germany
| | - Michael A Borger
- Department of Cardiac Surgery, University, Leipzig Heart Center, Struempellstrasse 39, 04289, Leipzig, Germany
| |
Collapse
|
21
|
Ding T, Zeng L, Xia Y, Zhang B, Cui D. miR-135a Mediates Mitochondrial Oxidative Respiratory Function through SIRT1 to Regulate Atrial Fibrosis. Cardiology 2024; 149:286-296. [PMID: 38228115 DOI: 10.1159/000536059] [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: 10/09/2023] [Accepted: 12/28/2023] [Indexed: 01/18/2024]
Abstract
INTRODUCTION This study aimed to explore the function of miR-135a in the progress of atrial fibrosis and the mechanism of miR-135a/SIRT1 (sirtuin 1) in human cardiac fibroblasts and mouse cardiac fibroblasts (MCFs) mediating the regulation of atrial fibrosis by mitochondrial oxidative respiration function. METHODS Using Ang II (angiotensin II) to induce fibrosis in HCFs (human corneal fibroblasts) and MCF (Michigan Cancer Foundation, MCF) cells in vitro, the miRNA-seq results of previous studies were validated. Proliferative and invasive ability of HCFs and MCFs was detected by Cell Counting Kit-8 assay (CCK-8) and scratch experiment after overexpressing miR-135a in HCFs and MCF cells. Protein and mRNA expression was tested using Western blot and qPCR. The target of miR-135a was verified as SIRT1 by a luciferase reporter assay and the activities of the mitochondrial respiratory enzyme complexes I, II, III, and IV were determined colorimetrically. The activities of malondialdehyde, reactive oxygen species, and superoxide dismutase in cells were detected with enzyme-linked immunosorbent assay (ELISA). RESULTS miR-135a expression was elevated in HCFs and MCFs cells in the Ang II group than control group. Overexpression of miR-135a could promote the proliferation, migration, oxidative stress, as well as fibrosis of cardiac fibroblasts and suppresses mitochondrial activity. In addition, we found SIRT1 was a target gene of miR-135a. What is more, the findings showed miR-135a promoted fibrosis in HCFs and MCFs cells acting through regulation of SIRT1. CONCLUSIONS miR-135a mediates mitochondrial oxidative respiratory function through SIRT1 to regulate atrial fibrosis.
Collapse
Affiliation(s)
- Tianhang Ding
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Qiqihar Medical University, Qiqihar, China
| | - Liyan Zeng
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Qiqihar Medical University, Qiqihar, China
| | - Ying Xia
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Qiqihar Medical University, Qiqihar, China
| | - Baojun Zhang
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Qiqihar Medical University, Qiqihar, China
| | - Dongji Cui
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Qiqihar Medical University, Qiqihar, China
| |
Collapse
|
22
|
Tastet L, Dixit S, Nguyen T, Lim LJ, Al-Akchar M, Bibby D, Arya F, Cristin L, Anwar S, Higuchi S, Hsia H, Lee YJ, Delling FN. Interstitial Fibrosis and Arrhythmic Mitral Valve Prolapse: Unravelling Sex-Based Differences. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.01.12.24301217. [PMID: 38260659 PMCID: PMC10802759 DOI: 10.1101/2024.01.12.24301217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Background Interstitial fibrosis as quantified by cardiac magnetic resonance (CMR) has been demonstrated in arrhythmic mitral valve prolapse (MVP), a condition with known female predominance. However, prior studies included only MVP cases with significant mitral regurgitation (MR) or mitral annular disjunction (MAD). We sought to evaluate the association between interstitial fibrosis and complex ventricular ectopy (ComVE) in MVPs unselected for MAD or severe MR, and to investigate the contribution of sex to this association. Methods We performed contrast CMR in consecutive individuals with MVP between 2020 and 2022. Extracellular volume fraction (ECV%), a surrogate marker for interstitial fibrosis, was quantified using T 1 mapping. Replacement fibrosis was assessed using late gadolinium enhancement (LGE). ComVE, defined as frequent premature ventricular contractions and/or non-sustained/sustained ventricular tachycardia (VT), was detected using ambulatory ECG monitoring. Results We identified 59 MVP cases without severe MR (49% women, 80% with mild or less MR) and available ECV% measurement. Among these, 23 (39%) had ComVE, including a case of aborted ventricular fibrillation (VF) and one with sudden arrhythmic death, both females. Global ECV% was significantly greater in ComVE versus non-ComVE (31%[27-33] vs 27%[23-30], p=0.002). In MVP-ComVE, higher segmental ECV% was not limited to the inferolateral/inferior LV wall, but was also demonstrated in atypical segments including the anterior/anterolateral wall (p<0.05). The association between ComVE and ECV% was driven by female sex (32%[30-33] vs 28%[26-30], p=0.003 in females; 31%[25-33] vs 26%[23-30], p=0.22 in males). ECV% remained independently associated with an increased risk of ComVE, including VT/VF, after adjustment for cardiovascular risk factors, MAD, and LGE (p<0.01). Conclusion In MVP without significant MR, interstitial fibrosis by CMR is associated with an increased risk of ComVE, suggesting a primary myopathic process. The stronger association between interstitial fibrosis and ComVE in females may explain why severe arrhythmic complications are more prevalent among women. Abstract Figure
Collapse
|
23
|
Ajmone Marsan N, Graziani F, Meucci MC, Wu HW, Lillo R, Bax JJ, Burzotta F, Massetti M, Jukema JW, Crea F. Valvular heart disease and cardiomyopathy: reappraisal of their interplay. Nat Rev Cardiol 2024; 21:37-50. [PMID: 37563454 DOI: 10.1038/s41569-023-00911-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/03/2023] [Indexed: 08/12/2023]
Abstract
Cardiomyopathies and valvular heart diseases are typically considered distinct diagnostic categories with dedicated guidelines for their management. However, the interplay between these conditions is increasingly being recognized and they frequently coexist, as in the paradigmatic examples of dilated cardiomyopathy and hypertrophic cardiomyopathy, which are often complicated by the occurrence of mitral regurgitation. Moreover, cardiomyopathies and valvular heart diseases can have a shared aetiology because several genetic or acquired diseases can affect both the cardiac valves and the myocardium. In addition, the association between cardiomyopathies and valvular heart diseases has important prognostic and therapeutic implications. Therefore, a better understanding of their shared pathophysiological mechanisms, as well as of the prevalence and predisposing factors to their association, might lead to a different approach in the risk stratification and management of these diseases. In this Review, we discuss the different scenarios in which valvular heart diseases and cardiomyopathies coexist, highlighting the need for an improved classification and clustering of these diseases with potential repercussions in the clinical management and, particularly, personalized therapeutic approaches.
Collapse
Affiliation(s)
- Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.
| | - Francesca Graziani
- Department of Cardiovascular Science, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Maria Chiara Meucci
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Cardiovascular Science, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Hoi W Wu
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Rosa Lillo
- Department of Cardiovascular Science, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Catholic University of the Sacred Heart, Rome, Italy
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
- Heart Center, University of Turku and Turku University Hospital, Turku, Finland
| | - Francesco Burzotta
- Department of Cardiovascular Science, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Catholic University of the Sacred Heart, Rome, Italy
| | - Massimo Massetti
- Department of Cardiovascular Science, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Catholic University of the Sacred Heart, Rome, Italy
| | - J Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
- Netherlands Heart Institute, Utrecht, The Netherlands
| | - Filippo Crea
- Department of Cardiovascular Science, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Catholic University of the Sacred Heart, Rome, Italy
| |
Collapse
|
24
|
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
|
25
|
Zhu L, Chua YL. Mitral Annular Disjunction: Clinical Implications and Surgical Considerations. Cardiol Res 2023; 14:421-428. [PMID: 38187510 PMCID: PMC10769617 DOI: 10.14740/cr1584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 10/28/2023] [Indexed: 01/09/2024] Open
Abstract
Mitral annular disjunction is a cardiac structural abnormality characterized by the distinct separation between the top of the left ventricular myocardium and the mitral annulus supporting the posterior mitral leaflet occurring during systole. It has recently gained wide attention due to the increasing recognition of the link between mitral annular disjunction and arrhythmogenic mitral valve prolapse, particularly, with the increased risks of ventricular arrhythmias resulting in sudden cardiac death. This review has summarized the recent progress in the diagnostic modalities, clinical implications of mitral annular disjunction, and its specific surgical considerations.
Collapse
Affiliation(s)
- Ling Zhu
- Department of Cardiothoracic Surgery, National Heart Centre Singapore, Singapore 169609, Singapore
| | - Yeow Leng Chua
- Department of Cardiothoracic Surgery, National Heart Centre Singapore, Singapore 169609, Singapore
| |
Collapse
|
26
|
Song C, Cui J, Zheng X, Lu J, Guo X, Wang S, Huang X. Mitral Valve Prolapse in Obstructive Hypertrophic Cardiomyopathy. Am J Cardiol 2023; 206:185-190. [PMID: 37708749 DOI: 10.1016/j.amjcard.2023.08.092] [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: 07/07/2023] [Revised: 08/10/2023] [Accepted: 08/17/2023] [Indexed: 09/16/2023]
Abstract
Obstructive hypertrophic cardiomyopathy (oHCM) and mitral valve (MV) prolapse (MVP) are the 2 conditions which could cause symptomatic heart failure and sudden cardiac death. The clinical characteristics and surgical outcomes of patients with oHCM and MVP have not been well reported. From April 2012 to February 2018, 84 patients with oHCM (28 patients with MVP and 56 gender- and age-matched patients without MVP) who underwent septal myectomy at our institution were enrolled in this study. Information on clinical characteristics and outcomes was obtained from electronic medical records and follow-up surveys. Compared with those without MVP, patients with MVP were more symptomatic (New York Heart Association class III to IV; 96% vs 77%), more often moderate-to-severe mitral regurgitation (86% vs 48%), atrial fibrillation (39% vs 11%) and higher incidence of nonsustained ventricular tachycardia (44% vs 15%). Twenty (71%) had MV repair and 8 (29%) had MV replacement. Compared with patients without MVP, those with MVP had a longer postoperative hospital stay (10.9 ± 6.4 vs 7.8 ± 2.8 days). None of the 84 study patients died during hospital or follow-up. At the most recent echocardiographic evaluation, left ventricular outflow tract gradient significantly decreased from 69.7 ± 35.4 millimeters of mercury to 7.3 ± 5.1 millimeters of mercury and the degree of mitral valve regurgitation improved from grade 2.43 ± 0.69 to grade 0.5 ± 0.69. In conclusion, MVP occurs rarely in oHCM, and was related to atrial fibrillation, ventricular arrhythmia and mitral regurgitation. Mitral valve surgery in combination with myectomy is effective and safe for patients with oHCM and MVP, relieving substantially left ventricular outflow tract gradients and mitral regurgitation.
Collapse
Affiliation(s)
| | - Jingang Cui
- Departments of Special Medical Treatment Center
| | | | - Jie Lu
- Departments of Special Medical Treatment Center
| | - Xinli Guo
- Departments of Special Medical Treatment Center
| | - Shuiyun Wang
- Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | | |
Collapse
|
27
|
Zoghbi WA, Chandrashekhar Y. Unanswered Questions in Primary Mitral Regurgitation. JACC Cardiovasc Imaging 2023; 16:1368-1370. [PMID: 37793718 DOI: 10.1016/j.jcmg.2023.09.001] [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] [Indexed: 10/06/2023]
|
28
|
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: 4] [Impact Index Per Article: 4.0] [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
|
29
|
Alqarawi W, Burwash IG, Krahn AD, Healey JS. Arrhythmic Mitral Valve Prolapse: Risk Assessment and Management. Can J Cardiol 2023; 39:1397-1409. [PMID: 37217162 DOI: 10.1016/j.cjca.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/26/2023] [Accepted: 05/16/2023] [Indexed: 05/24/2023] Open
Abstract
Arrhythmic mitral valve prolapse (MVP) has gained great interest recently because of the increasing recognition of its potential role in unexplained cardiac arrest. Although evidence has accumulated to show the association of arrhythmic MVP (AMVP) with sudden cardiac death (SCD), risk stratification and management remain unclear. Physicians are faced with the challenges of screening for AMVP among MVP patients and the dilemma of when and how to intervene to prevent SCD in these patients. In addition, there is little guidance to help approach MVP patients who present with an otherwise unexplained cardiac arrest to know whether MVP was the primary cause of cardiac arrest or just an innocent bystander. Herein we review the epidemiology and definition of AMVP, the risk and mechanisms of SCD, and summarize the clinical evidence behind risk markers of SCD and therapeutic interventions that could potentially prevent it. We also propose an algorithm that provides guidance as to how to screen for AMVP and what therapeutic interventions to use. Last, we propose a diagnostic algorithm for approaching patients with otherwise unexplained cardiac arrest who are shown to have MVP.
Collapse
Affiliation(s)
- Wael Alqarawi
- Department of Cardiac Sciences, College of Medicine, King Saud University, Riyadh, Saudi Arabia; Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Ian G Burwash
- Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Andrew D Krahn
- Center for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jeffrey S Healey
- Population Health Research Institute, McMaster University, and Hamilton Health Sciences, Hamilton, Ontario, Canada.
| |
Collapse
|
30
|
Essayagh B, Benfari G, Antoine C, Grigioni F, Le Tourneau T, Roussel JC, Bax JJ, Marsan NA, van Wijngaarden A, Tribouilloy C, Rusinaru D, Hochstadt A, Topilsky Y, Thapa P, Michelena HI, Enriquez-Sarano M. Response by Essayagh et al to Letter Regarding Article, "The MIDA-Q Mortality Risk Score: A Quantitative Prognostic Tool for the Mitral Valve Prolapse Spectrum". Circulation 2023; 148:980-981. [PMID: 37721975 DOI: 10.1161/circulationaha.123.065630] [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] [Indexed: 09/20/2023]
Affiliation(s)
- Benjamin Essayagh
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (B.E., G.B., C.A., P.T., H.I.M., M.E.-S.)
- Division of Echocardiography, Cardio X Clinic, Cannes, France (B.E.)
| | - Giovanni Benfari
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (B.E., G.B., C.A., P.T., H.I.M., M.E.-S.)
| | - Clemence Antoine
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (B.E., G.B., C.A., P.T., H.I.M., M.E.-S.)
| | - Francesco Grigioni
- Department of Cardiology, University Campus Bio-Medico, Rome, Italy (F.G.)
| | | | | | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, he Netherlands (J.J.B., N.A.M., A.v.W.)
| | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Center, he Netherlands (J.J.B., N.A.M., A.v.W.)
| | - Aniek van Wijngaarden
- Department of Cardiology, Leiden University Medical Center, he Netherlands (J.J.B., N.A.M., A.v.W.)
| | | | - Dan Rusinaru
- Department of Cardiology, University of Amiens, France (C.T., D.R.)
| | - Aviram Hochstadt
- Heart Institute, Wolfson Medical Center and the Sackler Faculty of Medicine, Tel-Aviv University, Israel (A.H.)
| | - Yan Topilsky
- Department of Cardiology, Tel Aviv Medical Center and Sackler Faculty of Medicine, Israel (Y.T.)
| | - Prabin Thapa
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (B.E., G.B., C.A., P.T., H.I.M., M.E.-S.)
| | - Hector I Michelena
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (B.E., G.B., C.A., P.T., H.I.M., M.E.-S.)
| | - Maurice Enriquez-Sarano
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (B.E., G.B., C.A., P.T., H.I.M., M.E.-S.)
| |
Collapse
|
31
|
Essayagh B, Sabbag A, El-Am E, Cavalcante JL, Michelena HI, Enriquez-Sarano M. Arrhythmic mitral valve prolapse and mitral annular disjunction: pathophysiology, risk stratification, and management. Eur Heart J 2023; 44:3121-3135. [PMID: 37561995 DOI: 10.1093/eurheartj/ehad491] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 06/11/2023] [Accepted: 07/19/2023] [Indexed: 08/12/2023] Open
Abstract
Mitral valve prolapse (MVP) is the most frequent valve condition but remains a conundrum in many aspects, particularly in regard to the existence and frequency of an arrhythmic form (AMVP) and its link to sudden cardiac death. Furthermore, the presence, frequency, and significance of the anatomic functional feature called mitral annular disjunction (MAD) have remained widely disputed. Recent case series and cohorts have shattered the concept that MVP is most generally benign and have emphasized the various phenotypes associated with clinically significant ventricular arrhythmias, including AMVP. The definition, evaluation, follow-up, and management of AMVP represent the focus of the present review, strengthened by recent coherent studies defining an arrhythmic MVP phenotypic that would affect a small subset of patients with MVP at concentrated high risk. The role of MAD in this context is of particular importance, and this review highlights the characteristics of AMVP phenotypes and MAD, their clinical, multimodality imaging, and rhythmic evaluation. These seminal facts lead to proposing a risk stratification clinical pathway with consideration of medical, rhythmologic, and surgical management and have been objects of recent expert consensus statements and of proposals for new research directions.
Collapse
Affiliation(s)
- Benjamin Essayagh
- From the Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905, USA
- Department of Echocardiography, Cardio X Clinic, Cannes, France
| | - Avi Sabbag
- The Davidai Center for Rhythm Disturbances and Pacing, Chaim Sheba Medical Center, Tel Hashomer and the Sackler School of Medicine, Tel Aviv University, Ramat-Gan, Israel
| | - Edward El-Am
- From the Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905, USA
| | - João L Cavalcante
- Department of Cardiovascular Medicine, Allina Health Minneapolis Heart Institute - Abbott Northwestern Hospital, 800 E 28th St, Minneapolis, MN 55407, USA
| | - Hector I Michelena
- From the Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905, USA
| | - Maurice Enriquez-Sarano
- Department of Cardiovascular Medicine, Allina Health Minneapolis Heart Institute - Abbott Northwestern Hospital, 800 E 28th St, Minneapolis, MN 55407, USA
| |
Collapse
|
32
|
Miller MA, Devesa A, Robson PM, Liao SL, Pyzik R, El-Eshmawi A, Boateng P, Pandis D, Dukkipati SR, Reddy VY, Adams DH, Fayad ZA, Trivieri MG. Arrhythmic Mitral Valve Prolapse With Only Mild or Moderate Mitral Regurgitation: Characterization of Myocardial Substrate. JACC Clin Electrophysiol 2023; 9:1709-1716. [PMID: 37227360 DOI: 10.1016/j.jacep.2023.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 03/29/2023] [Accepted: 04/09/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Sustained ventricular tachycardia and sudden cardiac death due to degenerative mitral valve prolapse (MVP) can occur in the absence of severe mitral regurgitation (MR). A significant percentage of patients with MVP-related sudden death do not have any evidence of replacement fibrosis, suggesting other unrecognized proarrhythmic factors may place these patients at risk. OBJECTIVES This study aims to characterize myocardial fibrosis/inflammation and ventricular arrhythmia complexity in patients with MVP and only mild or moderate MR. METHODS Prospective observational study of patients with MVP and only mild or moderate MR underwent ventricular arrhythmia characterization and hybrid positron emission tomography (PET)/magnetic resonance imaging (MRI). Coregistered hybrid 18F-fluorodeoxyglucose (18F-FDG)-PET and MRI late gadolinium enhancement images were assessed and categorized. Recruitment occurred in the cardiac electrophysiology clinic. RESULTS In 12 patients with degenerative MVP with only mild or moderate MR, of which a majority had complex ventricular ectopy (n = 10, 83%), focal (or focal-on-diffuse) uptake of 18F-FDG (PET-positive) was detected in 83% (n = 10) of patients. Three-quarters of the patients (n = 9, 75%) had FDG uptake that coexisted with areas of late gadolinium enhancement (PET/MRI-positive). Abnormal T1, T2 and extracellular volume (ECV) values were observed in 58% (n = 7), 25% (n = 3), and 16% (n = 2), respectively. CONCLUSIONS Most patients with degenerative MVP, ventricular ectopy, and mild or moderate MR show myocardial inflammation that is concordant with myocardial scar. Further study is needed to determine whether these findings contribute to the observation that most MVP-related sudden deaths occur in patients with less than severe MR.
Collapse
Affiliation(s)
- Marc A Miller
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Ana Devesa
- The BioMedical Engineering and Imaging Institute (BMEII), Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Philip M Robson
- The BioMedical Engineering and Imaging Institute (BMEII), Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Steve L Liao
- Division of Non-invasive Cardiovascular, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Renata Pyzik
- The BioMedical Engineering and Imaging Institute (BMEII), Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ahmed El-Eshmawi
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Percy Boateng
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Dimosthenis Pandis
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Srinivas R Dukkipati
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Vivek Y Reddy
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - David H Adams
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Zahi A Fayad
- The BioMedical Engineering and Imaging Institute (BMEII), Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Maria G Trivieri
- The BioMedical Engineering and Imaging Institute (BMEII), Icahn School of Medicine at Mount Sinai, New York, New York, USA
| |
Collapse
|
33
|
Tison GH, Abreau S, Barrios J, Lim LJ, Yang M, Crudo V, Shah DJ, Nguyen T, Hu G, Dixit S, Nah G, Arya F, Bibby D, Lee Y, Delling FN. Identifying Mitral Valve Prolapse at Risk for Arrhythmias and Fibrosis From Electrocardiograms Using Deep Learning. JACC. ADVANCES 2023; 2:100446. [PMID: 37936601 PMCID: PMC10629907 DOI: 10.1016/j.jacadv.2023.100446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 04/17/2023] [Accepted: 05/31/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND Mitral valve prolapse (MVP) is a common valvulopathy, with a subset developing sudden cardiac death or cardiac arrest. Complex ventricular ectopy (ComVE) is a marker of arrhythmic risk associated with myocardial fibrosis and increased mortality in MVP. OBJECTIVES The authors sought to evaluate whether electrocardiogram (ECG)-based machine learning can identify MVP at risk for ComVE, death and/or myocardial fibrosis on cardiac magnetic resonance (CMR) imaging. METHODS A deep convolutional neural network (CNN) was trained to detect ComVE using 6,916 12-lead ECGs from 569 MVP patients from the University of California-San Francisco between 2012 and 2020. A separate CNN was trained to detect late gadolinium enhancement (LGE) using 1,369 ECGs from 87 MVP patients with contrast CMR. RESULTS The prevalence of ComVE was 28% (160/569). The area under the receiver operating characteristic curve (AUC) of the CNN to detect ComVE was 0.80 (95% CI: 0.77-0.83) and remained high after excluding patients with moderate-severe mitral regurgitation [0.80 (95% CI: 0.77-0.83)] or bileaflet MVP [0.81 (95% CI: 0.76-0.85)]. AUC to detect all-cause mortality was 0.82 (95% CI: 0.77-0.87). ECG segments relevant to ComVE prediction were related to ventricular depolarization/repolarization (early-mid ST-segment and QRS from V1, V3, and III). LGE in the papillary muscles or basal inferolateral wall was present in 24% patients with available CMR; AUC for detection of LGE was 0.75 (95% CI: 0.68-0.82). CONCLUSIONS CNN-analyzed 12-lead ECGs can detect MVP at risk for ventricular arrhythmias, death and/or fibrosis and can identify novel ECG correlates of arrhythmic risk. ECG-based CNNs may help select those MVP patients requiring closer follow-up and/or a CMR.
Collapse
Affiliation(s)
- Geoffrey H. Tison
- Cardiovascular Division, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
- Bakar Computational Health Sciences Institute, University of California, San Francisco, California, USA
| | - Sean Abreau
- Cardiovascular Division, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Joshua Barrios
- Cardiovascular Division, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Lisa J. Lim
- Cardiovascular Division, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Michelle Yang
- Cardiovascular Division, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Valentina Crudo
- Division of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - Dipan J. Shah
- Division of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - Thuy Nguyen
- Cardiovascular Division, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Gene Hu
- Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Shalini Dixit
- Cardiovascular Division, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Gregory Nah
- Cardiovascular Division, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Farzin Arya
- Cardiovascular Division, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Dwight Bibby
- Cardiovascular Division, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Yoojin Lee
- Department of Radiology, University of California-San Francisco, San Francisco, California, USA
| | - Francesca N. Delling
- Cardiovascular Division, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| |
Collapse
|
34
|
Chakrabarti AK, Deshmukh A, Liang JJ, Madamanchi C, Ghannam M, Morady F, Bogun F. Mitral Annular Substrate and Ventricular Arrhythmias in Arrhythmogenic Mitral Valve Prolapse With Mitral Annular Disjunction. JACC Clin Electrophysiol 2023; 9:1265-1275. [PMID: 37086231 DOI: 10.1016/j.jacep.2023.02.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 01/18/2023] [Accepted: 02/08/2023] [Indexed: 04/23/2023]
Abstract
BACKGROUND In patients with bileaflet mitral valve prolapse (MVP), mitral annular disjunction (MAD) is associated with increased risk of sudden cardiac death via incompletely understood mechanisms. OBJECTIVES This study assessed the substrate for ventricular arrhythmias in patients with bileaflet MVP and MAD as well as outcomes of catheter ablation with an emphasis on sustained, monomorphic ventricular tachycardia (VT). METHODS A total of 18 consecutive patients (11 women, mean age 54 ± 15 years) with bileaflet MVP and MAD underwent catheter ablation for VT, and/or premature ventricular complexes (PVCs). Eight patients had a prior cardiac arrest. RESULTS PVCs were targeted for ablation in all 18 patients (symptomatic PVCs n = 15, PVC-induced ventricular fibrillation n = 3). Sustained monomorphic VT was targeted in 7 of 18 patients. Electroanatomic mapping showed low voltage in the area of the mitral annulus corresponding to VT target sites in 6 of 7 patients with sustained VT. Four of 7 patients had low voltage in the areas of MAD. Six of 7 patients with VT were rendered noninducible post-ablation. The PVC burden was reduced from 11.0% ± 10.4% to 4.0% ± 5.5% (P = 0.004). Over a mean follow-up of 33.9 ± 43.4 months, no VTs recurred. There were no major complications. No repeat ablations for VT occurred. Five of 18 patients required repeat ablation for PVCs. CONCLUSIONS In patients with bileaflet MVP and MAD undergoing catheter ablation, the mitral valve annulus often contains low-voltage areas harboring the substrate for monomorphic VT and PVCs. Ablation in these patients was safe and improved arrhythmia control.
Collapse
Affiliation(s)
- Apurba K Chakrabarti
- Section of Electrophysiology, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Amrish Deshmukh
- Section of Electrophysiology, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jackson J Liang
- Section of Electrophysiology, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Chaitanya Madamanchi
- Section of Electrophysiology, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael Ghannam
- Section of Electrophysiology, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Fred Morady
- Section of Electrophysiology, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Frank Bogun
- Section of Electrophysiology, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA.
| |
Collapse
|
35
|
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
|
36
|
Bazoukis G, Saplaouras A, Vlachos K, Mililis P, Letsas KP, Efremidis M, Liu T, Tse G. Predictors of Ventricular Arrhythmias in Patients With Mitral Valve Prolapse: A Meta-analysis. Cardiol Rev 2023; Publish Ahead of Print:00045415-990000000-00115. [PMID: 37335822 DOI: 10.1097/crd.0000000000000577] [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: 06/21/2023]
Abstract
Mitral valve prolapse (MVP) has an estimated prevalence of 2-3% in the general population. Patients with MVP have an increased risk of ventricular arrhythmic events. The aim of this meta-analysis was to identify easily obtained markers that can be used for the arrhythmic risk stratification of MVP patients. This meta-analysis was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA Statement). The search strategy identified 23 studies that were finally included in the study. The quantitative synthesis showed that late gadolinium enhancement (LGE) [RR 6.40 (2.11-19.39), I2 77%, P = 0.001], longer QTc interval [mean difference: 14.2 (8.92-19.49) I2 0%, P < 0.001], T-wave inversion in inferior leads [RR 1.60 (1.39-1.86), I2 0%, P < 0.001], mitral annular disjunction (MAD) [RR 1.77 (1.29-2.44), I2 37%, P = 0.0005], lower left ventricular ejection fraction (LVEF) [mean difference: -0.77 (-1.48, -0.07) I2 0%, P = 0.03], bileaflet MVP [RR 1.32 (1.16-1.49), I2 0%, P < 0.001], increased anterior [mean difference: 0.45 (0.28, 0.61), I2 0%, P < 0.001] and posterior [mean difference: 0.39 (0.26, 0.52), I2 0%, P < 0.001] mitral leaflet thickness were significantly associated with ventricular arrhythmias in MVP patients. On the other hand, gender, QRS duration, anterior, and posterior mitral leaflet length were not associated with increased risk of arrhythmias. In conclusion, inferior T-wave inversions, QTc interval, LGE, LVEF, MAD, bileaflet MVP, anterior, and posterior mitral leaflet thickness are easily obtained markers that can be used for the risk stratification of patients with MVP. Prospective studies should be designed for the better stratification of this population.
Collapse
Affiliation(s)
- George Bazoukis
- From the Department of Cardiology, Larnaca General Hospital, Larnaca, Cyprus
- Department of Basic and Clinical Sciences, University of Nicosia Medical School, Nicosia, Cyprus
| | | | | | - Panagiotis Mililis
- Onassis Cardiac Surgery Center, Electrophysiology Department, Athens, Greece
| | | | - Michael Efremidis
- Onassis Cardiac Surgery Center, Electrophysiology Department, Athens, Greece
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Gary Tse
- Kent and Medway Medical School, Canterbury, Kent, United Kingdom
| |
Collapse
|
37
|
Guglielmo M, Arangalage D, Bonino MA, Angelini G, Bonanni M, Pontone G, Pascale P, Leo LA, Faletra F, Schwitter J, Pedrazzini G, Monney P, Pavon AG. Additional value of cardiac magnetic resonance feature tracking parameters for the evaluation of the arrhythmic risk in patients with mitral valve prolapse. J Cardiovasc Magn Reson 2023; 25:32. [PMID: 37316826 PMCID: PMC10268415 DOI: 10.1186/s12968-023-00944-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 05/30/2023] [Indexed: 06/16/2023] Open
Abstract
OBJECTIVES The identification of patients with mitral valve prolapse (MVP) presenting high arrhythmic risk remains challenging. Cardiovascular Magnetic Resonance (CMR) feature tracking (FT) may improve risk stratification. We analyzed the role of CMR-FT parameters in relation to the incidence of complex ventricular arrhythmias (cVA) in patients with MVP and mitral annular disjunction (MAD). METHODS 42 patients with MVP and MAD who underwent 1.5 T CMR were classified as MAD-cVA (n = 23, 55%) in case of cVA diagnosed on a 24-h Holter monitoring and as MAD-noVA in the absence of cVA (n = 19, 45%). MAD length, late gadolinium enhancement (LGE), basal segments myocardial extracellular volume (ECV) and CMR-FT were assessed. RESULTS LGE was more frequent in the MAD-cVA group in comparison with the MAD-noVA group (78% vs 42%, p = 0.002) while no difference was observed in terms of basal ECV. Global longitudinal strain (GLS) was reduced in MAD-cVA compared to MAD-noVA (- 18.2% ± 4.6% vs - 25.1% ± 3.1%, p = 0.004) as well as global circumferential strain (GCS) at the mid-ventricular level (- 17.5% ± 4.7% vs - 21.6% ± 3.1%, p = 0.041). Univariate analysis identified as predictors of the incidence of cVA: GCS, circumferential strain (CS) in the basal and mid infero-lateral wall, GLS, regional longitudinal strain (LS) in the basal and mid-ventricular inferolateral wall. Reduced GLS [Odd ratio (OR):1.56 (confidence interval (CI) 95%: 1.45-2.47; p < 0.001)] and regional LS in the basal inferolateral wall [OR: 1.62 (CI 95%: 1.22-2.13; p < 0.001)] remained independent prognostic factors in multivariate analysis. CONCLUSION In patients with MVP and MAD, CMR-FT parameters are correlated with the incidence of cVA and may be of interest in arrhythmic risk stratification.
Collapse
Affiliation(s)
- Marco Guglielmo
- Division of Heart and Lungs, Department of Cardiology, Utrecht University, Utrecht University Medical Center, Utrecht, The Netherlands
- Department of Cardiology, Haga Teaching Hospital, The Hague, The Netherlands
| | - Dimitri Arangalage
- Cardiology Department, AP-HP, Bichat Hospital and Université de Paris, Paris, France
| | | | - Gianmarco Angelini
- Cardiology Unit, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Policlinico of Bari, University Hospital, Bari, Italy
| | - Michela Bonanni
- Department of Experimental Medicine, University of Rome “Tor Vergata”, Rome, Italy
| | | | - Patrizio Pascale
- Division of Cardiology, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Via Tesserete, 48, 6900 Lugano, Switzerland
- Department of Cardiology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- Center for Cardiac Magnetic Resonance of the CHUV (CRMC), Lausanne University Hospital, Lausanne, Switzerland
| | - Laura Anna Leo
- Division of Cardiology, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Via Tesserete, 48, 6900 Lugano, Switzerland
| | - Francesco Faletra
- Division of Cardiology, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Via Tesserete, 48, 6900 Lugano, Switzerland
| | - Jurg Schwitter
- Department of Cardiology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- Center for Cardiac Magnetic Resonance of the CHUV (CRMC), Lausanne University Hospital, Lausanne, Switzerland
- University of Lausanne (UniL), Lausanne, Switzerland
| | - Giovanni Pedrazzini
- Division of Cardiology, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Via Tesserete, 48, 6900 Lugano, Switzerland
| | - Pierre Monney
- Department of Cardiology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- Center for Cardiac Magnetic Resonance of the CHUV (CRMC), Lausanne University Hospital, Lausanne, Switzerland
- University of Lausanne (UniL), Lausanne, Switzerland
| | - Anna Giulia Pavon
- Division of Cardiology, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Via Tesserete, 48, 6900 Lugano, Switzerland
| |
Collapse
|
38
|
Ronco D, Buttiglione G, Garatti A, Parolari A. Biology of mitral valve prolapse: from general mechanisms to advanced molecular patterns-a narrative review. Front Cardiovasc Med 2023; 10:1128195. [PMID: 37332582 PMCID: PMC10272793 DOI: 10.3389/fcvm.2023.1128195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 05/11/2023] [Indexed: 06/20/2023] Open
Abstract
Mitral valve prolapse (MVP) represents the most frequent cause of primary mitral regurgitation. For several years, biological mechanisms underlying this condition attracted the attention of investigators, trying to identify the pathways responsible for such a peculiar condition. In the last ten years, cardiovascular research has moved from general biological mechanisms to altered molecular pathways activation. Overexpression of TGF-β signaling, for instance, was shown to play a key role in MVP, while angiotensin-II receptor blockade was found to limit MVP progression by acting on the same signaling pathway. Concerning extracellular matrix organization, the increased valvular interstitial cells density and dysregulated production of catalytic enzymes (matrix metalloproteinases above all) altering the homeostasis between collagen, elastin and proteoglycan components, have been shown to possibly provide a mechanistic basis contributing to the myxomatous MVP phenotype. Moreover, it has been observed that high levels of osteoprotegerin may contribute to the pathogenesis of MVP by increasing collagen deposition in degenerated mitral leaflets. Although MVP is believed to represent the result of multiple genetic pathways alterations, it is important to distinguish between syndromic and non-syndromic conditions. In the first case, such as in Marfan syndrome, the role of specific genes has been clearly identified, while in the latter a progressively increasing number of genetic loci have been thoroughly investigated. Moreover, genomics is gaining more interest as potential disease-causing genes and loci possibly associated with MVP progression and severity have been identified. Animal models could be of help in better understanding the molecular basis of MVP, possibly providing sufficient information to tackle specific mechanisms aimed at slowing down MVP progression, therefore developing non-surgical therapies impacting on the natural history of this condition. Although continuous progress has been made in this field, further translational studies are advocated to improve our knowledge of biological mechanisms underlying MVP development and progression.
Collapse
Affiliation(s)
- Daniele Ronco
- Department of Congenital Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
- Department of Universitary Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
- Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Gianpiero Buttiglione
- Department of Universitary Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Andrea Garatti
- Department of Universitary Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
| | - Alessandro Parolari
- Department of Universitary Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| |
Collapse
|
39
|
Spampinato RA, Marin-Cuartas M, Kampen A, Fahr F, Sieg F, Strotdrees E, Jahnke C, Klaeske K, Wiesner K, Morningstar JE, Nagata Y, Izquierdo-Garcia D, Dieterlen MT, Norris RA, Levine RA, Paetsch I, Borger MA. Left Ventricular Fibrosis and CMR Tissue Characterization of Papillary Muscles in Mitral Valve Prolapse Patients. RESEARCH SQUARE 2023:rs.3.rs-2936590. [PMID: 37292932 PMCID: PMC10246246 DOI: 10.21203/rs.3.rs-2936590/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Purpose Mitral valve prolapse (MVP) is associated with left ventricle (LV) fibrosis, including the papillary muscles (PM), which is in turn linked to malignant arrhythmias. This study aims to evaluate comprehensive tissue characterization of the PM by cardiovascular magnetic resonance (CMR) imaging and its association with LV fibrosis observed by intraoperative biopsies. Methods MVP patients with indication for surgery due to severe mitral regurgitation (n=19) underwent a preoperative CMR with characterization of the PM: dark-appearance on cine, T1 mapping, conventional bright blood (BB) and dark blood (DB) late gadolinium enhancement (LGE). CMR T1 mapping was performed on 21 healthy volunteers as controls. LV inferobasal myocardial biopsies were obtained in MVP patients and compared to CMR findings. Results MVP patients (54±10 years old, 14 male) had a dark-appearance of the PM with higher native T1 and extracellular volume (ECV) values compared with healthy volunteers (1096±78ms vs 994±54ms and 33.9±5.6% vs 25.9±3.1%, respectively, p<0.001). Seventeen MVP patients (89.5%) had fibrosis by biopsy. BB-LGE+ in LV and PM was identified in 5 (26.3%) patients, while DB-LGE+ was observed in LV in 9 (47.4%) and in PM in 15 (78.9%) patients. DB-LGE+ in PM was the only technique that showed no difference with detection of LV fibrosis by biopsy. Posteromedial PM was more frequently affected than the anterolateral (73.7% vs 36.8%, p=0.039) and correlated with biopsy-proven LV fibrosis (Rho 0.529, p=0.029). Conclusions CMR imaging in MVP patients referred for surgery shows a dark-appearance of the PM with higher T1 and ECV values compared with healthy volunteers. The presence of a positive DB-LGE at the posteromedial PM by CMR may serve as a better predictor of biopsy-proven LV inferobasal fibrosis than conventional CMR techniques.
Collapse
|
40
|
van Kampen A, Morningstar JE, Goudot G, Ingels N, Wenk JF, Nagata Y, Yaghoubian KM, Norris RA, Borger MA, Melnitchouk S, Levine RA, Jensen MO. Utilization of Engineering Advances for Detailed Biomechanical Characterization of the Mitral-Ventricular Relationship to Optimize Repair Strategies: A Comprehensive Review. Bioengineering (Basel) 2023; 10:601. [PMID: 37237671 PMCID: PMC10215167 DOI: 10.3390/bioengineering10050601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/10/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023] Open
Abstract
The geometrical details and biomechanical relationships of the mitral valve-left ventricular apparatus are very complex and have posed as an area of research interest for decades. These characteristics play a major role in identifying and perfecting the optimal approaches to treat diseases of this system when the restoration of biomechanical and mechano-biological conditions becomes the main target. Over the years, engineering approaches have helped to revolutionize the field in this regard. Furthermore, advanced modelling modalities have contributed greatly to the development of novel devices and less invasive strategies. This article provides an overview and narrative of the evolution of mitral valve therapy with special focus on two diseases frequently encountered by cardiac surgeons and interventional cardiologists: ischemic and degenerative mitral regurgitation.
Collapse
Affiliation(s)
- Antonia van Kampen
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- Leipzig Heart Centre, University Clinic of Cardiac Surgery, 02189 Leipzig, Germany
| | - Jordan E. Morningstar
- Department of Regenerative Medicine and Cell Biology, University of South Carolina, Charleston, SC 29425, USA
| | - Guillaume Goudot
- Cardiac Ultrasound Laboratory, Department of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Neil Ingels
- Department of Biomedical Engineering, University of Arkansas, Fayetteville, AR 72701, USA
| | - Jonathan F. Wenk
- Department of Mechanical Engineering, University of Kentucky, Lexington, KY 40508, USA;
| | - Yasufumi Nagata
- Cardiac Ultrasound Laboratory, Department of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Koushiar M. Yaghoubian
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Russell A. Norris
- Department of Regenerative Medicine and Cell Biology, University of South Carolina, Charleston, SC 29425, USA
| | - Michael A. Borger
- Leipzig Heart Centre, University Clinic of Cardiac Surgery, 02189 Leipzig, Germany
| | - Serguei Melnitchouk
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Robert A. Levine
- Cardiac Ultrasound Laboratory, Department of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Morten O. Jensen
- Department of Biomedical Engineering, University of Arkansas, Fayetteville, AR 72701, USA
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
| |
Collapse
|
41
|
el Mathari S, Kluin J, Hopman LHGA, Bhagirath P, Oudeman MAP, Vonk ABA, Nederveen AJ, Eberl S, Klautz RJM, Chamuleau SAJ, van Ooij P, Götte MJW. The role and implications of left atrial fibrosis in surgical mitral valve repair as assessed by CMR: the ALIVE study design and rationale. Front Cardiovasc Med 2023; 10:1166703. [PMID: 37252116 PMCID: PMC10213679 DOI: 10.3389/fcvm.2023.1166703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 04/03/2023] [Indexed: 05/31/2023] Open
Abstract
Background Patients with mitral regurgitation (MR) commonly suffer from left atrial (LA) remodeling. LA fibrosis is considered to be a key player in the LA remodeling process, as observed in atrial fibrillation (AF) patients. Literature on the presence and extent of LA fibrosis in MR patients however, is scarce and its clinical implications remain unknown. Therefore, the ALIVE trial was designed to investigate the presence of LA remodeling including LA fibrosis in MR patients prior to and after mitral valve repair (MVR) surgery. Methods The ALIVE trial is a single center, prospective pilot study investigating LA fibrosis in patients suffering from MR in the absence of AF (identifier NCT05345730). In total, 20 participants will undergo a CMR scan including 3D late gadolinium enhancement (LGE) imaging 2 week prior to MVR surgery and at 3 months follow-up. The primary objective of the ALIVE trial is to assess the extent and geometric distribution of LA fibrosis in MR patients and to determine effects of MVR surgery on reversed atrial remodelling. Implications This study will provide novel insights into the pathophysiological mechanism of fibrotic and volumetric atrial (reversed) remodeling in MR patients undergoing MVR surgery. Our results may contribute to improved clinical decision making and patient-specific treatment strategies in patients suffering from MR.
Collapse
Affiliation(s)
- Sulayman el Mathari
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Jolanda Kluin
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, Amsterdam, Netherlands
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Luuk H. G. A. Hopman
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Pranav Bhagirath
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Maurice A. P. Oudeman
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Alexander B. A. Vonk
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Aart J. Nederveen
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Susanne Eberl
- Department of Anesthesiology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Robert J. M. Klautz
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, Amsterdam, Netherlands
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Rotterdam, Netherlands
| | | | - Pim van Ooij
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Marco J. W. Götte
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, Netherlands
| |
Collapse
|
42
|
Nagata Y, Bertrand PB, Baliyan V, Kochav J, Kagan RD, Ujka K, Alfraidi H, van Kampen A, Morningstar JE, Dal-Bianco JP, Melnitchouk S, Holmvang G, Borger MA, Moore R, Hua L, Sultana R, Calle PV, Yum B, Guerrero JL, Neilan TG, Picard MH, Kim J, Delling FN, Hung J, Norris RA, Weinsaft JW, Levine RA. Abnormal Mechanics Relate to Myocardial Fibrosis and Ventricular Arrhythmias in Patients With Mitral Valve Prolapse. Circ Cardiovasc Imaging 2023; 16:e014963. [PMID: 37071717 PMCID: PMC10108844 DOI: 10.1161/circimaging.122.014963] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 03/08/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND The relation between ventricular arrhythmia and fibrosis in mitral valve prolapse (MVP) is reported, but underlying valve-induced mechanisms remain unknown. We evaluated the association between abnormal MVP-related mechanics and myocardial fibrosis, and their association with arrhythmia. METHODS We studied 113 patients with MVP with both echocardiogram and gadolinium cardiac magnetic resonance imaging for myocardial fibrosis. Two-dimensional and speckle-tracking echocardiography evaluated mitral regurgitation, superior leaflet and papillary muscle displacement with associated exaggerated basal myocardial systolic curling, and myocardial longitudinal strain. Follow-up assessed arrhythmic events (nonsustained or sustained ventricular tachycardia or ventricular fibrillation). RESULTS Myocardial fibrosis was observed in 43 patients with MVP, predominantly in the basal-midventricular inferior-lateral wall and papillary muscles. Patients with MVP with fibrosis had greater mitral regurgitation, prolapse, and superior papillary muscle displacement with basal curling and more impaired inferior-posterior basal strain than those without fibrosis (P<0.001). An abnormal strain pattern with distinct peaks pre-end-systole and post-end-systole in inferior-lateral wall was frequent in patients with fibrosis (81 versus 26%, P<0.001) but absent in patients without MVP with basal inferior-lateral wall fibrosis (n=20). During median follow-up of 1008 days, 36 of 87 patients with MVP with >6-month follow-up developed ventricular arrhythmias associated (univariable) with fibrosis, greater prolapse, mitral annular disjunction, and double-peak strain. In multivariable analysis, double-peak strain showed incremental risk of arrhythmia over fibrosis. CONCLUSIONS Basal inferior-posterior myocardial fibrosis in MVP is associated with abnormal MVP-related myocardial mechanics, which are potentially associated with ventricular arrhythmia. These associations suggest pathophysiological links between MVP-related mechanical abnormalities and myocardial fibrosis, which also may relate to ventricular arrhythmia and offer potential imaging markers of increased arrhythmic risk.
Collapse
Affiliation(s)
- Yasufumi Nagata
- Cardiac Ultrasound Laboratory (Y.N., P.B.B., H.A., J.P.D.-B., L.H., M.H.P., J.H., R.A.L.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Philippe B. Bertrand
- Cardiac Ultrasound Laboratory (Y.N., P.B.B., H.A., J.P.D.-B., L.H., M.H.P., J.H., R.A.L.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Vinit Baliyan
- Department of Radiology (V.B., G.H.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jonathan Kochav
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, New York, NY (J. Kochav, R.D.K., R.S., P.V.C., B.Y., J. Kim, J.W.W.)
| | - Ruth D. Kagan
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, New York, NY (J. Kochav, R.D.K., R.S., P.V.C., B.Y., J. Kim, J.W.W.)
| | - Kristian Ujka
- School of Cardiovascular Disease, University of Pisa, Italy (K.U.)
| | - Hassan Alfraidi
- Cardiac Ultrasound Laboratory (Y.N., P.B.B., H.A., J.P.D.-B., L.H., M.H.P., J.H., R.A.L.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Antonia van Kampen
- Cardiac Surgery (A.v.K., S.M.), Massachusetts General Hospital, Harvard Medical School, Boston
- University Department for Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Saxony, Germany (A.v.K., M.A.B.)
| | - Jordan E. Morningstar
- Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston (J.E.M., R.M., R.A.N.)
| | - Jacob P. Dal-Bianco
- Cardiac Ultrasound Laboratory (Y.N., P.B.B., H.A., J.P.D.-B., L.H., M.H.P., J.H., R.A.L.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Serguei Melnitchouk
- Cardiac Surgery (A.v.K., S.M.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Godtfred Holmvang
- Department of Radiology (V.B., G.H.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Michael A. Borger
- University Department for Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Saxony, Germany (A.v.K., M.A.B.)
| | - Reece Moore
- Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston (J.E.M., R.M., R.A.N.)
| | - Lanqi Hua
- Cardiac Ultrasound Laboratory (Y.N., P.B.B., H.A., J.P.D.-B., L.H., M.H.P., J.H., R.A.L.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Razia Sultana
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, New York, NY (J. Kochav, R.D.K., R.S., P.V.C., B.Y., J. Kim, J.W.W.)
| | - Pablo Villar Calle
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, New York, NY (J. Kochav, R.D.K., R.S., P.V.C., B.Y., J. Kim, J.W.W.)
| | - Brian Yum
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, New York, NY (J. Kochav, R.D.K., R.S., P.V.C., B.Y., J. Kim, J.W.W.)
| | - J. Luis Guerrero
- Surgical Cardiovascular Laboratory (J.L.G.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Tomas G. Neilan
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston (T.G.N.)
| | - Michael H. Picard
- Cardiac Ultrasound Laboratory (Y.N., P.B.B., H.A., J.P.D.-B., L.H., M.H.P., J.H., R.A.L.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jiwon Kim
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, New York, NY (J. Kochav, R.D.K., R.S., P.V.C., B.Y., J. Kim, J.W.W.)
| | - Francesca N. Delling
- Division of Cardiovascular Medicine, University of California, San Francisco (F.N.D.)
| | - Judy Hung
- Cardiac Ultrasound Laboratory (Y.N., P.B.B., H.A., J.P.D.-B., L.H., M.H.P., J.H., R.A.L.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Russell A. Norris
- Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston (J.E.M., R.M., R.A.N.)
| | - Jonathan W. Weinsaft
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, New York, NY (J. Kochav, R.D.K., R.S., P.V.C., B.Y., J. Kim, J.W.W.)
| | - Robert A. Levine
- Cardiac Ultrasound Laboratory (Y.N., P.B.B., H.A., J.P.D.-B., L.H., M.H.P., J.H., R.A.L.), Massachusetts General Hospital, Harvard Medical School, Boston
| |
Collapse
|
43
|
Battaglia V, Santangelo G, Bursi F, Simeoli P, Guazzi M. Arrhythmogenic Mitral Valve Prolapse and Sudden Cardiac Death: An Update and Current Perspectives. Curr Probl Cardiol 2023; 48:101724. [PMID: 36967070 DOI: 10.1016/j.cpcardiol.2023.101724] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 03/22/2023] [Indexed: 04/22/2023]
Abstract
Mitral valve prolapse (MVP) affects about 2% to 3% of the general population, mostly women, and is the most common cause of primary chronic mitral regurgitation (MR) in western countries. The natural history is heterogeneous and widely determined by the severity of MR. Although most patients remain asymptomatic with a near-normal life expectancy, approximately 5% to 10 % progress to severe MR. As largely recognized, left ventricular (LV) dysfunction due to chronic volume overload per se identifies a subgroup at risk of cardiac death. However, there is rising evidence of a link between MVP and life threating ventricular arrhythmias (VAs)/sudden cardiac death (SCD) in a small subset of middle-aged patients without significant MR, heart failure and remodeled hearts. The present review focuses on the underlying mechanism of electric instability and unexpected cardiac death in this subset of young patients, from the myocardial scarring of the LV infero-lateral wall due to mechanical stretch exerted by the prolapsing leaflets and mitral annular disjunction, to the inflammation's impact on fibrosis pathways along with a constitutional hyperadrenergic state. The heterogeneity of clinical course reveals a necessity of risk stratification, preferably through noninvasive multimodality imaging, that will help to identify and prevent adverse scenarios in young MVP patients.
Collapse
Affiliation(s)
- Valeria Battaglia
- Division of Cardiology, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan, Italy.
| | - Gloria Santangelo
- Division of Cardiology, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan, Italy
| | - Francesca Bursi
- Division of Cardiology, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan, Italy
| | - Pasquale Simeoli
- Division of Cardiology, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan, Italy
| | - Marco Guazzi
- Division of Cardiology, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan, Italy
| |
Collapse
|
44
|
Essayagh B, Benfari G, Antoine C, Grigioni F, Le Tourneau T, Roussel JC, Bax JJ, Delgado V, Ajmone Marsan N, van Wijngaarden A, Tribouilloy C, Rusinaru D, Hochstadt A, Topilsky Y, Thapa P, Michelena HI, Enriquez-Sarano M. The MIDA-Q Mortality Risk Score: A Quantitative Prognostic Tool for the Mitral Valve Prolapse Spectrum. Circulation 2023; 147:798-811. [PMID: 36573420 DOI: 10.1161/circulationaha.122.062612] [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: 10/31/2022] [Accepted: 12/06/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND Mitral valve prolapse (MVP) is responsible for a considerable disease burden but is widely heterogeneous. The lack of a comprehensive prognostic instrument covering the entire MVP spectrum, encompassing the quantified consequent degenerative mitral regurgitation (DMR), hinders clinical management and therapeutic trials. METHODS The new Mitral Regurgitation International Database Quantitative (MIDA-Q) registry enrolled 8187 consecutive patients (ages 63±16 years, 47% women, follow-up 5.5±3.3 years) first diagnosed with isolated MVP, without or with DMR quantified prospectively (measuring effective regurgitant orifice [ERO] and regurgitant volume) in routine practice of 5 tertiary care centers from North America, Europe, and the Middle East. The MIDA-Q score ranges from 0 to 15 by accumulating guideline-based risk factors and DMR severity. Long-term survival under medical management was the primary outcome end point. RESULTS MVP was associated with DMR absent/mild (ERO <20 mm2) in 50%, moderate (ERO 20-40 mm2) in 25%, and severe or higher (ERO ≥40 mm2) in 25%, with mean ERO 24±24 mm2, regurgitant volume 37±35 mL. Median MIDA-Q score was 4 with a wide distribution (10%-90% range, 0-9). MIDA-Q score was higher in patients with EuroScore II ≥1% versus <1% (median, 7 versus 3; P < 0.0001) but with wide overlap (10%-90% range, 4-11 versus 0-7) and mediocre correlation (R2 0.18). Five-year survival under medical management was strongly associated with MIDA-Q score, 97±1% with score 0, 95±1% with score 1 to 2, 82±1% with score 3 to 4, 67±1% with score 5 to 6, 60±1% with score 7 to 8, 44±1% with score 9 to 10, 35±1% with score 11 to 12, and 5±4% with MIDA-Q score ≥13, with hazard ratio 1.31 [1.29-1.33] per 1-point increment. Excess mortality with higher MIDA-Q scores persisted after adjustment for age, sex, and EuroScore II (adjusted hazard ratio, 1.13 [1.11-1.15] per 1-point increment). Subgroup analysis showed persistent association of MIDA-Q score with mortality in all possible subsets, in particular, with EuroScore II<1% (hazard ratio, 1.08 [1.02-1.14]) or ≥1% (hazard ratio, 1.11 [1.08-1.13]) and with no/mild DMR (hazard ratio, 1.14 [1.10-1.19]) or moderate/severe DMR (hazard ratio, 1.13 [1.10-1.16], all per 1-point increment with P<0.0001). Nested-model and bootstrapping analyses demonstrated incremental prognostic power of MIDA-Q score (all P<0.0001). CONCLUSIONS This large, international cohort of isolated MVP, with prospective DMR quantification in routine practice, demonstrates the wide range of risk factor accumulation and considerable heterogeneity of outcomes after MVP diagnosis. The MIDA-Q score is strongly, independently, and incrementally associated with long-term survival after MVP diagnosis, irrespective of presentation, and is therefore a crucial prognostic instrument for risk stratification, clinical trials, and management of patients diagnosed with all forms of MVP.
Collapse
Affiliation(s)
- Benjamin Essayagh
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (B.E., G.B., C.A., P.T., H.I.M., M.E.-S.)
- Division of Cardiovascular Diseases, Simone Veil Hospital, Cannes, France (B.E.)
| | - Giovanni Benfari
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (B.E., G.B., C.A., P.T., H.I.M., M.E.-S.)
| | - Clemence Antoine
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (B.E., G.B., C.A., P.T., H.I.M., M.E.-S.)
| | - Francesco Grigioni
- Department of Cardiology, University Campus Bio-Medico, Rome, Italy (F.G.)
| | | | | | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, The Netherlands (J.J.B., V.D., N.A.M., A.v.W.)
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, The Netherlands (J.J.B., V.D., N.A.M., A.v.W.)
- Heart Institute, Hospital University Germans Trias i Pujol, Badalona, Spain (V.D.)
| | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Center, The Netherlands (J.J.B., V.D., N.A.M., A.v.W.)
| | - Aniek van Wijngaarden
- Department of Cardiology, Leiden University Medical Center, The Netherlands (J.J.B., V.D., N.A.M., A.v.W.)
| | | | - Dan Rusinaru
- Department of Cardiology, University of Amiens, France (C.T., D.R.)
| | - Aviram Hochstadt
- Heart Institute, Wolfson Medical Center and the Sackler Faculty of Medicine, Tel-Aviv University, Israel (A.H.)
| | - Yan Topilsky
- Department of Cardiology, Tel Aviv Medical Center and Sackler Faculty of Medicine, Israel (Y.T.)
| | - Prabin Thapa
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (B.E., G.B., C.A., P.T., H.I.M., M.E.-S.)
| | - Hector I Michelena
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (B.E., G.B., C.A., P.T., H.I.M., M.E.-S.)
| | - Maurice Enriquez-Sarano
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (B.E., G.B., C.A., P.T., H.I.M., M.E.-S.)
- Minneapolis Heart Institute, MN (M.E.-S.)
| |
Collapse
|
45
|
Dieterlen MT, Klaeske K, Spampinato R, Marin-Cuartas M, Wiesner K, Morningstar J, Norris RA, Melnitchouk S, Levine RA, van Kampen A, Borger MA. Histopathological insights into mitral valve prolapse-induced fibrosis. Front Cardiovasc Med 2023; 10:1057986. [PMID: 36960475 PMCID: PMC10028262 DOI: 10.3389/fcvm.2023.1057986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 02/16/2023] [Indexed: 03/09/2023] Open
Abstract
Mitral valve prolapse (MVP) is a cardiac valve disease that not only affects the mitral valve (MV), provoking mitral regurgitation, but also leads to maladaptive structural changes in the heart. Such structural changes include the formation of left ventricular (LV) regionalized fibrosis, especially affecting the papillary muscles and inferobasal LV wall. The occurrence of regional fibrosis in MVP patients is hypothesized to be a consequence of increased mechanical stress on the papillary muscles and surrounding myocardium during systole and altered mitral annular motion. These mechanisms appear to induce fibrosis in valve-linked regions, independent of volume-overload remodeling effects of mitral regurgitation. In clinical practice, quantification of myocardial fibrosis is performed with cardiovascular magnetic resonance (CMR) imaging, even though CMR has sensitivity limitations in detecting myocardial fibrosis, especially in detecting interstitial fibrosis. Regional LV fibrosis is clinically relevant because even in the absence of mitral regurgitation, it has been associated with ventricular arrhythmias and sudden cardiac death in MVP patients. Myocardial fibrosis may also be associated with LV dysfunction following MV surgery. The current article provides an overview of current histopathological studies investigating LV fibrosis and remodeling in MVP patients. In addition, we elucidate the ability of histopathological studies to quantify fibrotic remodeling in MVP and gain deeper understanding of the pathophysiological processes. Furthermore, molecular changes such as alterations in collagen expression in MVP patients are reviewed.
Collapse
Affiliation(s)
- Maja-Theresa Dieterlen
- University Department of Cardiac Surgery, Heart Center Leipzig, HELIOS Clinic, Leipzig, Germany
| | - Kristin Klaeske
- University Department of Cardiac Surgery, Heart Center Leipzig, HELIOS Clinic, Leipzig, Germany
| | - Ricardo Spampinato
- University Department of Cardiac Surgery, Heart Center Leipzig, HELIOS Clinic, Leipzig, Germany
| | - Mateo Marin-Cuartas
- University Department of Cardiac Surgery, Heart Center Leipzig, HELIOS Clinic, Leipzig, Germany
| | - Karoline Wiesner
- University Department of Cardiac Surgery, Heart Center Leipzig, HELIOS Clinic, Leipzig, Germany
| | - Jordan Morningstar
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC, United States
| | - Russell A. Norris
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC, United States
| | - Serguei Melnitchouk
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Robert A. Levine
- Cardiac Ultrasound Laboratory, Harvard Medical School, Massachusetts General Hospital, Boston, MA, United States
| | - Antonia van Kampen
- University Department of Cardiac Surgery, Heart Center Leipzig, HELIOS Clinic, Leipzig, Germany
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Michael A. Borger
- University Department of Cardiac Surgery, Heart Center Leipzig, HELIOS Clinic, Leipzig, Germany
| |
Collapse
|
46
|
Kuzhel DA, Matyushin GV, Savchenko EA. Arrhythmic Mitral Valve Prolapse: New Menaces of the Known Disease. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2023. [DOI: 10.20996/1819-6446-2023-01-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023] Open
Abstract
Mitral valve prolapse (MVP) has long been the subject of intense discussions regarding the prognosis and follow-up tactics. In most cases, this condition has a benign prognosis. However, recent autopsy and follow-up studies have shown risks of developing sudden cardiac death (SCD) in some subgroups of patients who have this clinical phenomenon. The proposed literature review uses the population of patients with MVP with the highest probability of developing life-threatening ventricular tachyarrhythmias. Patients with the presence of a complex of changes, including bicuspid MVP, negative T waves in the inferior and lateral leads on a standard 12-lead electrocardiogram (ECG), and a special anatomical phenomenon called mitral annular disjunction (MAD), are at high risk of developing ventricular ectopias and VSS. A reflection of the high risk of SCD in such patients is the increase of ventricular ectopy according to Holter monitoring. The presence of a bicuspid MVP and the MAD phenomenon, which is a separation of the line of attachment of the posterior mitral leaflet from the basal inferior wall segment towards the atrial wall, determines the presence of a special form of MVP, the so-called arrhythmogenic MVP. Hence, in most cases MVP has a benign prognosis. However, patients with the aforementioned ar- rhythmic MVP signs must be given particular attention and annual follow-up including ECG control, Holter monitoring and echocardiographic examination of the heart to reduce the risk of ventricular tachyarrhythmias and SCD development.
Collapse
Affiliation(s)
- D. A. Kuzhel
- Professor V.F. Voyno-Yasenetsky Krasnoyarsk State Medical University; Regional state hospital №2
| | - G. V. Matyushin
- Professor V.F. Voyno-Yasenetsky Krasnoyarsk State Medical University
| | - E. A. Savchenko
- Professor V.F. Voyno-Yasenetsky Krasnoyarsk State Medical University
| |
Collapse
|
47
|
Acute and Chronic Changes in Myocardial Work Parameters in Patients with Severe Primary Mitral Regurgitation Undergoing Transcatheter Edge-to-Edge Repair. J Cardiovasc Dev Dis 2023; 10:jcdd10030100. [PMID: 36975864 PMCID: PMC10051684 DOI: 10.3390/jcdd10030100] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 02/21/2023] [Accepted: 02/24/2023] [Indexed: 03/03/2023] Open
Abstract
Background: The noninvasive assessment of myocardial work (MW) allows for the evaluation of left ventricular (LV) performance by considering the effect of LV afterload. This study aims to evaluate the acute and chronic impact of transcatheter edge-to-edge repair (TEER) on MW parameters and LV remodeling in patients with severe primary mitral regurgitation (PMR). Methods: A total of 71 patients (age: 77 ± 9 years, females: 44%) with moderate–to-severe or severe PMR (effective regurgitant orifice: 0.57 ± 0.31 cm2; regurgitant volume: 80 ± 34 mL; LV end-systolic diameter: 42 ± 12 mm) underwent TEER after a global assessment by the heart team. MW indices were evaluated before the procedure, at hospital discharge, and at 1-year follow-up. LV remodeling was described as the percentage variation in LVEDV between baseline and 1-year follow-up. Results: TEER caused an acute reduction in LVEF, global longitudinal strain (GLS), global MW index (GWI), work efficiency (GWE), and mechanical dispersion (MD) and a significant increase in wasted work (GWW). One year after the procedure, GLS, GWI, GWE, and MD recovered, whereas GWW remained significantly impaired. Baseline GWW (β = −0.29, p = 0.03) was an independent predictor of LV reverse remodeling at 1-year follow-up. Conclusions: In patients with severe PMR undergoing TEER, the acute reduction in LV preload causes significant impairment to all the parameters of LV performance. Baseline GWW was the only independent predictor of LV reverse remodeling, suggesting that a lower myocardial energetic efficiency in the context of chronic preload increase might impact the left ventricular response to mitral regurgitation correction.
Collapse
|
48
|
Kubala M, Essayagh B, Michelena HI, Enriquez-Sarano M, Tribouilloy C. Arrhythmic mitral valve prolapse in 2023: Evidence-based update. Front Cardiovasc Med 2023; 10:1130174. [PMID: 37144062 PMCID: PMC10153002 DOI: 10.3389/fcvm.2023.1130174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 04/03/2023] [Indexed: 05/06/2023] Open
Abstract
Patients with mitral valve prolapse (MVP) may develop ventricular arrhythmias, ranging from premature ventricular contractions through more complex non-sustained ventricular tachycardia to sustained life-threatening ventricular arrhythmias. The prevalence of MVP in autopsy series of young adults who died suddenly has been estimated to be between 4% and 7%. Thus, "arrhythmic MVP" has been reported as an underappreciated cause of sudden cardiac death, leading to a renewed interest in the study of this association. The term "arrhythmic MVP" refers to a small subset of patients who have, in the absence of any other arrhythmic substrate, MVP, with or without mitral annular disjunction, and frequent or complex ventricular arrhythmias. Our understanding of their coexistence in terms of contemporary management and prognosis is still incomplete. While literature regarding the arrhythmic MVP may be contrasting despite recent consensus document, the present review summarizes the relevant evidence concerning the diagnostic approach, prognostic implications, and targeted therapies for MVP-related ventricular arrhythmias. We also summarize recent data supporting left ventricular remodeling, which complicates the coexistence of MVP with ventricular arrhythmias. As the evidence for a putative link between MVP-associated ventricular arrhythmias and sudden cardiac death is scarce and based on scant and retrospective data, risk prediction remains a challenge. Thus, we aimed at listing potential risk factors from available seminal reports for further use in a more reliable prediction model that requires additional prospective data. Finally, we summarize evidence and guidelines on targeted therapies of ventricular arrhythmias in the setting of MVP, including implantable cardioverter defibrillators and catheter ablation. Our review highlights current knowledge gaps and provides an action plan for structured research on the pathophysiological genesis, diagnosis, prognostic impact, and optimal management of patients with arrhythmic MVP.
Collapse
Affiliation(s)
- Maciej Kubala
- Department of Cardiology, Amiens University Hospital, Amiens, France
- EA 7517, Jules Verne University of Picardie, Amiens, France
| | - Benjamin Essayagh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
- Department of Echocardiography, Cardio X Clinic, France
| | - Hector I. Michelena
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | | | - Christophe Tribouilloy
- Department of Cardiology, Amiens University Hospital, Amiens, France
- EA 7517, Jules Verne University of Picardie, Amiens, France
- Correspondence: Christophe Tribouilloy
| |
Collapse
|
49
|
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
|
50
|
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
|