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Gorecka M, Craven TP, Jex N, Chew PG, Dobson LE, Brown LAE, Higgins DM, Thirunavukarasu S, Sharrack N, Javed W, Kotha S, Giannoudi M, Procter H, Parent M, Schlosshan D, Swoboda PP, Plein S, Levelt E, Greenwood JP. Mitral regurgitation assessment by cardiovascular magnetic resonance imaging during continuous in-scanner exercise: a feasibility study. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2024; 40:1543-1553. [PMID: 38780711 DOI: 10.1007/s10554-024-03141-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 05/13/2024] [Indexed: 05/25/2024]
Abstract
PURPOSE Exercise imaging using current modalities can be challenging. This was patient focused study to establish the feasibility and reproducibility of exercise-cardiovascular magnetic resonance imaging (EX-CMR) acquired during continuous in-scanner exercise in asymptomatic patients with primary mitral regurgitation (MR). METHODS This was a prospective, feasibility study. Biventricular volumes/function, aortic flow volume, MR volume (MR-Rvol) and regurgitant fraction (MR-RF) were assessed at rest and during low- (Low-EX) and moderate-intensity exercise (Mod-EX) in asymptomatic patients with primary MR. RESULTS Twenty-five patients completed EX-CMR without complications. Whilst there were no significant changes in the left ventricular (LV) volumes, there was a significant increase in the LVEF (rest 63 ± 5% vs. Mod-EX 68 ± 6%;p = 0.01). There was a significant reduction in the right ventricular (RV) end-systolic volume (rest 68 ml(60-75) vs. Mod-EX 46 ml(39-59);p < 0.001) and a significant increase in the RV ejection fraction (rest 55 ± 5% vs. Mod-EX 65 ± 8%;p < 0.001). Whilst overall, there were no significant group changes in the MR-Rvol and MR-RF, individual responses were variable, with MR-Rvol increasing by ≥ 15 ml in 4(16%) patients and decreasing by ≥ 15 ml in 9(36%) of patients. The intra- and inter-observer reproducibility of LV volumes and aortic flow measurements were excellent, including at Mod-EX. CONCLUSION EX-CMR is feasible and reproducible in patients with primary MR. During exercise, there is an increase in the LV and RV ejection fraction, reduction in the RV end-systolic volume and a variable response of MR-Rvol and MR-RF. Understanding the individual variability in MR-Rvol and MR-RF during physiological exercise may be clinically important.
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Affiliation(s)
- Miroslawa Gorecka
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK
| | - Thomas P Craven
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK
| | - Nick Jex
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK
| | - Pei G Chew
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK
| | - Laura E Dobson
- Department of Cardiology, Wythenshawe Hospital, Manchester University NHS Trust, Manchester, UK
| | - Louise A E Brown
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK
| | | | - Sharmaine Thirunavukarasu
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK
| | - Noor Sharrack
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK
| | - Wasim Javed
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK
| | - Sindhoora Kotha
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK
| | - Marilena Giannoudi
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK
| | - Henry Procter
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK
| | - Martine Parent
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK
| | - Dominik Schlosshan
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK
| | - Peter P Swoboda
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK
| | - Sven Plein
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK
| | - Eylem Levelt
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK
| | - John P Greenwood
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK.
- Baker Heart and Diabetes Institute & Monash University, Melbourne, Australia.
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Dandel M. It is time to think about further optimization of the echocardiographic assessment of left ventricular responses to mitral regurgitation. Int J Cardiol 2024; 401:131841. [PMID: 38340988 DOI: 10.1016/j.ijcard.2024.131841] [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: 01/17/2024] [Accepted: 02/07/2024] [Indexed: 02/12/2024]
Affiliation(s)
- Michael Dandel
- German Centre for Heart and Circulatory Research (DZHK), German Centre for Cardiovascular Research (DZHK), Potsdamer Str., 5810785 Berlin, Germany.
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3
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Gentile F, Buoncristiani F, Sciarrone P, Bazan L, Panichella G, Gasparini S, Chubuchny V, Taddei C, Poggianti E, Fabiani I, Petersen C, Lancellotti P, Passino C, Emdin M, Giannoni A. Left ventricular outflow tract velocity-time integral improves outcome prediction in patients with secondary mitral regurgitation. Int J Cardiol 2023; 392:131272. [PMID: 37604287 DOI: 10.1016/j.ijcard.2023.131272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/12/2023] [Accepted: 08/17/2023] [Indexed: 08/23/2023]
Abstract
AIMS Left ventricular outflow velocity-time integral (LVOT-VTI) has been shown to improve outcome prediction in different patients' subsets, with or without heart failure (HF). Nevertheless, the prognostic value of LVOT-VTI in patients with HF and secondary mitral regurgitation (MR) has never been investigated so far. Therefore, in the present study, we aimed to assess the prognostic value different metrics of LV forward output, including LVOT-VTI, in HF patients with secondary MR. METHODS AND RESULTS Consecutive patients with HF and moderate-to-severe/severe secondary MR and systolic dysfunction (i.e., left ventricular ejection fraction [LVEF] <50%) were retrospectively selected and followed-up for the primary endpoint of cardiac death. Out of the 287 patients analyzed (aged 74 ± 11 years, 70% men, 46% ischemic etiology, mean LVEF 30 ± 9%, mean LVOT-VTI 20 ± 5 cm), 71 met the primary endpoint over a 33-month median follow-up (16-47 months). Patients with an LVOT-VTI ≤17 cm (n = 96, 32%) showed the greatest risk of cardiac death (Log Rank 44.3, p < 0.001) and all-cause mortality (Log rank 8.6, p = 0.003). At multivariable regression analysis, all the measures of LV forward volume (namely LVOT-VTI, stroke volume index, cardiac output, and cardiac index) were predictors of poor outcomes. Among these, LVOT-VTI was the most accurate in risk prediction (univariable C-statistics 0.70 [95%CI 0.64-0.77]). CONCLUSION Left ventricular forward output, noninvasively estimated through LVOT-VTI, improves outcome prediction in HF patients with low LVEF and secondary MR.
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Affiliation(s)
- Francesco Gentile
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | | | | | - Lorenzo Bazan
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Giorgia Panichella
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Simone Gasparini
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | | | | | | | | | | | - Patrizio Lancellotti
- University of Liège Hospital, Cardiology Department, GIGA Cardiovascular Sciences, CHU Sart Tilman, Liège, Belgium; Gruppo Villa Maria Care and Research, Maria Cecilia Hospital, Cotignola, and Anthea Hospital, Bari, Italy
| | - Claudio Passino
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Michele Emdin
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Alberto Giannoni
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione Toscana Gabriele Monasterio, Pisa, Italy.
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Osswald A, Shehada SE, Zubarevich A, Kamler M, Thielmann M, Sommer W, Weymann A, Ruhparwar A, El Gabry M, Schmack B. Short-term mechanical support with the Impella 5.x for mitral valve surgery in advanced heart failure-protected cardiac surgery. Front Cardiovasc Med 2023; 10:1229336. [PMID: 37547249 PMCID: PMC10400355 DOI: 10.3389/fcvm.2023.1229336] [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: 05/26/2023] [Accepted: 06/26/2023] [Indexed: 08/08/2023] Open
Abstract
Introduction Surgical treatment of patients with mitral valve regurgitation and advanced heart failure remains challenging. In order to avoid peri-operative low cardiac output, Impella 5.0 or 5.5 (5.x), implanted electively in a one-stage procedure, may serve as a peri-operative short-term mechanical circulatory support system (st-MCS) in patients undergoing mitral valve surgery. Methods Between July 2017 and April 2022, 11 consecutive patients underwent high-risk mitral valve surgery for mitral regurgitation supported with an Impella 5.x system (Abiomed, Inc. Danvers, MA). All patients were discussed in the heart team and were either not eligible for transcatheter edge-to-edge repair (TEER) or surgery was considered favorable. In all cases, the indication for Impella 5.x implantation was made during the preoperative planning phase. Results The mean age at the time of surgery was 61.6 ± 7.7 years. All patients presented with mitral regurgitation due to either ischemic (n = 5) or dilatative (n = 6) cardiomyopathy with a mean ejection fraction of 21 ± 4% (EuroScore II 6.1 ± 2.5). Uneventful mitral valve repair (n = 8) or replacement (n = 3) was performed via median sternotomy (n = 8) or right lateral mini thoracotomy (n = 3). In six patients, concomitant procedures, either tricuspid valve repair, aortic valve replacement or CABG were necessary. The mean duration on Impella support was 8 ± 5 days. All, but one patient, were successfully weaned from st-MCS, with no Impella-related complications. 30-day survival was 90.9%. Conclusion Protected cardiac surgery with st-MCS using the Impella 5.x is safe and feasible when applied in high-risk mitral valve surgery without st-MCS-related complications, resulting in excellent outcomes. This strategy might offer an alternative and comprehensive approach for the treatment of patients with mitral regurgitation in advanced heart failure, deemed ineligible for TEER or with need of concomitant surgery.
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Affiliation(s)
- Anja Osswald
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany
| | - Sharaf-Eldin Shehada
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany
| | - Alina Zubarevich
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany
| | - Markus Kamler
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany
| | - Matthias Thielmann
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany
| | - Wiebke Sommer
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Alexander Weymann
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Arjang Ruhparwar
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Mohamed El Gabry
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany
| | - Bastian Schmack
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
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Petolat E, Theron A, Resseguier N, Fabre C, Norscini G, Badaoui R, Habib G, Collart F, Zaffran S, Porto A, Avierinos JF. Prognostic value of forward flow indices in primary mitral regurgitation due to mitral valve prolapse. Front Cardiovasc Med 2023; 10:1076708. [PMID: 36910534 PMCID: PMC9995829 DOI: 10.3389/fcvm.2023.1076708] [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: 10/21/2022] [Accepted: 01/30/2023] [Indexed: 02/25/2023] Open
Abstract
Background Degenerative mitral regurgitation (DMR) due to mitral valve prolapse (MVP) is a common valve disease associated with significant morbidity and mortality. Timing for surgery is debated for asymptomatic patients without Class I indication, prompting the search for novel parameters of early left ventricular (LV) systolic dysfunction. Aims To evaluate the prognostic impact of preoperative forward flow indices on the occurrence of post-operative LV systolic dysfunction. Methods We retrospectively included all consecutive patients with severe DMR due to MVP who underwent mitral valve repair between 2014 and 2019. LVOTTVI, forward stroke volume index, and forward LVEF were assessed as potential risk factors for LVEF <50% at 6 months post-operatively. Results A total of 198 patients were included: 154 patients (78%) were asymptomatic, and 46 patients (23%) had hypertension. The mean preoperative LVEF was 69 ± 9%. 35 patients (18%) had LVEF ≤ 60%, and 61 patients (31%) had LVESD ≥40 mm. The mean post-operative LVEF was 59 ± 9%, and 21 patients (11%) had post-operative LVEF<50%. Based on multivariable analysis, LVOTTVI was the strongest independent predictor of post-operative LV dysfunction after adjustment for age, sex, symptoms, LVEF, LV end systolic diameter, atrial fibrillation and left atrial volume index (0.75 [0.62-0.91], p < 0.01). The best sensitivity (81%) and specificity (63%) was obtained with LVOTTVI ≤15 cm based on ROC curve analysis. Conclusion LVOTTVI represents an independent marker of myocardial performance impairment in the presence of severe DMR. LVOTTVI could be an earlier marker than traditional echo parameters and aids in the optimization of the timing of surgery.
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Affiliation(s)
- Elisabeth Petolat
- Department of Cardiology, La Timone Hospital, Marseille, France.,Department of Cardiac Surgery, La Timone Hospital, Marseille, France
| | - Alexis Theron
- Department of Cardiac Surgery, La Timone Hospital, Marseille, France
| | | | | | - Giulia Norscini
- Department of Cardiology, La Timone Hospital, Marseille, France
| | - Rita Badaoui
- Department of Cardiac Surgery, La Timone Hospital, Marseille, France
| | - Gilbert Habib
- Department of Cardiology, La Timone Hospital, Marseille, France
| | - Frederic Collart
- Department of Cardiac Surgery, La Timone Hospital, Marseille, France
| | - Stéphane Zaffran
- U1251 INSERM, Marseille Medical Genetics, Aix-Marseille University, Marseille, France
| | - Alizée Porto
- Department of Cardiac Surgery, La Timone Hospital, Marseille, France
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Significance of Left Ventricular Ejection Time in Primary Mitral Regurgitation. Am J Cardiol 2022; 178:97-105. [PMID: 35778308 DOI: 10.1016/j.amjcard.2022.05.019] [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] [Received: 02/21/2022] [Revised: 05/15/2022] [Accepted: 05/17/2022] [Indexed: 11/23/2022]
Abstract
The optimal timing for mitral valve (MV) surgery in asymptomatic patients with primary mitral regurgitation (MR) remains controversial. We aimed at evaluating the relation between left ventricular ejection time (LVET) and outcome in patients with moderate or severe chronic primary MR because of prolapse. Clinical, Doppler echocardiographic, and outcome data prospectively collected from 302 patients (median age 61 [54 to 74] years, 34% women) with moderate or severe primary MR were analyzed. Patients were retrospectively stratified by quartiles of LVET. The primary end point of the study was the composite of need for MV surgery or all-cause mortality. During a median follow-up time of 66 (25th to 75th percentile, 33 to 95) months, 178 patients reached the primary end point. Patients in the lowest quartile of LVET (<260 ms) were at high risk for adverse events compared with those in the other quartiles of LVET (global p = 0.005), whereas the rate of events was similar for the other quartiles (p = NS for all). After adjustment for clinical predictors of outcome, including age, gender, history of atrial fibrillation, MR severity, and current recommended triggers for MV surgery in asymptomatic primary MR, LVET <260 ms was associated with an increased risk of events (adjusted hazard ratio 1.49, 95% confidence interval 1.03 to 2.16, p = 0.033). In conclusion, we observed that shorter LVET is associated with increased risk of adverse events in patients with moderate or severe primary MR because of prolapse. Further studies are required to investigate whether shorter LVET has a direct effect on outcomes or is solely a risk marker in primary MR.
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Bernard J, Altes A, Dupuis M, Toubal O, Mahjoub H, Tastet L, Côté N, Clavel MA, Dumortier H, Tartar J, O'Connor K, Bernier M, Beaudoin J, Maréchaux S, Pibarot P. Cardiac Damage Staging Classification in Asymptomatic Moderate or Severe Primary Mitral Regurgitation. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2022; 6:100004. [PMID: 37273475 PMCID: PMC10236891 DOI: 10.1016/j.shj.2022.100004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/09/2021] [Accepted: 12/13/2021] [Indexed: 06/06/2023]
Abstract
Background Optimal timing for intervention remains uncertain in asymptomatic patients with primary mitral regurgitation (MR). We aimed to assess the prognostic value of a new cardiac damage staging classification in patients with asymptomatic moderate or severe primary MR. Methods Clinical, Doppler-echocardiographic, and outcome data prospectively collected in 338 asymptomatic patients (64 ± 15 years, 68% men) with at least moderate primary MR were retrospectively analyzed. Patients were hierarchically classified as per the following staging classification: no cardiac damage (stage 0), mild left ventricular or left atrial damage (stage 1), moderate or severe left ventricular or left atrial damage (stage 2), pulmonary vasculature or tricuspid valve damage (stage 3), or right ventricular damage (stage 4). Results There was a stepwise increase in 10-year mortality rates as per cardiac damage stage: 20.0% in stage 0, 25.6% in stage 1, 31.5% in stage 2, and 61.3% in stage 3-4 (p < 0.001). The staging classification was significantly associated with increased risk of mortality (hazard ratio = 1.41 per one-stage increase, 95% confidence interval: 1.07-1.85, p = 0.015) and the composite of cardiovascular mortality or hospitalization (hazard ratio = 1.51 per one-stage increase, 95% confidence interval: 1.07-2.15, p = 0.020) in multivariable analysis adjusted for EuroSCORE II, mitral valve intervention as a time-dependent variable, and other risk factors. The proposed scheme showed incremental value over several clinical variables (net reclassification index = 0.40, p = 0.03). Conclusions The new staging classification provides independent and incremental prognostic value in patients with asymptomatic moderate or severe MR.
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Affiliation(s)
- Jérémy Bernard
- Institut universitaire de cardiologie et de pneumologie de Québec/Québec Heart & Lung Institute, Université Laval / Laval University, Québec City, Québec, Canada
| | - Alexandre Altes
- Department of Cardiology, Institut Catholique de Lille / Catholic Institute of Lille, Université Catholique de Lille / Catholic University of Lille, Lille France
| | - Marlène Dupuis
- Institut universitaire de cardiologie et de pneumologie de Québec/Québec Heart & Lung Institute, Université Laval / Laval University, Québec City, Québec, Canada
| | - Oumhani Toubal
- Institut universitaire de cardiologie et de pneumologie de Québec/Québec Heart & Lung Institute, Université Laval / Laval University, Québec City, Québec, Canada
| | - Haïfa Mahjoub
- Institut universitaire de cardiologie et de pneumologie de Québec/Québec Heart & Lung Institute, Université Laval / Laval University, Québec City, Québec, Canada
| | - Lionel Tastet
- Institut universitaire de cardiologie et de pneumologie de Québec/Québec Heart & Lung Institute, Université Laval / Laval University, Québec City, Québec, Canada
| | - Nancy Côté
- Institut universitaire de cardiologie et de pneumologie de Québec/Québec Heart & Lung Institute, Université Laval / Laval University, Québec City, Québec, Canada
| | - Marie-Annick Clavel
- Institut universitaire de cardiologie et de pneumologie de Québec/Québec Heart & Lung Institute, Université Laval / Laval University, Québec City, Québec, Canada
| | - Hélène Dumortier
- Department of Cardiology, Institut Catholique de Lille / Catholic Institute of Lille, Université Catholique de Lille / Catholic University of Lille, Lille France
| | - Jean Tartar
- Department of Cardiology, Institut Catholique de Lille / Catholic Institute of Lille, Université Catholique de Lille / Catholic University of Lille, Lille France
| | - Kim O'Connor
- Institut universitaire de cardiologie et de pneumologie de Québec/Québec Heart & Lung Institute, Université Laval / Laval University, Québec City, Québec, Canada
| | - Mathieu Bernier
- Institut universitaire de cardiologie et de pneumologie de Québec/Québec Heart & Lung Institute, Université Laval / Laval University, Québec City, Québec, Canada
| | - Jonathan Beaudoin
- Institut universitaire de cardiologie et de pneumologie de Québec/Québec Heart & Lung Institute, Université Laval / Laval University, Québec City, Québec, Canada
| | - Sylvestre Maréchaux
- Department of Cardiology, Institut Catholique de Lille / Catholic Institute of Lille, Université Catholique de Lille / Catholic University of Lille, Lille France
| | - Philippe Pibarot
- Institut universitaire de cardiologie et de pneumologie de Québec/Québec Heart & Lung Institute, Université Laval / Laval University, Québec City, Québec, Canada
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Kamsheh AM, O'Connor MJ, Rossano JW. Management of circulatory failure after Fontan surgery. Front Pediatr 2022; 10:1020984. [PMID: 36425396 PMCID: PMC9679629 DOI: 10.3389/fped.2022.1020984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/18/2022] [Indexed: 11/11/2022] Open
Abstract
With improvement in survival after Fontan surgery resulting in an increasing number of older survivors, there are more patients with a Fontan circulation experiencing circulatory failure each year. Fontan circulatory failure may have a number of underlying etiologies. Once Fontan failure manifests, prognosis is poor, with patient freedom from death or transplant at 10 years of only about 40%. Medical treatments used include traditional heart failure medications such as renin-angiotensin-aldosterone system blockers and beta-blockers, diuretics for symptomatic management, antiarrhythmics for rhythm control, and phosphodiesterase-5 inhibitors to decrease PVR and improve preload. These oral medical therapies are typically not very effective and have little data demonstrating benefit; if there are no surgical or catheter-based interventions to improve the Fontan circulation, patients with severe symptoms often require inotropic medications or mechanical circulatory support. Mechanical circulatory support benefits patients with ventricular dysfunction but may not be as useful in patients with other forms of Fontan failure. Transplant remains the definitive treatment for circulatory failure after Fontan, but patients with a Fontan circulation face many challenges both before and after transplant. There remains significant room and urgent need for improvement in the management and outcomes of patients with circulatory failure after Fontan surgery.
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Affiliation(s)
- Alicia M Kamsheh
- Division of Cardiology, Children's Hospital of Philadelphia, United States
| | - Matthew J O'Connor
- Division of Cardiology, Children's Hospital of Philadelphia, United States
| | - Joseph W Rossano
- Division of Cardiology, Children's Hospital of Philadelphia, United States
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Nair VV, Das S, Nair RB, George TP, Kathayanat JT, Chooriyil N, Radhakrishnan R, Thanathu Krishnan Nair J. Mitral valve repair in chronic severe mitral regurgitation: short-term results and analysis of mortality predictors. Indian J Thorac Cardiovasc Surg 2021; 37:506-513. [PMID: 34511756 DOI: 10.1007/s12055-021-01160-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 01/24/2021] [Accepted: 01/26/2021] [Indexed: 11/26/2022] Open
Abstract
Introduction Mitral valve repair is the accepted treatment for mitral regurgitation (MR) but lack of resources and socioeconomic concerns delay surgical referral and intervention in developing countries. We evaluated immediate and short-term results of mitral valve repair for non-ischemic MR at our centre and aimed to identify the predictors of in-hospital and follow-up mortality. Materials and methods The study was conducted at a tertiary-level hospital in South India. All patients >18 years with severe non-ischemic MR who underwent mitral valve repair over a period of 6 years were included. Perioperative data was collected from hospital records and follow-up data was obtained by prospective methods. Results There were 244 patients (170 males). Most of the patients were in the age group 31-60 years (76.6%). Aetiology of MR was degenerative (n = 159; 65.2%), rheumatic (n = 34; 13.9%), structural (n = 42; 17.2%), or miscellaneous (n = 9; 3.7%). All patients underwent ring annuloplasty with various valve repair techniques. One hundred patients (44.7%) underwent additional cardiac procedures. At discharge, MR was moderate in 4 patients; the rest had no or mild MR. The mean hospital stay of survivors was 7.1 days (SD 2.52, range 5-25 days). There were 9 in-hospital deaths (3.68%) and 10 deaths during follow-up (4.2%). The mean follow-up period was 1.39 years, complete for 87.6%. Pre-operative left ventricle ejection fraction (LVEF) <60% (p = 0.04) was found to be significantly associated with immediate mortality. Logistic regression analysis detected age (p = 0.019), female sex (p = 0.015), and left ventricular (LV) dysfunction at discharge (p = 0.025) to be significantly associated with follow-up mortality. Conclusion Pre-operative LV dysfunction was identified as a significant risk factor for in-hospital mortality. Female sex, age greater than 45 years, and LV dysfunction at discharge were found to be significantly associated with follow-up mortality. Hence, it is important to perform mitral valve repair in severe regurgitation patients before significant LV dysfunction sets in for a better outcome.
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Affiliation(s)
| | - Syam Das
- Government Medical College, Kottayam, India
| | | | | | | | - Nidheesh Chooriyil
- Department of Cardiovascular and Thoracic Surgery, Government Medical College, Kottayam, India
| | - Ratish Radhakrishnan
- Department of Cardiovascular and Thoracic Surgery, Government Medical College, Kottayam, India
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Kim J, Nam JS, Kim Y, Chin JH, Choi IC. Forward Left Ventricular Ejection Fraction as a Predictor of Postoperative Left Ventricular Dysfunction in Patients with Degenerative Mitral Regurgitation. J Clin Med 2021; 10:jcm10143013. [PMID: 34300179 PMCID: PMC8306203 DOI: 10.3390/jcm10143013] [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: 05/31/2021] [Accepted: 07/05/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Left ventricular dysfunction (LVD) can occur immediately after mitral valve repair (MVr) for degenerative mitral regurgitation (DMR) in some patients with normal preoperative left ventricular ejection fraction (LVEF). This study investigated whether forward LVEF, calculated as left ventricular outflow tract stroke volume divided by left ventricular end-diastolic volume, could predict LVD immediately after MVr in patients with DMR and normal LVEF. Methods: Echocardiographic and clinical data were retrospectively evaluated in 234 patients with DMR ≥ moderate and preoperative LVEF ≥ 60%. LVD and non-LVD were defined as LVEF < 50% and ≥50%, respectively, as measured by echocardiography after MVr and before discharge. Results: Of the 234 patients, 52 (22.2%) developed LVD at median three days (interquartile range: 3–4 days). Preoperative forward LVEF in the LVD and non-LVD groups were 24.0% (18.9–29.5%) and 33.2% (26.4–39.4%), respectively (p < 0.001). Receiver operating characteristic (ROC) analyses showed that forward LVEF was predictive of LVD, with an area under the ROC curve of 0.79 (95% confidence interval: 0.73–0.86), and an optimal cut-off was 31.8% (sensitivity: 88.5%, specificity: 58.2%, positive predictive value: 37.7%, and negative predictive value: 94.6%). Preoperative forward LVEF significantly correlated with preoperative mitral regurgitant volume (correlation coefficient [CC] = −0.86, p < 0.001) and regurgitant fraction (CC = −0.98, p < 0.001), but not with preoperative LVEF (CC = 0.112, p = 0.088). Conclusion: Preoperative forward LVEF could be useful in predicting postoperative LVD immediately after MVr in patients with DMR and normal LVEF, with an optimal cut-off of 31.8%.
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Affiliation(s)
| | | | | | - Ji-Hyun Chin
- Correspondence: ; Tel.: +82-2-3010-5632; Fax: +82-2-3010-6790
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11
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Bastos MB, Burkhoff D, Maly J, Daemen J, den Uil CA, Ameloot K, Lenzen M, Mahfoud F, Zijlstra F, Schreuder JJ, Van Mieghem NM. Invasive left ventricle pressure-volume analysis: overview and practical clinical implications. Eur Heart J 2021; 41:1286-1297. [PMID: 31435675 PMCID: PMC7084193 DOI: 10.1093/eurheartj/ehz552] [Citation(s) in RCA: 101] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 04/22/2019] [Accepted: 08/07/2019] [Indexed: 12/31/2022] Open
Abstract
Ventricular pressure–volume (PV) analysis is the reference method for the study of cardiac mechanics. Advances in calibration algorithms and measuring techniques brought new perspectives for its application in different research and clinical settings. Simultaneous PV measurement in the heart chambers offers unique insights into mechanical cardiac efficiency. Beat to beat invasive PV monitoring can be instrumental in the understanding and management of heart failure, valvular heart disease, and mechanical cardiac support. This review focuses on intra cardiac left ventricular PV analysis principles, interpretation of signals, and potential clinical applications. ![]()
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Affiliation(s)
- Marcelo B Bastos
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Centre, Office Nt 645, Dr Molewaterplein 40 3015 GD, Rotterdam, The Netherlands
| | | | - Jiri Maly
- Department of Cardiac and Transplant Surgery, IKEM, Prague, Czech Republic
| | - Joost Daemen
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Centre, Office Nt 645, Dr Molewaterplein 40 3015 GD, Rotterdam, The Netherlands
| | - Corstiaan A den Uil
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Centre, Office Nt 645, Dr Molewaterplein 40 3015 GD, Rotterdam, The Netherlands.,Department of Intensive Care Medicine, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Koen Ameloot
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Centre, Office Nt 645, Dr Molewaterplein 40 3015 GD, Rotterdam, The Netherlands
| | - Mattie Lenzen
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Centre, Office Nt 645, Dr Molewaterplein 40 3015 GD, Rotterdam, The Netherlands
| | - Felix Mahfoud
- Department of Internal Medicine III, Cardiology, Angiology, Intensive Care Medicine, Saarland University Hospital, Homburg/Saar, Germany
| | - Felix Zijlstra
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Centre, Office Nt 645, Dr Molewaterplein 40 3015 GD, Rotterdam, The Netherlands
| | - Jan J Schreuder
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Centre, Office Nt 645, Dr Molewaterplein 40 3015 GD, Rotterdam, The Netherlands
| | - Nicolas M Van Mieghem
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Centre, Office Nt 645, Dr Molewaterplein 40 3015 GD, Rotterdam, The Netherlands
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12
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Abstract
PURPOSE OF REVIEW The review summarizes the key parameters that can aid in determining the optimal treatment of ischemic mitral regurgitation (IMR). RECENT FINDINGS Left ventricular (LV) and mitral valve (MV) parameters are important for surgical planning and risk stratification in IMR. Although LV dimensions is one of the main parameters used in the guidelines, volumes more accurately depict LV remodelling. Furthermore, wall motion abnormalities and wall motion score index can also be useful for surgical planning in treatment of IMR. Viability is best measured with cardiac magnetic resonance, but it is not feasible in certain centres. In contrast, measurement of strain with echocardiography is an emerging and feasible tool for estimating viability. MV leaflet tethering and pattern measured with echocardiography are also useful for MV surgery. Anterior leaflet excursion angle can identify patients in whom undersized ring annuloplasty is potentially unsuitable. SUMMARY Treatment of IMR relies on accurate parameters that can determine the optimal surgical approach. In some patients, lack of viable myocardium suggests inadequacy of revascularization and thus, an adjunctive left ventricular reconstruction may be necessary. Degree and pattern of MV leaflet tethering can indicate whether ring annuloplasty, which is the most common repair technique, is sufficient or an adjunctive sub-valvular intervention is beneficial.
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Sugimura Y, Katahira S, Rellecke P, Kamiya H, Minol JP, Immohr MB, Aubin H, Sixt SU, Horn P, Westenfeld R, Doenst T, Lichtenberg A, Akhyari P. The analysis of left ventricular ejection fraction after minimally invasive surgery for primary mitral valve regurgitation. J Card Surg 2020; 36:661-669. [PMID: 33336536 DOI: 10.1111/jocs.15256] [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: 09/02/2020] [Revised: 10/09/2020] [Accepted: 10/31/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Although minimally invasive mitral valve surgery (MIMVS) has become the first choice for primary mitral regurgitation (MR) in recent years, clinical evidence in this field is yet limited. The main focus of this study was the analysis of preoperative (Pre), postoperative (Post), and 1-year follow-up (Fu) data in our series of MIMVS to identify factors that have an impact on the left ventricular ejection fraction (LVEF) evolution after MIMVS. METHODS We reviewed the perioperative and 1-year follow-up data from 436 patients with primary MR (338 isolated MIMVS und 98 MIMVS combined with tricuspid valve repair) to analyze patients' baseline characteristics, the change of LV size, the postoperative evolution of LVEF and its factors, and the clinical outcomes. RESULTS The overall mean value of ejection fraction (EF) slightly decreased at 1-year follow-up (mean change of LVEF: -2.63 ± 9.00%). A significant correlation was observed for preoperative EF (PreEF) und EF evolution, the higher PreEF the more pronounced decreased EF evolution (in all 436 patients; r = -.54, p < .001, in isolated MIMVS; r = -.54, p < .001, in combined MIMVS; r = -.53, p < .001). Statistically significant differences for negative EF evolution were evident in patients with mild or greater tricuspid valve regurgitation (TR) (in all patients; p < .05, odds ratio [OR] = 1.64, in isolated MIMVS; p < .01, OR = 1.93, respectively). Overall clinical outcome in New York Heart Association classification at 1 year was remarkably improved. CONCLUSIONS Our results suggest an excellent clinical outcome at 1 year, although mean LVEF slightly declined over time. TR could be a predictor of worsened follow-up LVEF in patients undergoing MIMVS.
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Affiliation(s)
- Yukiharu Sugimura
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Shintaro Katahira
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany.,Department of Cardiothoracic Surgery, University Hospital, Tohoku University, Sendai, Japan
| | - Philipp Rellecke
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Hiroyuki Kamiya
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Jan-Philipp Minol
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Moritz Benjamin Immohr
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Hug Aubin
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Stephan Urs Sixt
- Department of Anesthesiology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Patrick Horn
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Ralf Westenfeld
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Friedrich Schiller University Jena, Jena, Germany
| | - Artur Lichtenberg
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Payam Akhyari
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
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Yousef HA, Hamdan AES, Elminshawy A, Mohammed NAA, Ibrahim AS. Corrected calculation of the overestimated ejection fraction in valvular heart disease by phase-contrast cardiac magnetic resonance imaging for better prediction of patient morbidity. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2020. [DOI: 10.1186/s43055-019-0130-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
To establish a more accurate technique for the assessment of the left ventricular function correlated with patients’ clinical condition avoiding the miscalculation of the ejection fraction in valvular regurgitation. A prospective study carried out between July 2018 and June 2019. The studied group included 35 subjects, 25 patients with valvular regurgitation, and 10 healthy control subjects. All subjects underwent cardiovascular magnetic resonance examination to evaluate the ejection fraction by two methods: the volumetric method which assesses stroke volume via subtraction of the end-systolic volume from the end-diastolic volume, and phase-contrast method which assesses the aortic stroke volume via a through-plane phase contrast across the aortic valve. The sensitivity, specificity, P value and the area under the curve of both methods were calculated.
Results
In the healthy group, using the volumetric method, the calculated mean ejection fraction was 62.44 ± 6.61, while that calculated by the phase-contrast method was 64.34 ± 5.33, with a non-significant difference (P = 0.62) showing the validity of the phase-contrast method. In the patients’ group, by using the volumetric method, the calculated mean ejection fraction was 47.17 ± 14.31%, which was significantly higher than that calculated by the phase-contrast method (29.39 ± 7.98%) (P = 0.02). According to the results of the calculation of the ejection fraction by the volumetric method, there were 18 patients (72%) having impaired cardiac function and 7 (28%) patients of normal function; while according to the phase-contrast method, all the 25 patients had impaired cardiac function. The current study shows that the phase-contrast cardiac magnetic resonance had 89.29% sensitivity and 85.7% specificity in diagnosing impaired cardiac function with the area under the curve of 0.87 (P = 0.00).
Conclusion
The phase-contrast cardiac magnetic resonance can provide a better assessment of the ejection fraction in valvular regurgitation.
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Global longitudinal strain: is it a superior assessment method for left ventricular function in patients with chronic mitral regurgitation undergoing mitral valve replacement? Indian J Thorac Cardiovasc Surg 2019; 36:119-126. [PMID: 33061110 DOI: 10.1007/s12055-019-00854-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 06/27/2019] [Accepted: 07/18/2019] [Indexed: 12/14/2022] Open
Abstract
Purpose Left ventricular ejection fraction may remain normal or even higher despite significant impairment of contractility in cases of mitral regurgitation. The aim of this study is to evaluate the changes in left ventricular function after mitral valve replacement and to study the role of global longitudinal strain in detecting early left ventricular dysfunction using speckle tracking. Method Study involved 31 patients who underwent mitral valve replacement for mitral regurgitation. Patient's preoperative and postoperative echocardiography (conventional parameters and global longitudinal strain) and other parameters like functional status, radiological findings, and electrocardiogram were recorded to evaluate left ventricular function. Results All patients presented in advanced stage with New York heart association class III (67.7%) and IV (32.3%). There was significant decline in left ventricular ejection fraction (with the mean value from 64.58 to 40.13%) and global longitudinal strain (- 15.57 ± 4.98to - 8.97) in the immediate postoperative period (~ 7 days). However, there was a rise in both left ventricular ejection fraction (mean 52.48%) and in global longitudinal strain (mean - 14.44 ± 3.67) at 3 months. Left ventricular and atrial size decreased significantly immediately after surgery, which further declined at 3 months. We also found that patients who attained a left ventricular ejection fraction of > 50% in postoperative period had better left ventricular ejection fraction and global longitudinal strain preoperatively. In addition, they had smaller cardiac size and milder pulmonary hypertension comparatively. Conclusions Mitral valve replacement in mitral regurgitation results in decline in left ventricular function immediately after surgery. In patients with chronic mitral regurgitation, left ventricular ejection fraction is fallacious and global longitudinal strain can be an important tool to assess left ventricular ejection fraction.
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