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Zhu E, Zhang C, Wang S, Ma X, Lai Y. The association between myocardial scar and the response of moderate ischemic mitral regurgitation to isolated coronary artery bypass grafting. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1328. [PMID: 34532465 PMCID: PMC8422129 DOI: 10.21037/atm-21-3622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 08/20/2021] [Indexed: 11/06/2022]
Abstract
Background The factors that associated with the response of moderate ischemic mitral regurgitation (IMR) to isolated coronary artery bypass grafting (CABG) remain unclear. This study aims to evaluate whether left ventricular (LV) myocardial scar assessed by cardiovascular magnetic resonance (CMR) is associated with the outcome of moderate IMR after isolated CABG. Methods Forty-six patients with coronary artery disease (CAD) and moderate IMR who underwent isolated CABG between January 2014 and February 2019 in Anzhen Hospital Affiliated to Capital Medical University were enrolled in this case-control study. All patients underwent CMR and echocardiography before surgery. Patients were classified into two groups according to the severity of IMR 1 year after CABG: an improved group (no or mild IMR) and an unimproved group (moderate or severe IMR). Univariate and multivariate logistic regression analyses were used to assess the association between individual variables and unimproved IMR at 1-year post-CABG. Results Compared to patients in the improved group, the patients in the unimproved group had a significantly greater amount of LV myocardial scar (18.0%±9.5% vs. 30.8%±11.2%, P<0.001). In the multiple logistic regression model, after adjustment for age, sex, and body mass index, only LV myocardial scar (OR: 0.89, 95% CI: 0.83–0.96, P=0.001) was independently associated with unimproved IMR after isolated CABG. Furthermore, there was no difference in the 3-year overall survival rates between the two groups (92.3% vs. 90.3%, P=0.46). In addition, patients in the unimproved group had a higher New York Heart Association (NYHA) classification (P=0.01) and more major adverse cardiac events such as MI, angina pectoris, and readmission for heart failure (P=0.03). Conclusions A greater amount of preoperative LV myocardial scar was associated with unimproved moderate IMR after isolated CABG. Measuring preoperative LV myocardial scar is helpful to predict post-operative outcome and determine optimal surgery in patients with moderate IMR.
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Affiliation(s)
- Enjun Zhu
- Department of Cardiovascular Surgery, Anzhen Hospital Affiliated to Capital Medical University, Beijing, China
| | - Chen Zhang
- Department of Radiology, Anzhen Hospital Affiliated to Capital Medical University, Beijing, China
| | - Shengwei Wang
- Department of Cardiovascular Surgery, Anzhen Hospital Affiliated to Capital Medical University, Beijing, China
| | - Xiaohai Ma
- Department of Interventional Diagnosis and Treatment, Anzhen Hospital Affiliated to Capital Medical University, Beijing, China
| | - Yongqiang Lai
- Department of Cardiovascular Surgery, Anzhen Hospital Affiliated to Capital Medical University, Beijing, China
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Recent insights into pathophysiology and management of mechanical complications of myocardial infarction. Curr Opin Cardiol 2021; 36:623-629. [PMID: 34397468 DOI: 10.1097/hco.0000000000000881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Mechanical complications of myocardial infarction are a group of postischemic events and include papillary muscle rupture resulting in ischemic mitral regurgitation, ventricular septal defect, left ventricle free wall rupture, pseudoaneurysm, and true aneurysm. Advances made in management strategies, such as the institution of 'Code STEMI' and percutaneous interventions, have lowered the incidence of these complications. However, their presentation is still associated with increased morbidity and mortality. Early diagnosis and appropriate management is crucial for facilitating better clinical outcomes. RECENT FINDINGS Although the exact timing of a curative intervention is not known, emerging percutaneous and transcatheter approaches and improving mechanical circulatory support (MCS) devices have greatly enhanced our ability to manage and treat some of the complications postinfarct. SUMMARY Although the incidence of mechanical complications of myocardial infarction has decreased over the past few decades, these complications are still associated with high rates of morbidity and mortality. The combination of early and accurate diagnosis and subsequent appropriate management are imperative for optimizing clinical outcomes. Although more randomized clinical trials are needed, mechanical circulatory support devices and emerging therapeutic strategies can be offered to carefully selected patients.
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Manzan E, Azzolina D, Gregori D, Bizzotto E, Colli A, Gerosa G. Combining echocardiographic and anatomic variables to predict outcomes of mitral valve repair with the NeoChord procedure. Ann Cardiothorac Surg 2021; 10:122-130. [PMID: 33575182 PMCID: PMC7867418 DOI: 10.21037/acs-2020-mv-96] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 11/20/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Trans-apical, echo-guided NeoChord mitral valve (MV) repair is an innovative procedure to treat degenerative mitral regurgitation (MR) without concomitant annuloplasty. Recently, leaflet-to-annulus index (LAI) has been identified as a positive prognostic predictor of outcomes at 1-year follow up. The aim of this study is to develop a pre-operative predictor tool to assess probability of success with NeoChord procedure utilizing multi-factor echocardiographic and anatomic variables. METHODS We included ninety-one consecutive patients with prolapse/flail of the posterior mitral leaflet, who subsequently underwent NeoChord MV repair between November 2013 and October 2016. All patients completed post-operative echocardiographic follow-up assessments for up to 2 years. A random forest regression algorithm identified and ranked the most relevant predictors of moderate-severe MR. A multi-variable Cox regression model was performed at follow-up intervals, to assess variables associated with residual MR that was classified as mild or less. Bootstrapping re-samples were used to validate an estimated survival model. Predictive accuracy was assessed using a discrimination index that corrected for over-optimism. RESULTS We developed a nomogram which used the results of a multi-variable model to predict the probability of mild or less residual MR at follow-up periods (discharge, 1, 3, 6 months, 1 and 2 years). Identified predictors included LAI, systolic pulmonary artery pressure, indexed left ventricle end-systolic volume (iLVESV), prolapse/flail width (FW), systolic antero-posterior (AP) annulus diameter, systolic latero-lateral (LL) annulus diameter and presence of calcification. CONCLUSIONS A NeoChord MV repair prediction tool would be helpful in clinical decision-making and in the identification of patients who may benefit from a ringless mitral valve repair using the NeoChord procedure.
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Affiliation(s)
- Erica Manzan
- Cardiac Surgery Unit, Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padua, Padua, Italy
- Cardiac Surgery Unit, A.O.R. San Carlo Hospital, Potenza, Italy
| | - Danila Azzolina
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | | | - Andrea Colli
- Cardiac Surgery Unit, Department of Surgical, Medical and Molecular Pathology and Critical Care, University of Pisa, Pisa, Italy
| | - Gino Gerosa
- Cardiac Surgery Unit, Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padua, Padua, Italy
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Calafiore AM, Totaro A, Testa N, Sacra C, Castellano G, Guarracini S, Di Marco M, Prapas S, Gaudino M, Lorusso R, Paparella D, Di Mauro M. The secret life of the mitral valve. J Card Surg 2020; 36:247-259. [PMID: 33135267 DOI: 10.1111/jocs.15151] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 10/13/2020] [Indexed: 01/08/2023]
Abstract
In secondary mitral regurgitation, the concept that the mitral valve (MV) is an innocent bystander, has been challenged by many studies in the last decades. The MV is a living structure with intrinsic plasticity that reacts to changes in stretch or in mechanical stress activating biohumoral mechanisms that have, as purpose, the adaptation of the valve to the new environment. If the adaptation is balanced, the leaflets increase both surface and length and the chordae tendineae lengthen: the result is a valve with different characteristics, but able to avoid or to limit the regurgitation. However, if the adaptation is unbalanced, the leaflets and the chords do not change their size, but become stiffer and rigid, with moderate or severe regurgitation. These changes are mediated mainly by a cytokine, the transforming growth factor-β (TGF-β), which is able to promote the changes that the MV needs to adapt to a new hemodynamic environment. In general, mild TGF-β activation facilitates leaflet growth, excessive TGF-β activation, as after myocardial infarction, results in profibrotic changes in the leaflets, with increased thickness and stiffness. The MV is then a plastic organism, that reacts to the external stimuli, trying to maintain its physiologic integrity. This review has the goal to unveil the secret life of the MV, to understand which stimuli can trigger its plasticity, and to explain why the equation "large heart = moderate/severe mitral regurgitation" and "small heart = no/mild mitral regurgitation" does not work into the clinical practice.
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Affiliation(s)
| | - Antonio Totaro
- Department of Cardiovascular Sciences, Gemelli Molise, Campobasso, Italy
| | - Nicola Testa
- Department of Cardiovascular Sciences, Gemelli Molise, Campobasso, Italy
| | - Cosimo Sacra
- Department of Cardiovascular Sciences, Gemelli Molise, Campobasso, Italy
| | - Gaetano Castellano
- Division of Anesthesia and Intensive Care, Gemelli Molise, Campobasso, Italy
| | | | - Massimo Di Marco
- Department of Cardiology, "Santo Spirito" Hospital, Pescara, Italy
| | - Sotirios Prapas
- Department of Cardiac Surgery, Henry Durant Hospital, Athens, Greece
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York City, New York, USA
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Unit, Heart and Vascular Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
| | - Domenico Paparella
- Department of Emergency and Organ Transplants, Santa Maria Hospital, GVM Care & Research, Aldo Moro University of Bari, Bari, Italy
| | - Michele Di Mauro
- Department of Cardiology, "Pierangeli" Hospital, Pescara, Italy.,Cardio-Thoracic Surgery Unit, Heart and Vascular Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
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Colli A, Beiras-Fernández A, Ruf T, Vahl CF, Munzel T, Von Bardeleben RS. Reparación mitral percutánea: abordaje combinado en procedimiento único. Rev Esp Cardiol 2019. [DOI: 10.1016/j.recesp.2019.03.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Transcatheter Mitral Valve Repair: Single Stage Combo Approach. ACTA ACUST UNITED AC 2019; 72:972-975. [PMID: 31080165 DOI: 10.1016/j.rec.2019.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 03/25/2019] [Indexed: 11/23/2022]
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Yoshida S, Fukushima S, Miyagawa S, Yoshikawa Y, Hata H, Saito S, Saito T, Domae K, Kashiyama N, Matsuura R, Toda K, Sawa Y. The Adaptive Remodeling of the Anterior Mitral Leaflet and Chordae Tendineae Is Associated with Mitral Valve Function in Advanced Ischemic and Nonischemic Dilated Cardiomyopathy. Int Heart J 2018; 59:959-967. [DOI: 10.1536/ihj.17-465] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Shohei Yoshida
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Satsuki Fukushima
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Shigeru Miyagawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Yasushi Yoshikawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Hiroki Hata
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Shunsuke Saito
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Tetsuya Saito
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Keitaro Domae
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Noriyuki Kashiyama
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Ryohei Matsuura
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Koichi Toda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
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Kainuma S, Funatsu T, Kondoh H, Yokota T, Maeda S, Shudo Y, Matsue H, Nishino M, Daimon T, Toda K, Sawa Y, Taniguchi K. Beneficial effects of restrictive annuloplasty on subvalvular geometry in patients with functional mitral regurgitation and advanced cardiomyopathy. J Thorac Cardiovasc Surg 2017; 156:630-638.e1. [PMID: 29395191 DOI: 10.1016/j.jtcvs.2017.11.090] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 11/15/2017] [Accepted: 11/29/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVES The effects of restrictive mitral annuloplasty (RMA) on subvalvular geometry remains unknown. We evaluated changes in left ventricular (LV) function, severity of mitral regurgitation (MR), and leaflet tethering parameters after RMA and clarified their associations. METHODS In 44 patients with clinically relevant functional MR who underwent RMA, distances between papillary muscle (PM) tips and anterior mitral annulus (PM tethering distance), leaflet angles relative to lines connecting annuli, and interpapillary muscle distance (IPMD) were serially quantified. RESULTS One month after surgery, LV function and MR severity improved with decreased anterior (34 ± 5 to 30 ± 4 mm) and posterior PM tethering distance (37 ± 4 to 32 ± 4 mm), anterior leaflet angle (32 ± 8° to 22 ± 7°), and IPMD (31 ± 6 to 25 ± 5 mm), whereas these variables remained abnormal and posterior leaflet angle increased (34 ± 8° to 48 ± 14°; P < .01 for all). During follow-up (66 ± 37 months), these effects were maintained in 33 patients without MR recurrence, whereas 11 with it showed worsened tethering with less LV function recovery. Multiple linear regression analyses identified that change in MR severity from baseline to 12-month examination independently associated with corresponding change in IPMD (parameter estimate of 0.100 with standard error of 0.039; P = .019) and that in posterior PM tethering distance (parameter estimate of -0.104 with standard error of 0.045; P = .035), whereas not with change in posterior-leaflet angle. The IPMD change was independently associated with change in LV end-systolic dimension (parameter estimate of 0.299 with standard error of 0.110; P = .013). CONCLUSIONS The RMA procedure partially relieved leaflet tethering, evidenced by decreased tethering distances and IPMD; the latter was the main determinant of MR. These beneficial effects might be mainly attributed to post-RMA reverse LV remodeling, potentially offsetting the negative effect of augmented posterior leaflet angle in selected patients.
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Affiliation(s)
- Satoshi Kainuma
- Department of Cardiovascular Surgery, Japan Organization of Occupational Health and Safety, Osaka Rosai Hospital, Sakai, Osaka, Japan; Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Toshihiro Funatsu
- Department of Cardiovascular Surgery, Japan Organization of Occupational Health and Safety, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Haruhiko Kondoh
- Department of Cardiovascular Surgery, Japan Organization of Occupational Health and Safety, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Takenori Yokota
- Department of Cardiovascular Surgery, Japan Organization of Occupational Health and Safety, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Shusaku Maeda
- Department of Cardiovascular Surgery, Japan Organization of Occupational Health and Safety, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Yasuhiro Shudo
- Department of Cardiovascular Surgery, Japan Organization of Occupational Health and Safety, Osaka Rosai Hospital, Sakai, Osaka, Japan; Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hajime Matsue
- Department of Cardiovascular Surgery, Japan Organization of Occupational Health and Safety, Osaka Rosai Hospital, Sakai, Osaka, Japan; Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Masami Nishino
- Department of Cardiology, Japan Organization of Occupational Health and Safety, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Takashi Daimon
- Department of Biostatistics, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Koichi Toda
- Department of Cardiovascular Surgery, Japan Organization of Occupational Health and Safety, Osaka Rosai Hospital, Sakai, Osaka, Japan; Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Kazuhiro Taniguchi
- Department of Cardiovascular Surgery, Japan Organization of Occupational Health and Safety, Osaka Rosai Hospital, Sakai, Osaka, Japan.
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