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Cocianni D, Perotto M, Barbisan D, Contessi S, Rizzi JG, Savonitto G, Zocca E, Brollo E, Soranzo E, De Luca A, Fabris E, Merlo M, Sinagra G, Stolfo D. In-hospital evolution of secondary mitral regurgitation in acutely decompensated heart failure. J Cardiovasc Med (Hagerstown) 2024; 25:789-798. [PMID: 39347727 DOI: 10.2459/jcm.0000000000001667] [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: 04/21/2024] [Accepted: 08/26/2024] [Indexed: 10/01/2024]
Abstract
AIMS Secondary mitral regurgitation (MR) negatively affects prognosis in acutely decompensated heart failure (ADHF), but can be rapidly sensitive to changes in volume status and medical interventions. We sought to assess the evolution of secondary MR in patients hospitalized for ADHF and its prognostic implications. METHODS We retrospectively enrolled 782 patients admitted for ADHF with at least two in-hospital echocardiographic evaluations of MR. We classified MR severity as none-mild or moderate-severe. Based on MR evolution, patients were divided into 'persistent moderate-severe MR', 'improved MR' (from moderate-severe to none-mild) and 'persistent none-mild MR'. RESULTS Four hundred and forty patients (56%) had moderate-severe MR at first evaluation, of whom 144 (33% of patients with baseline moderate-severe MR) had 'improved MR', while 296 (67%) had 'persistent moderate-severe MR'. Patients with improved MR had better clinical, laboratory and echocardiographic parameters of decongestion at discharge compared with those with persistent moderate-severe MR and showed a higher up-titration of recommended therapies. Left ventricular volume, ejection fraction and serum urea were the predictors of improved MR at multivariable analysis. After adjustment, no differences in 5-years survival (primary outcome) were observed according to baseline MR severity. When patients were stratified according to the in-hospital changes in MR severity, improved MR was associated with lower risk of 5-years mortality, compared with both persistent none-mild MR [hazard ratio (HR) = 0.505, P = 0.032] and persistent moderate-severe MR (HR = 0.556, P = 0.040). CONCLUSIONS The severity of MR frequently improved during hospitalization for ADHF; the extent and the changes in MR severity during the in-hospital stay identified distinct patient phenotypes, and seemed to portend different long-term outcomes, with higher 5-years survival associated with improvement in MR.
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Affiliation(s)
- Daniele Cocianni
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University Hospital of Trieste, Trieste, Italy
| | - Maria Perotto
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University Hospital of Trieste, Trieste, Italy
| | - Davide Barbisan
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University Hospital of Trieste, Trieste, Italy
| | - Stefano Contessi
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University Hospital of Trieste, Trieste, Italy
| | - Jacopo Giulio Rizzi
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University Hospital of Trieste, Trieste, Italy
| | - Giulio Savonitto
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University Hospital of Trieste, Trieste, Italy
| | - Eugenio Zocca
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University Hospital of Trieste, Trieste, Italy
| | - Enrico Brollo
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University Hospital of Trieste, Trieste, Italy
| | - Elisa Soranzo
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University Hospital of Trieste, Trieste, Italy
| | - Antonio De Luca
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University Hospital of Trieste, Trieste, Italy
| | - Enrico Fabris
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University Hospital of Trieste, Trieste, Italy
| | - Marco Merlo
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University Hospital of Trieste, Trieste, Italy
| | - Gianfranco Sinagra
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University Hospital of Trieste, Trieste, Italy
| | - Davide Stolfo
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University Hospital of Trieste, Trieste, Italy
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
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Harm T, Schwarz FJ, Zdanyte M, Goldschmied A, Baas L, Aidery P, Shcherbyna S, Toskas I, Keller T, Kast I, Schreieck J, Geisler T, Gawaz MP, Mueller KAL. Novel 3-dimensional effective regurgitation orifice area quantification serves as a reliable tool to identify severe mitral valve regurgitation. Sci Rep 2024; 14:22067. [PMID: 39333219 PMCID: PMC11437129 DOI: 10.1038/s41598-024-73264-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 09/16/2024] [Indexed: 09/29/2024] Open
Abstract
A precise quantification of mitral regurgitation (MR) severity is essential for treatment and outcome of patients with MR. 3D echocardiography facilitates estimation of MR but selection of patients with necessity of invasive treatment remains challenging. We investigate effective regurgitation orifice area (EROA) quantification by 3D compared to 2D echocardiography in patients with MR and highlight the improved discrimination of MR severity. We consecutively enrolled fifty patients with primary or secondary and at least moderate MR undergoing 2D and 3D colour Doppler echocardiography prior to transcatheter edge-to-edge repair (TEER). Improved accuracy of MR grading using 3D vena contracta area (VCA) as an estimate of EROA was compared to 2D proximal isovelocity surface area (PISA) quantification method and a multiparameter reference standard. Quantification of EROA remarkably varies between 2D and 3D echocardiography and the discrimination between moderate and severe MR was significantly (p = 0.001) different using 2D PISA or 3D VCA, respectively. 3D VCA correlated significantly (r = 0.501, p < 0.001) better with the pre-defined MR severity. We detected crucial differences in the correct identification of severe MR between 2D and 3D techniques, thus 2D PISA significantly (p < 0.0001) underestimates EROA due to clinical and morphological parameters. The assessment of 3D VCA resulted in improved diagnostic accuracy.
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Affiliation(s)
- Tobias Harm
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Frederic-Joaquim Schwarz
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Monika Zdanyte
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Andreas Goldschmied
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Livia Baas
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Parwez Aidery
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Serhii Shcherbyna
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Ioannis Toskas
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Timea Keller
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Isabela Kast
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Juergen Schreieck
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Tobias Geisler
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Meinrad Paul Gawaz
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Karin Anne Lydia Mueller
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany.
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Hoevelmann J, Markwirth P, Tokcan M, Haring B. What's new in heart failure? August-September 2024. Eur J Heart Fail 2024; 26:1665-1668. [PMID: 39331814 DOI: 10.1002/ejhf.3399] [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: 07/12/2024] [Accepted: 07/12/2024] [Indexed: 07/28/2024] Open
Affiliation(s)
- Julian Hoevelmann
- Department of Internal Medicine III, Saarland University Hospital, Homburg, Germany
- Cape Heart Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Philipp Markwirth
- Department of Internal Medicine III, Saarland University Hospital, Homburg, Germany
| | - Mert Tokcan
- Department of Internal Medicine III, Saarland University Hospital, Homburg, Germany
| | - Bernhard Haring
- Department of Internal Medicine III, Saarland University Hospital, Homburg, Germany
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
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Wang Z, Zeng Y, Qiu H, Chen L, Chen J, Li C. Relationship between the severity of functional mitral regurgitation at admission and one-year outcomes in patients hospitalized for acute heart failure with mildly reduced ejection fraction. BMC Cardiovasc Disord 2024; 24:357. [PMID: 39003444 PMCID: PMC11245784 DOI: 10.1186/s12872-024-04017-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 06/27/2024] [Indexed: 07/15/2024] Open
Abstract
BACKGROUND The epidemiological distribution of functional mitral regurgitation (FMR) in heart failure (HF) and mildly reduced ejection fraction (HFmrEF) patients and its impact on outcomes remains unclear. We attempt to investigate the prognosis of FMR in patients with HFmrEF. METHODS The HF center registry study is a prospective, single, observational study conducted at the Second Affiliated Hospital of Shenzhen University, where 2330 patients with acute HF (AHF) were enrolled and 890 HFmrEF patients were included in the analysis. The patients were stratified into three categories based on the severity of FMR: none/mild, moderate, and moderate-to-severe/severe groups. Subsequently, a comparison of the clinical characteristics among these groups was conducted, along with an assessment of the incidence of the primary endpoint (comprising all-cause mortality and readmission for HF) during a one-year follow-up period. RESULTS The one-year follow-up results indicated that the primary composite endpoint occurrence rates in the three groups were 23.5%, 32.9%, and 36.5%, respectively. The all-cause mortality rates in the three groups were 9.3%, 13.7%, and 16.4% respectively. Survival analysis demonstrated a statistically significant difference in the occurrence rates of the primary composite endpoint and all-cause mortality among the three groups (P < 0.05). Multifactor Cox regression revealed that moderate FMR and moderate-to-severe/severe FMR were independent risk factors for adverse clinical prognosis in HFmrEF patients, with hazard ratios and 95% confidence intervals of 1.382 (1.020-1.872, P = 0.037) and 1.546 (1.092-2.190, P = 0.014) respectively. CONCLUSIONS Moderate FMR and moderate-to-severe/severe FMR independently predict an unfavorable prognosis in patients with HFmrEF.
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Affiliation(s)
- Zhenhua Wang
- Department of Cardiology, The Second Affiliated Hospital of Shenzhen University (The People's Hospital of Baoan Shenzhen), Shenzhen, 518100, China
| | - Yue Zeng
- Graduate School, Guangdong Medical University, Zhanjiang, 524000, China
| | - Hanzhao Qiu
- Graduate School, Guangdong Medical University, Zhanjiang, 524000, China
| | - Li Chen
- Department of Cardiology, The Second Affiliated Hospital of Shenzhen University (The People's Hospital of Baoan Shenzhen), Shenzhen, 518100, China
| | - Jun Chen
- Department of Cardiology, Baoan District Central Hospital of Shenzhen, Shenzhen, 518100, China
| | - Chaosheng Li
- Department of Cardiology, The Second Affiliated Hospital of Shenzhen University (The People's Hospital of Baoan Shenzhen), Shenzhen, 518100, China.
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Kessler M, Rottbauer W, von Bardeleben RS, Grasso C, Lurz P, Mahoney P, Price M, Williams M, Denti P, Estevez-Loureiro R, Kar S, Maisano F. Impact of heart failure hospitalizations on clinical outcomes after mitral transcatheter edge-to-edge repair: Results from the EXPAND study. Eur J Heart Fail 2024; 26:1495-1503. [PMID: 38726573 DOI: 10.1002/ejhf.3250] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 03/21/2024] [Accepted: 04/09/2024] [Indexed: 07/26/2024] Open
Abstract
AIM This analysis aimed to compare the clinical outcomes associated with heart failure (HF) readmissions and to identify associations with HF hospitalizations (HFH) in patients treated with the MitraClip™ NTR/XTR System in the EXPAND study. METHODS AND RESULTS The global, real-world EXPAND study enrolled 1041 patients with primary or secondary mitral regurgitation (MR) treated with the MitraClip NTR/XTR System. Echocardiograms were analysed by an independent echocardiographic core laboratory. The study population was stratified into HFH and No-HFH groups based on the occurrence of HFH 1 year post-index procedure. Clinical outcomes including MR severity, New York Heart Association (NYHA) functional class, Kansas City Cardiomyopathy Questionnaire (KCCQ) score, and all-cause mortality were compared (HFH: n = 181; No-HFH: n = 860). Both groups achieved consistent 1-year MR reduction to ≤1+ (HFH vs. No-HFH: 87.3% vs. 89.5%, p = 0.6) and significant 1-year improvement in KCCQ scores (+16.5 vs. +22.3, p = 0.09) and NYHA functional class. However, more patients in the No-HFH group had 1-year NYHA class ≤II (HFH vs. No-HFH: 67.9% vs. 81.9%, p < 0.01). All-cause mortality at 1 year was 36.8% in the HFH group versus 10.4% in the No-HFH group (p < 0.001). The HFH rate decreased by 63% at 1 year post-M-TEER versus 1 year pre-treatment (relative risk 0.4, p < 0.001). Independent HFH associations were MR ≥2+ at discharge, HFH 1 year prior to treatment, baseline NYHA class ≥III, baseline tricuspid regurgitation ≥2+, and baseline left ventricular ejection fraction ≤40%. CONCLUSIONS This study reports the impact of HFH on clinical outcomes post-treatment in the EXPAND study. Results demonstrate that the occurrence of HFH was associated with worse 1-year survival, and treatment with the MitraClip system substantially reduced HFH and improved patient symptoms and quality of life.
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Affiliation(s)
- Mirjam Kessler
- Ulm University Heart Center, University of Ulm, Ulm, Germany
| | | | | | - Carmelo Grasso
- Ferrarotto Hospital, University of Catania, Catania, Italy
| | - Philipp Lurz
- University Medical Center of Johannes Gutenberg University, Mainz, Germany
| | - Paul Mahoney
- Heart Center Leipzig - University Hospital, Leipzig, Germany
| | | | - Mathew Williams
- Heart Valve Center, New York University Langone Health, New York, NY, USA
| | - Paolo Denti
- San Raffaele University Hospital, Milan, Italy
| | | | - Saibal Kar
- Los Robles Regional Medical Center, HCA Healthcare, Thousand Oaks, CA, USA
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Yu M, Bouatia-Naji N. Insights into the Inherited Basis of Valvular Heart Disease. Curr Cardiol Rep 2024; 26:381-392. [PMID: 38581562 DOI: 10.1007/s11886-024-02041-6] [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] [Accepted: 03/07/2024] [Indexed: 04/08/2024]
Abstract
PURPOSE OF REVIEW: Increases in the availability of genetic data and advances in the tools and methods for their analyses have enabled well-powered genetic association studies that have significantly enhanced our understanding of the genetic factors underlying both rare and common valve diseases. Valvular heart diseases, such as congenital valve malformations and degenerative valve lesions, increase the risk of heart failure, arrhythmias, and sudden death. In this review, we provide an updated overview of our current understanding of the genetic mechanisms underlying valvular heart diseases. With a focus on discoveries from the past 5 years, we describe recent insights into genetic risk and underlying biological pathways. RECENT FINDINGS: Recently acquired knowledge around valvular heart disease genetics has provided important insights into novel mechanisms related to disease pathogenesis. Newly identified risk loci associated valvular heart disease mainly regulate the composition of the extracellular matrix, accelerate the endothelial-to-mesenchymal transition, contribute to cilia formation processes, and play roles in lipid metabolism. Large-scale genomic analyses have identified numerous risk loci, genes, and biological pathways associated with degenerative valve disease and congenital valve malformations. Shared risk genes suggest common mechanistic pathways for various valve pathologies. More recent studies have combined cardiac magnetic resonance imaging and machine learning to offer a novel approach for exploring genotype-phenotype relationships regarding valve disease. Progress in the field holds promise for targeted prevention, particularly through the application of polygenic risk scores, and innovative therapies based on the biological mechanisms for predominant forms of valvular heart diseases.
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Affiliation(s)
- Mengyao Yu
- Shanghai Pudong Hospital, Human Phenome Institute, Fudan University Pudong Medical Center, Zhangjiang Fudan International Innovation Center, Fundan University, 825 Zhangheng Road, Pudong District, Shanghai, 201203, China.
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Akbar AF, Zhou AL, Wang A, Feng ASN, Rizaldi AA, Ruck JM, Kilic A. Special Considerations for Advanced Heart Failure Surgeries: Durable Left Ventricular Devices and Heart Transplantation. J Cardiovasc Dev Dis 2024; 11:119. [PMID: 38667737 PMCID: PMC11050210 DOI: 10.3390/jcdd11040119] [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: 03/02/2024] [Revised: 04/08/2024] [Accepted: 04/13/2024] [Indexed: 04/28/2024] Open
Abstract
Heart transplantation and durable left ventricular assist devices (LVADs) represent two definitive therapies for end-stage heart failure in the modern era. Despite technological advances, both treatment modalities continue to experience unique risks that impact surgical and perioperative decision-making. Here, we review special populations and factors that impact risk in LVAD and heart transplant surgery and examine critical decisions in the management of these patients. As both heart transplantation and the use of durable LVADs as destination therapy continue to increase, these considerations will be of increasing relevance in managing advanced heart failure and improving outcomes.
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Affiliation(s)
| | | | | | | | | | | | - Ahmet Kilic
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins Hospital, 1800 Orleans Street, Zayed 7107, Baltimore, MD 21287, USA; (A.F.A.); (A.L.Z.); (A.W.); (A.S.N.F.); (A.A.R.); (J.M.R.)
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8
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Magaldi M, Nogue E, Molinari N, De Luca N, Dupuy AM, Leclercq F, Pasquie JL, Roubille C, Mercier G, Cristol JP, Roubille F. Predicting One-Year Mortality after Discharge Using Acute Heart Failure Score (AHFS). J Clin Med 2024; 13:2018. [PMID: 38610783 PMCID: PMC11012877 DOI: 10.3390/jcm13072018] [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: 02/23/2024] [Revised: 03/18/2024] [Accepted: 03/26/2024] [Indexed: 04/14/2024] Open
Abstract
Background: Acute heart failure (AHF) represents a leading cause of unscheduled hospital stays, frequent rehospitalisations, and mortality worldwide. The aim of our study was to develop a bedside prognostic tool, a multivariable predictive risk score, that is useful in daily practice, thus providing an early prognostic evaluation at admission and an accurate risk stratification after discharge in patients with AHF. Methods: This study is a subanalysis of the STADE HF study, which is a single-centre, prospective, randomised controlled trial enrolling 123 patients admitted to hospital for AHF. Here, 117 patients were included in the analysis, due to data exhaustivity. Regression analysis was performed to determine predictive variables for one-year mortality and/or rehospitalisation after discharge. Results: During the first year after discharge, 23 patients died. After modellisation, the variables considered to be of prognostic relevance in terms of mortality were (1) non-ischaemic aetiology of HF, (2) elevated creatinine levels at admission, (3) moderate/severe mitral regurgitation, and (4) prior HF hospitalisation. We designed a linear model based on these four independent predictive variables, and it showed a good ability to score and predict patient mortality with an AUC of 0.84 (95%CI: 0.76-0.92), thus denoting a high discriminative ability. A risk score equation was developed. During the first year after discharge, we observed as well that 41 patients died or were rehospitalised; hence, while searching for a model that could predict worsening health conditions (i.e., death and/or rehospitalisation), only two predictive variables were identified: non-ischaemic HF aetiology and previous HF hospitalisation (also included in the one-year mortality model). This second modellisation showed a more discrete discriminative ability with an AUC of 0.67 (95% C.I. 0.59-0.77). Conclusions: The proposed risk score and model, based on readily available predictive variables, are promising and useful tools to assess, respectively, the one-year mortality risk and the one-year mortality and/or rehospitalisations in patients hospitalised for AHF and to assist clinicians in the management of patients with HF aiming at improving their prognosis.
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Affiliation(s)
- Mariarosaria Magaldi
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy; (M.M.)
- Cardiology Department, Montpellier University Hospital, Inserm U1046, CNRS UMR 9214, PhyMedExp, 34295 Montpellier, France (J.-L.P.)
| | - Erika Nogue
- Clinical Research and Epidemiology Unit, University Hospital of Montpellier, Montpellier University, 34090 Montpellier, France
| | - Nicolas Molinari
- Institute of Epidemiology and Public Health, INSERM, INRIA, CHU Montpellier, University of Montpellier, 34090 Montpellier, France
| | - Nicola De Luca
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy; (M.M.)
| | - Anne-Marie Dupuy
- Département de Biochimie et Hormonologie, Centre de Ressources Biologiques, CHU de Montpellier, 34295 Montpellier, France;
| | - Florence Leclercq
- Cardiology Department, Montpellier University Hospital, Inserm U1046, CNRS UMR 9214, PhyMedExp, 34295 Montpellier, France (J.-L.P.)
| | - Jean-Luc Pasquie
- Cardiology Department, Montpellier University Hospital, Inserm U1046, CNRS UMR 9214, PhyMedExp, 34295 Montpellier, France (J.-L.P.)
| | - Camille Roubille
- PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR 9214, CEDEX 5, 34090 Montpellier, France
- Department of Internal Medicine PhyMedExp CHU Montpellier, Montpellier University, 34090 Montpellier, France
| | - Grégoire Mercier
- Department of Statistics, Montpellier University Hospital, CEDEX 5, 34090 Montpellier, France;
| | - Jean-Paul Cristol
- PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR 9214, CEDEX 5, 34090 Montpellier, France
- Laboratory of Biochemistry, Montpellier University Hospital, CEDEX 5, 34090 Montpellier, France
| | - François Roubille
- Cardiology Department, Montpellier University Hospital, Inserm U1046, CNRS UMR 9214, PhyMedExp, 34295 Montpellier, France (J.-L.P.)
- PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR 9214, CEDEX 5, 34090 Montpellier, France
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Okada M, Tanaka N, Onishi T, Tanaka K, Hirao Y, Harada S, Koyama Y, Watanabe H, Okamura A, Iwakura K, Fujii K, Sakata Y, Inoue K. Impact of Residual Functional Mitral Regurgitation After Atrial Fibrillation Ablation on Clinical Outcomes in Patients With Left Ventricular Systolic Dysfunction. Am J Cardiol 2023; 191:66-75. [PMID: 36641982 DOI: 10.1016/j.amjcard.2022.12.024] [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: 09/04/2022] [Revised: 12/09/2022] [Accepted: 12/23/2022] [Indexed: 01/15/2023]
Abstract
Functional mitral regurgitation (FMR) negatively impacts the prognosis in patients with atrial fibrillation (AF) and reduced left ventricular (LV) ejection fraction (LVEF). Although structural reverse remodeling after AF ablation can reduce FMR severity, the prognostic impact of FMR and its evolution remain unclear. Of 491 patients with baseline LVEF <50% who underwent first-time AF ablation, 134 patients (27%) had grade 2 to 4 FMR at baseline. Among them, 88 patients (66%) exhibited FMR improvement to grade 0 to 1 FMR 6 months after AF ablation. Conversely, among 357 with baseline grade 0 to 1 FMR, 13 patients (3.6%) exhibited FMR worsening to grade 2 to 4 FMR despite AF ablation. Assessment with multidetector computed tomography revealed that an increase in the left atrial emptying fraction (odds ratio 3.55 per 10% increase; 95% confidence interval 2.12 to 5.95) and a reduction in the LV end-diastolic volume index (1.35 per 10-ml/m2 decrease; 1.04 to 1.76) were identified as contributors to the FMR improvement. During a follow-up of 43 months, patients with postprocedural grade 2 to 4 FMR more frequently experienced hospitalizations for heart failure or cardiovascular death than those with grade 0 to 1 FMR (30.5% vs 4.6%, log-rank p <0.001). An age-adjusted multivariate Cox regression analysis including baseline and postprocedural FMR revealed that postprocedural grade 2 to 4 FMR (hazard ratio, 3.24; 95% confidence interval 1.43 to 7.35) was significantly associated with unfavorable events. In conclusion, AF ablation modified and often improved FMR severity in patients with reduced LVEF. Residual grade 2 to 4 FMR 6 months after AF ablation was associated with a poor prognosis.
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Affiliation(s)
- Masato Okada
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Nobuaki Tanaka
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Toshinari Onishi
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Koji Tanaka
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Yuko Hirao
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Shinichi Harada
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Yasushi Koyama
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Heitaro Watanabe
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Atsunori Okamura
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Katsuomi Iwakura
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Kenshi Fujii
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Koichi Inoue
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan; Cardiovascular Division, National Hospital Organization Osaka National Hospital, Osaka, Japan.
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10
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Pagnesi M, Adamo M, Ter Maaten JM, Beldhuis IE, Cotter G, Davison BA, Felker GM, Filippatos G, Greenberg BH, Pang PS, Ponikowski P, Sama IE, Severin T, Gimpelewicz C, Voors AA, Teerlink JR, Metra M. Impact of mitral regurgitation in patients with acute heart failure: insights from the RELAX-AHF-2 trial. Eur J Heart Fail 2023; 25:541-552. [PMID: 36915227 DOI: 10.1002/ejhf.2820] [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: 12/08/2022] [Revised: 02/25/2023] [Accepted: 02/27/2023] [Indexed: 03/16/2023] Open
Abstract
AIMS The impact of mitral regurgitation (MR) in patients hospitalized for acute heart failure (AHF) is not well established. We assessed the role of MR in patients enrolled in the Relaxin in Acute Heart Failure 2 (RELAX-AHF-2) trial. METHODS AND RESULTS Patients enrolled in RELAX-AHF-2 with available data regarding MR status were included in this analysis. Baseline characteristics, in-hospital data, and clinical outcomes through 180-day follow-up were evaluated. The impact of moderate/severe MR was assessed. Among 6420 AHF patients with known MR status, 1810 patients (28.2%) had moderate/severe MR. Compared to patients with no/mild MR, those with moderate/severe MR were more likely to have history of heart failure (HF), prior HF hospitalization, more comorbidities, symptoms/signs of HF, lower left ventricular ejection fraction and higher N-terminal pro-B-type natriuretic peptide levels. Moderate/severe MR was associated with longer length of hospital stay, higher rates of residual dyspnoea, increased jugular venous pressure through the index hospitalization and a higher unadjusted risk of the composite of cardiovascular (CV) death or rehospitalization for HF/renal failure (RF) through 180 days (crude hazard ratio [HR] 1.15, 95% confidence interval [CI] 1.03-1.27, p = 0.01). The association between moderate/severe MR and poorer outcomes was not maintained in a multivariable model including several covariates of interest (adjusted HR 1.03, 95% CI 0.91-1.17, p = 0.65). Similar findings were observed for HF/RF rehospitalization alone. CONCLUSIONS In patients with AHF, moderate/severe MR was associated with a worse clinical profile but did not have an independent prognostic impact on clinical outcomes.
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Affiliation(s)
- Matteo Pagnesi
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marianna Adamo
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Jozine M Ter Maaten
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Iris E Beldhuis
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Gad Cotter
- Momentum Research, Inc., Durham, NC, USA
| | | | - G Michael Felker
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Gerasimos Filippatos
- Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Barry H Greenberg
- Division of Cardiology, University of California San Diego, San Diego, CA, USA
| | - Peter S Pang
- Department of Emergency Medicine, Indiana University School of Medicine and the Regenstrief Institute, Indianapolis, IN, USA
| | - Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
| | - Iziah E Sama
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | | | - Adriaan A Voors
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Marco Metra
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
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11
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Dimarakis I, Callan P, Khorsandi M, Pal JD, Bravo CA, Mahr C, Keenan JE. Pathophysiology and management of valvular disease in patients with destination left ventricular assist devices. Front Cardiovasc Med 2022; 9:1029825. [PMID: 36407458 PMCID: PMC9669306 DOI: 10.3389/fcvm.2022.1029825] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 09/29/2022] [Indexed: 11/06/2022] Open
Abstract
Over the last two decades, implantable continuous flow left ventricular assist devices (LVAD) have proven to be invaluable tools for the management of selected advanced heart failure patients, improving patient longevity and quality of life. The presence of concomitant valvular pathology, including that involving the tricuspid, mitral, and aortic valve, has important implications relating to the decision to move forward with LVAD implantation. Furthermore, the presence of concomitant valvular pathology often influences the surgical strategy for LVAD implantation. Concomitant valve repair or replacement is not uncommonly required in such circumstances, which increases surgical complexity and has demonstrated prognostic implications both short and longer term following LVAD implantation. Beyond the index operation, it is also well established that certain valvular pathologies may develop or worsen over time following LVAD support. The presence of pre-existing valvular pathology or that which develops following LVAD implant is of particular importance to the destination therapy LVAD patient population. As these patients are not expected to have the opportunity for heart transplantation in the future, optimization of LVAD support including ameliorating valvular disease is critical for the maximization of patient longevity and quality of life. As collective experience has grown over time, the ability of clinicians to effectively address concomitant valvular pathology in LVAD patients has improved in the pre-implant, implant, and post-implant phase, through both medical management and procedural optimization. Nevertheless, there remains uncertainty over many facets of concomitant valvular pathology in advanced heart failure patients, and the understanding of how to best approach these conditions in the LVAD patient population continues to evolve. Herein, we present a comprehensive review of the current state of the field relating to the pathophysiology and management of valvular disease in destination LVAD patients.
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Affiliation(s)
- Ioannis Dimarakis
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, United States
- Department of Cardiothoracic Transplantation, Manchester University Hospital NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
| | - Paul Callan
- Department of Cardiothoracic Transplantation, Manchester University Hospital NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
| | - Maziar Khorsandi
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, United States
| | - Jay D. Pal
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, United States
| | - Claudio A. Bravo
- Division of Cardiology, Department of Medicine, University of Washington Medical Center, Seattle, WA, United States
| | - Claudius Mahr
- Division of Cardiology, Department of Medicine, University of Washington Medical Center, Seattle, WA, United States
| | - Jeffrey E. Keenan
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, United States
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12
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Milwidsky A, Mathai SV, Topilsky Y, Jorde UP. Medical Therapy for Functional Mitral Regurgitation. Circ Heart Fail 2022; 15:e009689. [PMID: 35862021 DOI: 10.1161/circheartfailure.122.009689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Functional mitral regurgitation (FMR) can be broadly categorized into 2 main groups: ventricular and atrial, which often coexist. The former is secondary to left ventricular remodeling usually in the setting of heart failure with reduced ejection fraction or less frequently due to ischemic papillary muscle remodeling. Atrial FMR develops due to atrial and annular dilatation related to atrial fibrillation/flutter or from increased atrial pressures in the setting of heart failure with preserved ejection fraction. Guideline-directed medical therapy is the first step and prevails as the mainstay in the treatment of FMR. In this review, we address the medical therapeutic options for FMR management and highlight a targeted approach for each FMR category. We further address important clinical and echocardiographic characteristics to aid in determining when medical therapy is expected to have a low yield and an appropriate window for effective interventional approaches exists.
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Affiliation(s)
- Assi Milwidsky
- Department of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (A.M., U.P.J.).,Department of Cardiology, Tel-Aviv Sourasky Medical Center (affiliated with the Sackler School of Medicine), Tel-Aviv University, Israel (A.M., Y.T.)
| | - Sheetal Vasundara Mathai
- Department of Medicine, Jacobi Medical Center and Albert Einstein College of Medicine, Bronx, NY (S.V.M.)
| | - Yan Topilsky
- Department of Cardiology, Tel-Aviv Sourasky Medical Center (affiliated with the Sackler School of Medicine), Tel-Aviv University, Israel (A.M., Y.T.)
| | - Ulrich P Jorde
- Department of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (A.M., U.P.J.)
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13
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Dandel M. Role of Echocardiography in the Management of Patients with Advanced (Stage D) Heart Failure Related to Nonischemic Cardiomyopathy. Rev Cardiovasc Med 2022; 23:214. [PMID: 39077176 PMCID: PMC11273760 DOI: 10.31083/j.rcm2306214] [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: 02/17/2022] [Revised: 05/10/2022] [Accepted: 05/17/2022] [Indexed: 07/31/2024] Open
Abstract
Echocardiography (ECHO) is indispensable for evaluation of patients with terminal chronic heart failure (HF) who require transplantation or mechanical circulatory support by a left- or biventricular assist device (LVAD or BiVAD, respectively). In LVAD candidates, ECHO represents the first-line investigation necessary for a timely discovery of heart-related risk factors for potentially life-threatening post-operative adverse events, including identification of patients who necessitate a biventricular support. ECHO is also required for intra-operative guiding of VAD implantation and finding of the most appropriate setting of the device for an optimal ventricular unloading, postoperative surveillance of the VAD support, and monitoring of the RV changes in LVAD recipients. Thanks to the ECHO, which has decisively contributed to the proof that prolonged VAD support can facilitate cardiac reverse remodeling and functional improvement to levels which allow successful weaning of carefully selected patients from LVAD or BiVAD, the previous opinion that chronic non-ischemic cardiomyopathy (NICMP) is irreversible could be refuted. In patients with normalized and stable right heart catheter-derived hemodynamic parameters obtained at short-term interruptions of VAD support, ECHO has proved able to predict post-weaning long-term freedom from HF recurrence in patients with pre-implant terminal chronic NICMP. The purpose of this article is to offer an actualized theoretical and practical support for clinicians engaged in this particularly challenging and topical issue especially due to the new practical aspects which have emerged in conjunction with the growing use of long-term ventricular assist devices as bridge-to-transplantation or as destination therapy, as well as the increasing evidence that, in some patients, such VAD can become a bridge-to-recovery, allowing the removal of the device after a longer support time.
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Affiliation(s)
- Michael Dandel
- German Centre for Heart and Circulatory Research (DZHK) Partner Site Berlin, 10785 Berlin, Germany
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